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E71 - Why has cancer gone to pot? - with Dr. Paul Daeninck

Therapeutic cannabis use is to cancer, as salt and pepper is to the dinner table; ubiquitous yet individualized. In the past 20 years, oncologist Paul Daeninck, MD, MSc, MSc., FRCPC has not only seen cannabis slowly infiltrate personalized cancer care treatment plans, but also how it eventually changed a country’s relationship with an illegal drug. Although we trust the chef to properly season our food, we know why people should not use salt and some people simply will not like pepper. In this episode, Kirk and Trevor sit at the table, feeding on the knowledge of Winnipeg’s Top Pot Doc learning how cannabis seasons his practise. Kirk and Trevor quickly come to understand how this unassuming man is so admired for his leadership, compassion, and research within Cancer Care Manitoba network, which is the provincially mandated cancer agency providing clinical services to both children and adults.

Episode Transcript

Kirk: Trevor

Trevor: yeah, so we're back and you were just saying off camera, you can't believe we're up to 70 plus episodes and we finally hit cancer. 

Kirk: Yeah, yeah. How did that happen? I mean, like, when you think about. 

Trevor: I don't know. 

Kirk: When you think about cannabis. And in cannabis culture, cancer has been a huge, huge part of why cannabis became medicinal legal in Canada. And we and we cover it in episode seventy-one? You know. 

Trevor: And even to this day, if you look in the official official official indications of cannabis, it is one of the few things; nausea associated with cancer chemotherapy is an official indication for cannabis, like everywhere. That's not controversial in the least. Every mainstream doctor will agree with that. But yeah, we didn't quite get around to it. 

Kirk: We're a little slow on the uptake. But you know what? We found Manitoba's pot, Dr. Paul Daeninck. He's very accessible Trevor, to the point that I just Googled him, now I found him. I found him through mutual colleagues. And I'm going to bring you a future story that I'm still working on. And my goal was to find a story on cannabis with palliative care. And, of course, who do you go to? But Paul Daeninck and I had got a story from Dr. Pinnick, who I who I'm working on that story still, with exclusively on the palliative side. But she recommended that we talk to this fellow. So she got a hold of him and he accepted and emailed us and said he would do the podcast. Now, today, I just Googled him to prepare to talk to you and like, man, I've got a sheet of paper. It's right there with his cell phone on it. Through the Internet, you can find his cell phone, his phone number, his email. He's very accessible. So he is the site coordinator. 

Trevor: Don't harass them. No, give him a little bit of time. 

Kirk: But the man is very accessible and you'll hear it. And I'm really thinking this is going to be a long episode Trevor. I had a conversation with him for a good hour and it's a solid hour. I don't see a lot of editing happening. So people settle in. This is going to be a longer podcast. But it but 

Trevor: Interesting, like Dr. Daeninck knows a lot about a lot. And Kirk had him talk about a lot about a lot. 

Kirk: Yeah. And and we talk about cancer. We get into palliative and we get into the future, which like stand by people. He throws a couple good ones out there that I did I'm quite fond of. So let's introduce him. So he is to Site Coordinator of the St. Boniface Unit. The attending medical oncologist for Cancer Care, Manitoba; Associate Professor, Department of Internal Medicine, University of Manitoba, cross deployment to the Department of Family Medicine, University of Manitoba Consultant and Palliative Care, the Winnipeg Regional Health Authority Palliative Care Program medical oncologist, palliative medicine consultant. He's the chair of the Symptoms Management Palliative Care Disease Site at Cancer Care, Associate Professor and Leader for the Palliative Care Longitudinal theme for Undergraduate education at the School of Medicine. He has been on lots of committees. I'm sure he knows many of the people that we've interviewed. Again, I have to apologize. He should have been one of our first five, right? Yeah. 

Trevor: Yeah, he should have been, you know, baby number two or three. Yeah, but and anyway, we finally got we finally got around to a Manitoban who knows a little bit about cannabis

Kirk: and knows a little bit of cannabis, I'm going to be right up and honest with you. I did a little bit of prep for this interview, but not a lot. And again, the reason why I didn't do a lot is because, again, cannabis and cancer is like salt and pepper, right? I mean, how much do you have to research as a health professional to understand Canada's role in cancer? I mean, it's been publicized for twenty years. So and I think the first thing I said to him was, man, I don't know why we haven't talked to you sooner. This is bewildering. So you know what? I know you probably have things to say, but let's it's going to be a long one. Let's just sneak into the interview. 

Trevor: Yeah, absolutely. Let's talk first. 

Kirk: OK, done. 

Dr. Paul Daeninck: My name is Paul Daeninck. I am an oncologist and palliative medicine specialist working out of Cancer Care Manitoba. I've been with Cancer Care Manitoba since nineteen ninety eight and I've been working in the cannabis space since about two thousand. At that time I met a couple of people who were working in the space, I had some skepticism about what it was going to do for us. I was a pretty typical and conservative oncologist, but as I found out more and more, I became, I guess, enlightened or made aware of what was going on with cannabis and the benefits, the potential benefits for our patients in both cancer in terms of the treatment and treatment of their symptoms related to palliative medicine. 

Kirk: OK, so you've been in you've been in it since before it was even legal for medicinal use. 

Dr. Paul Daeninck: It was around the time that Al Rock (Canadian Health Minister) 1997-2002) came up with the we're going to have a medicinal program. And it was I think it was nineteen ninety-nine that it came up with that, but it was around two thousand or two thousand one where I was recruited to a group called the Canadian Consortium for the Investigation of Cannabinoids. And once I met a bunch of people there and realized the research, the potential, I was kind of hooked. 

Kirk: OK, interesting. So you weren't dragged into it by your patients? 

Dr. Paul Daeninck: No, no. And I would say we probably knew about it beforehand, like patients would bring it up, but I wouldn't necessarily be able to talk with any knowledge about it. I knew that it wouldn't hurt. But at the same time, you want to minimize their use of it. At that time, we call it illicit drugs or illegal drugs. And we also didn't want to have any interactions with our chemotherapies or with the medications we were using for symptom management. We definitely didn't want them to get high because that would be a problem. Right. Or that's what we thought. 

Kirk: Yeah, you can't have that. OK, so let's let's talk about the early days then. So you're involved with a group of people who are actually researching it. How were you doing the research? 

Dr. Paul Daeninck: How did we do the research? 

Kirk: How did you, did you gather what you knew? Did you actually start your own? How did all that work? 

Dr. Paul Daeninck: So it was a bit of a combination of both? First off, the consortium was put together by a group of basic researchers, early clinicians. The focus really was at that time on pain. But as we started to collect more people, as well as collect more information from other centers, we realized it could be useful for other symptoms, including nausea. We we knew a little bit around chemotherapy induced nausea. People have been using some form of cannabis or THC product for literally decades. And so we knew about that. But it was more around, OK, how do we get this into the hands of our patients? It's how do we convince them that it's a reasonable alternative? How do we get it into there hands? How do we get a safe product into their hands? That was a big question for me because I knew that patients who were on chemotherapy or were immunosuppressed were at risk. If they got street cannabis that was infected or infiltrated with stuff like a fungus or bacteria, it could be a real problem for them. And we saw a number of case reports of people getting essentially life limiting or a deadly fungus infection because of their use of street cannabis that wasn't made safe or inspected, that sort of thing. 

Kirk: Interesting, interesting. So, OK, going back we are still on the early days. So in a sense then you were being driven by patient use at that point? 

Dr. Paul Daeninck: Correct. ya, and it's interesting because as I learned more about cannabis, I think that I was more open to hearing about it from patients. And then sometimes I also brought it up with patients. It was I would say in the early days it was still, I wouldn't say verboten, but it was certainly frowned upon that doctors would talk about the possible use of something that's thought to be illegal or illicit. Causes all sorts of troubles. But again, you know, there was a need; patients would come forward with their needs. They obviously weren't getting benefit out of the medication we were using. Or the other thing that we were starting we were starting to see was people saying, I don't like these other medications that I'm on. They give me terrible side effects. Can we get off of some of these pain medications or some of these medications for nausea medications, for other things? So it was it was an interesting transition. I'd say when I'm looking back, I'd say it's a very interesting transition, how things went from solidly in the no camp to very solidly in the yes and promote camp. So it's yeah, we're 

Kirk: we're at that point now, I imagine, solidly understood and actually being promoted. So are you saying that that took the twenty to twenty-one years. 

Dr. Paul Daeninck: No. 

Kirk: I'm still. I'm still. I'm still in the early days because in the early days, I mean, I've been nursing for almost 40 years and of course, I've never really been an oncology nurse, but of course, to dabble in you see patients in outpatients and stuff. And many patients would tell me unofficially, quote unquote, that they're using cannabis and they don't tell their doctor because they're afraid their doctor will. You must have gone through that that that phase of practice. 

Dr. Paul Daeninck: Absolutely. Absolutely. So patients would come in. They would tell us that they don't need this medication for nausea yet. We know with that chemotherapy, it's going to be causing a lot of troubles. And then you kind of have some key questions and then it comes up. I I've always tried to make patients comfortable so that they could share anything and everything with us in our pain and symptom clinics. And in doing that, we were able to get more information, learn more about what else they're taking. So as you may have heard from other people, alternative and complementary treatments for patients and cancer are very commonplace. Most of them don't want to talk about it with their physicians because there's either some stigma associated with it or they feel they're going to lose the trust of the physician. They're not going to be a good patient. And yet finding out about that information gives us some sense as to what are the holes, what are the where are we missing things in treating our patients? And it also, to be honest, it strengthens the therapeutic relationship that you have with patients. They trust you more. 

Kirk: Well, I congratulate you on that because I would as I listen to speak, the stories that I heard happened to me in Alberta. I I spent I spent the majority of my practice from nineteen eighty two to two thousand in Alberta. So I know of two or three cases specifically where the patients would not discuss it with the doctor. The doctor did not ask. And when the doctor found out that the family was sneaking in the cannabis, he actually said, you'll have to find yourself a new to Oncologists. And so I congratulate you on that because there's not a lot of you around for patients to shop around for patients to shop around for them.

Dr. Paul Daeninck: No, no. And early on, you know, once you start working with patients and early on they started to talk to each other, so suddenly you got the reputation as the only doctor in town or the only oncologist in town that understands cannabis and is willing to write the prescription or to write the medical document for these patients. So I did get a bit of a rep as a Pot Doc. 

Kirk: Yeah. And and and how were you with that? 

Dr. Paul Daeninck: Initially, I was a little hesitant. Honestly, I kind of fell ill. I'm not sure I want that as a as a nickname, but now I'm actually very comfortable with it. I'm I use it to my advantage to say that I understand the nature of cannabis. I understand what you're going through. Let us see if we can find something that'll help with the troubles that you're having. And my friends, I mean, I have to show you this. My friends and family have taken over with that. So I get things like this now. 

Kirk: All prescriptions of marijuana. Look at that. That's a big jar. That's all over your desk, is it? 

Dr. Paul Daeninck: Yes. Yes. And, you know, I have done some work with industry as well. And I'm very open to teaching. But not only patients, but health care professionals. Probably I'm going to say conservatively a half dozen to a dozen times a year, I'm doing some form of teaching or rounds where I'm talking about the use of cannabis in cancer, end of life care, palliative care, all really important because many people want to be updated. They want to know where the current status is. They want some of it is also dispelling myths. You know, there's been a lot of myths over the years and especially I'd say in the last ten years, there's been some myths around the use of cannabis for cancer that are particularly important to dispel. You know, like cannabis cures cancer. 

Kirk: Well, that's that's actually one of my later questions for you. But you can dip into that one if you'd like to hear the whole Rick Simpson's oil thing. 

Dr. Paul Daeninck: Right, right. Right. So Rick Simpson and, you know, I don't know the full story, but the story is I can put it together was he had some concentrated cannabis products. It probably was what we would have called hash at one time. And he discovered that he had a lesion or our growth on his skin. And he said, hey, if I rub it on there, let's see what happens. He never had it checked out by a physician. It was never diagnosed as cancer, the lesion, the growth, whatever disappeared over a period of time. Thus, he now can cure cancer with his with his product. And then, of course, everybody kind of took off after that. And some of it was taken directly from Rick. Other times people would create it and then they call it Rick Simpson oil 

Kirk: they make their own. 

Dr. Paul Daeninck: Yeah, yeah, exactly. And the big issue there is that we don't know what's in it. It's not like it comes from Health Canada or from a recognized distributor where you get the contents on there. Many patients got very sick because it was so concentrated. The they kept on saying, well, I take a grain of rice once a day or twice a day and I increase it. And I really didn't know what was going in there. So I would say, well, look, obviously this is an important thing for you. Let's take a look at a better or a safer supply. There are some people, though. It's very difficult to I don't want to say convince them, but to talk to them about the use of this that it could cause some harm. I've had probably about under a half dozen patients who chose to go the Rick Simpson route rather than the chemotherapy route. Unfortunately, all of them died and I would say died prematurely because they did not have access to any of our chemotherapies or they chose not to access any of our chemotherapies, and especially for things like what we would think is an eminently curable colon cancer, for instance. And I think that that that actually is a danger. We don't want patients to be believing something where the people are selling it with the focus of just making money. If we want to be able to say, hey, if this is something that you feel very strongly about, I don't see a problem in using it with chemotherapy. In fact, it might be really helpful when we're talking about nausea or appetite, pain, and so we can move forward with that. But sometimes and I've had a few that have been quite dogmatic about it, that they that's the only focus that they're going to do. That's all they're going to do. And so I'm I'm kind of left in the position of following them to minimize harm.

Kirk: And I did that was a way forward conversation. So going back a little bit. So cannabis in the early early 2000s, it just becomes legal. I imagine now patients are coming to you more. Where did where did you use cannabis in early cancer? Well, early 2000s, I guess. And so how did you use it and what in what formulations? 

Dr. Paul Daeninck: So mostly we were using it for nausea associated with chemotherapy. For some people, it was appetite stimulation. We had known that the people who smoke cannabis recreationally get the munchies. There was a little bit of emerging data that the use of THC or THC CBD products would increase appetite. So that was definitely something that we used. And also with pain patients who had pain, mostly what I'd call neuropathic pain, where the nerves were the problem or they were involved in the cancer in some way. That's when our our biggest focus was. I would say that probably we were looking at one company at that time that was Prairie Plant Systems at the time, out of initially out of Flin Flon and then later on out of Saskatoon. And, you know, people would come forward with some products from the streets and let me see them. And because, again, we had no idea what the content was. We didn't know what was in there. We didn't know how safe it was prepared. We would suggest maybe we would look at this this product out of CannaMed. Well, what became CannaMed, but Prairie Plant Systems at that time and I know that I wrote a lot of medical documents at that time, the part A, the part B, I would confirm some things with other family physicians. So it was quite it was quite a time off. 

Kirk: Yeah, sure. My phone is ringing in my roomba's going. Doing work out of the kitchen. So now I was reading some of your presentations. I went on the cancer care and found some of your presentations you've done and you have labeled cannabis as as on-label and off-label. And I got to tell you, that's the first time I've seen cannabis listed that way. Can you explain how you do that or how does that work for you? 

Dr. Paul Daeninck: So officially, Health Canada has approved a pharmaceutical cannabinoid, this would be nabilone. That's the first one that was approved,Marinol, Dronabinal was also approved. It's now off the market. And also we have Sativex has been approved for use. So the official indications there are nausea, vomiting due to chemotherapy, chronic pain or pain due to cancer and also MS spasms, M.S. related pain and spasms. So whenever I'm talking about the use of cannabis with some of our other cancer patients or patients who have advanced disease, these are things that I mentioned. I want to make sure that they understand that there is that option for patients. I mean, it's not it's not a perfect option. That was the only thing that we had when we started out back in the early aughts. From a pharmaceutical point of view, those are the things that were covered. It was some patients didn't have the money to buy the cannabis from the licensed producer or the licensed producers over a period of time. So we were really focusing in on what was on-label or the things that were actually approved by Health Canada. When we talk about off-label, what we mean are things where there's research, strong research just to support the use of this. But it isn't necessarily approved under a Health Canada framework using a pharmaceutical, even the whole thing around the Health Canada Licensed Producer Medical Cannabis Program, there's they haven't come up with a indication as much as you can use it for this sort of these sort of things. And they haven't put a limit on what you can or can't use it. They really leave it to the purview of the physician, to the decision of the physician and the patient. But there is a certain responsibility that we as health care professionals take in saying this patient is appropriate to use some form of medical cannabis product. 

Kirk: It is interesting how it is since legalization, I was really once one statistic, almost 300000 people. Two hundred and ninety seven thousand you had listed as medical patients in eighteen. Do you just throw this question or do you know if the number is increased since legalization are going down? 

Dr. Paul Daeninck: Interestingly, they went up in some places that are down in others. 

Kirk: So it was regional specific. 

Dr. Paul Daeninck: Yes, exactly. On a per capita. Ah, sorry. On a country wide basis, we're talking closer to four hundred thousand. Now the latest numbers out of you know they published them a little while ago and that was to the end of I think it was September of twenty-twenty. Those numbers had gone up to nearly four hundred thousand. But if you take a look at different regions, for instance in B.C. they have the smallest number of people who are approved for medical use, probably because they have a high density of dispensaries, people using it from friends. You know, there's a lot of access to product, 

Kirk: the unofficial dispensaries. 

Dr. Paul Daeninck: Yeah, exactly. Exactly. You know, and if you take a look at what happened to Alberta initially, there was kind of an increase up and it kind of leveled out and then it came down a little bit. And once the pandemic started, things started going up again. Ontario has always been kind of up and down because they have a very poor distribution network. Quebec has not high numbers. Manitoba has some pretty good numbers. The East Coast has some pretty good numbers as well. And again, it's all due to distribution. So, you know, people are going out there and some of it is seeing what's happening with the recreational market. And people will come to us, hey, I've tried a certain product. I'd like to use this medically. What's the difference between what you can give me medically and what I can get recreationally? Will they pay for it? Will it be covered under pharmacare if I get it by a medical physician? So there's a number, you know, and that's the other thing that I think is important. We have to sit down and educate patients because the amount of information that's out there is huge it and it kind of runs the gamut of, you know, how to grow your own to this cure is everything. You can use it for anything, everything, that sort of information. And I think it's important for patients to really know the true goods. Let's let's sit down and have a good discussion on what you would use it for. Why would you use it? How do we start? What's the dose that we use? Those sorts of things? 

Kirk: And I guess that's a good segue way to this question. Are you did you, I guess, in the early days, did used Nabilone more often than you used to flower? And now we're using more flower than Nabilone. How's it been changing and use. 

Dr. Paul Daeninck: Excellent question. So you're right, initially we were using Nabilone partly because we knew what it was, what it was and how much they were able to use, it was covered under pharmacare. Patients were happy to use it, and it was effective for the nausea, for the appetite issues that they had. Isn't a great medication for pain, mainly because it's a bit of a hammer when it comes to the dosing. It's a very concentrated form of THC and many people get very sleepy or they get side effects from it. However, as just as you said, over time, I've become much more comfortable with the use of flower and the other sort of cannabis products that are out there. And now, you know, I think I have three patients that are still using Nabilone of one sort or another. And it's interesting, it's mostly for sleep. They take it as a bit of a sleep aid and they know it's going to be predictable. They could take the one pill. They get a really good night's sleep. One of those patients is a gent who has PTSD on top of his cancer, and he says that this is the best thing for him. So it's it's nice to see that you can kind of treat two things at once with one medication. 

Kirk: Yeah, no kidding. And I guess the other thing that we'll move into flower and as you probably, as you as you know, what makes cannabis so very difficult is not every plant you strain is the same. So have you come up with an understanding of strains or types or Sativa verses Indica? If that's actually something in your world, how do you how do you recommend somebody to move into their flower or their their medical products that would be derived other than Nabilone? 

Dr. Paul Daeninck: Excellent question. So in general, we would like patients to start with a combination of THC, CBD product. I'm not a great supporter of smoked or smoked product, mainly because of the potential damage that people can get into their lungs. But I do understand, if you've been using it for several years, let's say that you've been a frequent user or enjoy enjoyment from a recreational point of view. It's going to be hard to believe that other products will work. But most of our patients are elderly. They tell me right off the bat they don't want to get high. They don't want any of the side effects. So we are often looking for a product that is high in CBD, the Sativa Indica question. That's an excellent question, but I don't think that we have enough research to say that one is better than the other. I know that there's a lot of personal experience and a lot of people say this one is better for me in terms of sleep and mellowness. And others say this gives me more energy. The issue, though, is that I don't know what the THC CBD content is. And to me, those two are the active ingredients. If we can figure out a ratio of those that will work for an individual, that's the best thing to look at. So patients will say, I don't want to get high. I just want to give this a try. Well, then let's start with some CBD dominant product. And as you know, there's a number of those on the market, maybe 20 percent CBD, less than one percent THC, a good place to start. And then we find a dose that kind of works for them. The older the patient, the smaller the dose you want to start, the more naive, the smaller the dose. You know, start low, go slow is a really good term that we use to a bit of a thing to go by. When patients come in, though, and they've already been using some cannabis for some time, maybe because of friends that have been giving it or they have a history of recreational use, then we try to figure out, are you using THC dominance? Do we want to add CBD into it to get some benefit out of that? And then we're kind of looking for, again, a combination that's going to work for them. Or do we buy to do we order two products, one THC dominant, one CBD dominant, and find the ratio that works for them? 

Kirk: OK, so you I mean, the way you're explaining this to me, you're obviously using oils or capsules, 

Dr. Paul Daeninck: oils, capsules. I'm OK with edibles as well, although that's a fairly new development out there. Patients that come to us and they want to use flower for inhalational purposes or to smoke, then we'll come up with a product that works for them. Often with those patients, they're using it for kind of a breakthrough as opposed to those who are using it on a regular basis, because, as you know, if you have pain, you want to use something that kind of lasts a long time as a long duration of action. So it's becoming, you know, it becomes difficult. Smoke, three, four, five, six, six joints a day and never get off the couch, so, you know, so I do recommend that if people are having some difficulty with movement pain or with break through pain, that there is something like this that we can use, you know, both an inhalation or one of the vaporizers or if they like, they can smoke. But again, they have to know that there is the potential for damage in their lungs. 

Kirk: So operationalizing this, obviously, patients that are chemotherapy patients, they're out-patients, they're coming, going. So are they encouraged to dose before they come into the into the building or how's that work? How are the other health professionals involved with the care and using cannabis? 

Dr. Paul Daeninck: Yeah, I definitely tell people to use it before they come in. So if nausea is the big problem, they're coming in for chemotherapy. I might say you can dose the night before, dose the morning of come in and get your chemotherapy and then maybe dose on the either on the way home or at home. Do not drive. Make sure that you're that you have a driver. We'd like to have a support person there for that individual that's become difficult in the whole covid-19 area with the lockdowns and the restrictions. So, you know, for instance, oils and capsules lend themselves very nicely to this. You could take a capsule or a little bit of oil on a cookie or something before bed in the morning, that sort of thing. And the link, the duration of action, maybe as long as eight hours. When patients are using it more for pain, then we're kind of looking at other options. Should we be using it on a regular basis? Should we only be using it at night? Because night time is the problem. So we'll work together with them to find a dosing and a time dosing and time schedule that'll work really well. 

Kirk: Boy, I'm sticking a lot on the cancer. I wanted to move into a little bit of end of life planning and palliative care. Can you explain to me how cannabis is being used in palliative care now? That's an open question. You can start anywhere you'd like.  

Dr. Paul Daeninck: I think it's I think it's best to look at there are patients that start using it during their chemotherapy, their cancer treatments, and then they just continue to use it through their end of life care stage, partly because they've had the benefit. There's no reason to pull that away or to swap it out with another medication because it has unique properties and unique benefits to them. We also know, though, that some patients feel, well, OK, my chemotherapy is finished. I don't need to worry about interacting with anything, you know, bring it on. Let me try this. I've heard all about it. My grandson gives me a joint. Oh, man. That really made me feel good. There was a lot of mellowness in there. What we find is that some people are using it for the distress of knowing that they have a shortened life, that life is finite, they know that there's going to be a certain day when things are going to change. They want to kind of minimize that uncertainty, that that whole feeling of angst as they're going through this. So, of course, in my mind, hey, this is much better than some of the medications that we have that we would ordinarily use that for. And although there's no evidence, there is a lot of patients who tell us through different studies or different observational studies that this is exactly what they're using it for. They find that their appetites improve their quality of life, their whole quality of life improves when they're using this medication as opposed to what was happening before, when we'd load them up with medications like opioids for pain and benzodiazepines or other medications. 

Kirk: So I guess why is there no evidence? I mean, I would imagine people have been using palliative care, cannabis in palliative care for a long time. Why don't we have evidence by now? And are you involved with gathering some evidence now?  

Dr. Paul Daeninck: Yes. And, you know Kirk, there actually is evidence out there. It's just you have to look at the right places. And I think that part of the whole trouble also was one of the biggest nations that does research in palliative medicine is the United States. They have not have access in a widespread way to this medication trying to get approvals from the FDA and other sort of groups to move forward with this; It's very difficult. In fact, they didn't get getting these sort of approvals has been downright impossible for many organizations. So what we've what has happened is a lot of observational studies, what's actually been happening on the ground, what's happening in palliative care clinics, what's happening in hospices, how do how do palliative care health professionals feel about all of this? But I would say in the last two to three years, we've been seeing more research. There was a recent study by a group led by a fellow named Good. Out of the United States, northwestern United States. They looked at patients who were using or who were wanting to use this product. They had a THC and CBD available to them. They asked them to find a dose that worked for them. So there was a dose titration part of the study. And they instead of looking at just one symptom, let's focus on pain. They said here's a whole bunch of symptoms that could be the trouble. Tell us what you think about this. So they started to look at kind of an overall picture, a holistic picture of what's going on with these patients. They were looking at a global impression of change and they found that out of these patients. It's forty four percent said that they had benefit in a number of areas. They were using what's called the Edmonton's symptom assessment scale. Then they were the showed that there was benefit there. And almost half of them said that there was an improvement in their global impression of change. There was significant improvement in anxiety and depression factors or depression measurements. And we were able to get a better idea of the dosing for this. So patients were using up to about five to 10 milligrams of THC. They were using much more CBD than I think that we were used to. The range was, if I remember correctly, 10 or 15 to three hundred milligrams a day of CBD. And these were patients who were finding the dose that worked for them, the tolerance as well as the benefits. So looking at that study, it gives us a better sense that, yes, cancer sorry, palliative care patients may be frail, but they certainly can be studied. This product is safe in these patients and we have to be able to be open with the patients and let them sort of do a little bit of titration themselves. So, you know, there is that that study, I think, is a key study and palliative medicine, it's going to really define where we should go afterwards.

Kirk: OK, so where did you get your training from? I mean, obviously you are obviously obviously you are a physician or oncologist. You went through the you went through that specialized training. How did you learn about pot? How did you become the pot doctor? 

Dr. Paul Daeninck: Oh, man. You know, a lot of it was learning on the fly. Some of it was learning from the patients. You know, when you have patients that are experienced in the use of, let's say, recreational cannabis, I sit them down and I want to know, what have they used? How do they. Use that sort of thing, and I will say having a community of physicians, the CCIC, that consortium of of cannabis producers or cannabis researchers and clinicians has been really, really helpful because when something comes up, oh, I've got a patient with this sort of pain, what should I do? Oh, well, this is what I've done. Oh, you should have a look at this study or take a look at this information. At the time that we started, we had a lot of preclinical information we had. Hey, you use it in this in this animal model and you get benefit in terms of pain.  In this animal model, you get benefit in terms of nausea. So then you say, OK, if it works on those animals, let's see what happens in humans based on these small studies that we have available to us. And then you kind of learn from I don't want to say learn from mistakes, but you have little trials, what we call end of one trials. Hey, something worked really well in that patient. Let's let's extrapolate that to patient B. Hey, that worked really well in this patient. Let's do it to patient C. See that sort of thing. 

Kirk: So you're learning. You're learning as you go. Now, you're obviously keeping notes inside the patient charts, but you keep your own global notes. Do you have your own binder of of cheat sheets? Like, how do you how do you how do you document your own learning? 

Dr. Paul Daeninck: Partly through that. Partly through the that. But also partly I would say every time I do a presentation, I go back to the literature, I go back to what I'm I know the sources that are really good for me and then I'm able to bring that and share that with other other people there, the health care professionals. But it also informs my practice. You know, when the licensed producers started to bring out these capsules, I didn't have a whole lot of experience with it because that was new to me was so I would say to patients, have you tried this capsule? If you haven't, could you would you be open to trying this? We'd start with a small dose and then increase over time. So those sorts of things would happen. And also, as we've had more people more experienced with this, you start to have, I'm going to say, physician support groups where you can go to a conference or you can go to a webinar and talk to people about what was your experience with this? Oh, that sounds like a really cool idea. Why don't I try to bring that in for some of my patients as well? 

Kirk: Did you ever have any problems with the college? 

Dr. Paul Daeninck: To be honest, no. I personally have not had any problems with college, although I will say I was asked to sit on a committee of the college to look at medical cannabis, and we were doing some really interesting work that was there. But because of my work with some of the industry, like I have, I do some teaching and it is industry sponsored events. I they asked me, maybe it's not the best. The perception isn't very good there. Why don't you step down? And I was happy to do that because I think that that's important, even though I told them right at the beginning, I had many conflicts of interest. You know, I don't think that people kind of read past the first line or something. 

Kirk: Right. Well, there's not a lot of docs are doing this even even today. I talked to some family docs about are they are they interested in cannabis? And when Doc said, I don't want to be the pot doc and I said and I said, wouldn't it be interesting if pot turned out to be the true miracle drug? Everyone everyone that uses it says it is. And in ten years from now, wouldn't you wish you were the pot doc? And he laughed at me and said, no, not today. 

Dr. Paul Daeninck: Not that. That's a really interesting comment, Kirk. Initially, I didn't either. You know, when I was initially told of the development of the CCC and partly because of my work in palliative medicine and in oncology, I said, well, don't know. I my my colleague here will take that on. He he had some interest in it and we kind of encouraged him to get involved. Within a year, he moved to a different province, you know, to practice, and it fell upon me again. And so I was kind of like, all right. But I must admit that that was a bit of a career changing move for me. I was I've been very interested in this area ever since. I've been amazed at the changes that have happened. If you asked me twenty years ago that we'd be in a time where there was legalized cannabis products in Canada, I would have said go drown. 

Kirk: Yeah, yeah. Well, if you said to me twenty years ago that I'd be hosting a podcast on cannabis would be like not as a nurse, I'd lose my license. But what's. Happening in the future, what's what do you think's going to happen with cannabis in cancer care, palliative care in the future? Where are we going? 

Dr. Paul Daeninck: OK, really good question. And I just recently reviewed that we had the cannabinoids in clinical practice study or conference about a week ago, and it was an excellent conference. My God, we had people from all over the world giving us information and such on both the basics, as well as the applied science around cannabis. So where are we going with cannabis and cancer? Number one, I think there's been enough evidence to tell us that cannabis does not cause cancer. That has been a story or a myth that many of us... 

Kirk: Good to know. 

Dr. Paul Daeninck: You know, that's something that's been around for a while. People were worried that people smoking all of this, you're going to damage your lungs. Yes. But the the damage is different than cancer itself. So if tobacco if you're a pure tobacco smoker, you have a high risk of lung cancer. If you're a pure cannabis smoker, the there's actually maybe a protective effect against lung cancer. You may get kind of a COPD type situation, but you certainly don't get an increase in cancer itself or the onset of cancer. There's still some question about does cannabis cause germ cell tumors in young men? There's still a kind of teasing that out with epidemiologic studies. But it's pretty clear that cannabis is not the cause of things like breast cancer, lung cancer, head and neck cancers. So looking at that information, first of all, kind of makes me feel more comfortable suggesting to patients that we can continue. Secondly, I think that we have to start looking at does cannabis have a role in the treatment of cancer? We know that it works very well for some of these problematic symptoms associated with cancer, whether we're talking about chemotherapy or other things. But there's a whole whole literature out there going back to I believe it was nineteen seventy-five, that they applied a little bit of THC to lung cancer in a in an animal. And you had a reduction in the size of the tumor, you had a reduction in the malignancy, you know, the aggressiveness of the tumor. And over that period of time there's been a lot more information regarding the use of cannabis and cannabinoids for cancer products in the preclinical the cell culture, the animal models. Most recently, which I think is a huge step forward. They're now looking at how do we administer this? How do we administer this with chemotherapy? There was a couple of papers that were published in the last couple of months where they were they had infused what's called nanoparticles or micro particles with cannabis products. They use this in ovarian cancer. And the other one was head/neck cancer, I think it was a head and neck cancer that they were using it in. And they were able to show that there was a significant reduction in the viability of cells. They showed a decrease in the size of the tumors when they infused this and it actually was CBD plus the chemotherapy. So there wasn't it wasn't a THC product that they were looking at. They were looking at just at a CBD product. So, again, that kind of gives us a little bit of a roadmap on where to start looking at this. And we also don't know much about the dosing. Do we come in and say to everybody, we want you to be dosed during the chemotherapy? Is it after the chemotherapy? Is it for the two weeks while you're on chemotherapy? And some of that is still still still not clear? I think it's pretty clear when it comes to symptoms. But in terms of treatment, we still don't have the enough evidence to tell us one way or the other. One other study I would just want to mention is that there was a study out of England looking at patients who had glioblastoma. This is a terrible malignancy that people usually die within one year of diagnosis. This despite surgery, radiation, chemotherapy. This group used a product that actually I think was a Nabixomal that they added into the treatment for these patients and they were able to see it to show that they could live longer, like at one year. Eighty five percent were still alive when they were using the cannabis and the chemotherapy. People who are using placebo, there is less than 50 percent who are alive. So a small study, only around twenty one people involved, but a very clear benefit for these patients who were using this product. And I think, again, it sends us on a good direction on what to do with or where to start looking at the studies where these patients are 

Kirk: very interesting, actually very exciting. What do you know about CBN as a cannabinoid? 

Dr. Paul Daeninck: CBN is a new one? It is out there like CBG or THCa, CBDa. There's a number of products that are starting to catch the attention of researchers. We don't have a lot of clinical trials, human trials on this, partly because these are harder to isolate and they've always been just part of the cannabis plant. So when you get a cannabis extract or when you're smoking the flower, there is a whole bunch of cannabinoids in there when when you don't know all the measurements or all the concentrations of the products that are in there. So CBN or any of those others are products that have started to be used in the preclinical era. And we're going to I think we're going to start seeing them come up as as products for clinical trials. Kirk, the question comes, do we use it as a single agent or do we use it in combination, 

Kirk: the entourage effect.

Dr. Paul Daeninck: Exactly, exactly. And, you know, it's interesting. We've always, you know, in terms of the cannabis world and let's talk about pharmaceutical companies. They're always looking for the silver bullet. They're looking for the one product that's going to work for that that patient. And yet the benefits that we are seeing come from people using either whole extracts or cannabis flower. So there's got to be more than just the THC or the CBD or even the combination of that. What about the terpene? What about the flavonoids? What about these other cannabinoids that are in there? I think that you need to have an open mind. And again, I would have said five years ago, no, 10 years ago, we're just interested in THC and CBD. But now with all this other information that's coming up, some of the really interesting work that's coming up around terpene. Hey, yeah, I think that the the way forward is to use all of the products together to get the best benefits for our patients. 

Kirk: The reason why I specifically mentioned CBN is it does seem new. But what I've been reading and also, I guess just my own experiences is that it's supposed to be the one that makes you sleepy, right? Oh, yes. It's the older THC converts to CBN as the flower ages. So I'm thinking for palliative care patients, CBN might actually be the one to help them sleep through their distress. So that's why I was wondering if that would be something you knew about. 

Dr. Paul Daeninck: Absolutely. I'd be very interested in looking at that and as part of a study. Here's an interesting factoid. Yesterday we had a meeting of the Canadian Cancer Trials Group, and I'm part of what's called the symptom control subgroup. One of the discussions we had was, hey, let's get a team together, get a project together, design a project, get it funded and get get going on a national basis. We're looking at four national studies for our patients having cancer and those with advanced cancer and palliative palliative care. So I you know, there's there's lots of good intention. There's lots of people who are very interested in working with this. One of the barriers in Canada, ironically, is Health Canada. We're saying we want to do this. Yeah, we want to do this study. And they say, oh, wait a second, we need to fill in this form. We need to get you this license. We need to do this. Oh, it's a multi-center trial. Well, each center needs to get this done. And it has been awful in trying to get a study going because of all the barriers that are being put up to by Health Canada to the point where Canada is actually starting to fall behind in terms of its research agenda in cannabis products. 

Kirk: We've heard Dr. Linda Balneaves was talking. Yeah, she was telling us about that. And it's interesting that we're legal, recreational. And that seems to be where a lot of the research is going on the recreational side and not necessarily on the medicinal side. Are you are you involved, like you said? Have you lead any of your own research or you participate? You're participating in this one research project in the last ten years have been participating in research? 

Dr. Paul Daeninck: Yeah, we've we've certainly taken a look at our own information, like our own patient data. We've done some retrospective analysis of the information from our Pain and Symptom Clinic we presented at at national conventions. One of them we presented at the European Association of Palliative Care, we were looking at patients who were using it for what we call chemotherapy induced peripheral neuropathy or bad neuropathic pain after chemotherapies. And we saw that the majority of patients who were using some form of cannabis product had benefit, had a reduction in their pain, had an increase in their quality of life. Another study that we looked at, we chose we picked twenty five cases at random and we were able to show that there was a quite significant decrease in the amount of pain medication they were using. They reduced by about on average, 70 milligrams of morphine equivalent per day by use 

Kirk: seven zero 

Dr. Paul Daeninck: seven zero. 

Kirk: Now, that's something that's very big. Like how much how much does the average palliative patient use a day on morphine? 

Dr. Paul Daeninck: It can be very it can vary. But yeah, we have patients that are using literally hundreds of milligrams of morphine equivalent per day. Think of a fentanyl patch, even the twenty-five micrograms, that's one hundred two hundred and fifty milligrams of morphine per day. 

Kirk: Right. OK, right. All right. 

Dr. Paul Daeninck: And our patients are on like three hundred four hundred micrograms fentanyl per day. So, you know, and, you know, patients really want this. They want us to do the studies. They come in and they say, hey, is there a study that I can get in on this? We are very close to opening one at our cancer care in Manitoba for patients who have symptoms. We're looking at pain, nausea, anxiety, sleep. And we've got a cannabis extract or a series of cannabis extracts that we're going to test with these patients. This is a multicenter trial across Canada. It's led by Dr. Philippa Hawley out of the BC Cancer Agency. And this has been this has been a bit of an exercise in frustration for Philippa trying to get this approved across Canada. She has a supplier of products. She has the funds to do this. But we've waited over a year for Health Canada to give us the OK to move forward. 

Kirk: Yeah, nothing. Nothing, nothing moves quickly in a bureaucracy. Right. I've occupied a lot of your time. I'm sure. I sure Thank you for this. Any final words, sir? Any question. I didn't explore that you'd like to discuss. 

Dr. Paul Daeninck: I think I think many people out there have a much more open view of cannabis than 10, 20 years ago. I see that certain generations have a much better knowledge base. I would say the millennials and younger have a better knowledge base about this, partly because of what's available on the Internet, the freedom of knowing that they aren't going to be persecuted for using cannabis in a recreational fashion. And I find that people that are older, let's say about 65, 70 years of age and older, they are embracing it as well, maybe partly because of their experience in the nineteen sixties when they were younger people. But also they see that, hey, you know, I've got these various chronic conditions, I, I don't really care what it does. I just want it to improve because the medications I'm using right now aren't making a big difference. And then there's a population I, I would put myself in that population kind of between the baby boomers and the millennials. There is a population that grew up during the Reagan years, the just say no years. And those are people that have difficulty. They have real difficulty coming to us and saying, you know, my son, my grandson has given me a bag of pot. What do I do with this? I'm I'm just so scared. I'm afraid I'm going to get high. I'm afraid I'm going to cause problems. You know, there's still this whole thing, the stigma of using this. And I think that's that's an area that we need to look at. How do we educate people as to the safe use of this? How do we allow people to use it without that stigma? And also, I think education around why do we use it? It's not that we're saying to people, I want you to use it to get high so you forget your cancer or your pain, but rather, I want to get your pain under control so you can function better. You know, you're dysfunctional because of the pain. Let's get you to be functional with the medication 

Kirk: and cannabis allows. That's that's astounding. 

Dr. Paul Daeninck: Absolutely. Absolutely. 

Kirk: As I was just going to say, one education just pitch our podcast at your patient that'll help them. Yeah. The other thing, you know, I just actually it's interesting. I did have a question I wanted to ask you, and it just popped up on my news feed as I was listening to you speak. Psychedelics in palliative care? Now, I mean, we're reefer medness, but where is where's palliative care going with micro dosing psychedelics such as magic mushrooms and others? Are you into that game yet or is that the next the next experience? 

Dr. Paul Daeninck: That's the next frontier. If I can say that, Kirk, I will say probably about five years ago we started talking about it at an international conference of palliative medicine that I was at. Very interesting, really interesting data. I mean, it was very small. We were talking about case reports, very highly supervised, organized case reports. But the more that we see, I see that there is benefit, especially more for the the distress, the anxiety, the depression associated with going through a chronic disease and getting to that stage end of life stage. I haven't seen a lot of information around things like pain or nausea, but certainly in terms of a global benefit for patients, it really can make a huge difference, like a 180 difference to those patients who have undergone it. You know, we've had we've had such a challenge getting people to accept cannabis. You can imagine when we say, yeah, we're starting to use LSD. 

Kirk: Yeah, yeah. We're going back to the psychedelic trips. It's interesting how medicine just goes in circles sometimes. Yes. Yeah. Music we give all of our guests an opportunity to ask for some music at the end of their segment. What would you like us to play? 

Dr. Paul Daeninck: Oh, man, I love Steppenwolf. 

Kirk: okay a little motorbike riding music. 

Dr. Paul Daeninck: Yeah. Or magic carpet ride. I like magic carpet. Right. 

Kirk: You know what I think, Rene, when like playing that one. All right Sir, thank you again. 

Dr. Paul Daeninck: All right. 

Kirk: So what do you think about that first thing that he said about the future, what we do know about cannabis and that we know that cannabis does not cause cancer. Right. And didn't and didn't Peter Tosh say that and Legalize it? You know, like, 

Trevor: I'll I'll defer to your knowledge of the Peter Tosh lyrics. 

Kirk: Yes. Yes. You know, but so. Yes. So I thought that was quite fascinating. I think the whole interview is worth going to that point. So all those chronic cannabis smokers, you might get COPD in the future, and he did say might, but I like the fact that he said that it might actually have some preventative cancer components, which is also fascinating. Anyways, I'm going to let you talk because obviously they've been listening to me talk. Go ahead. What did you think? Yeah, no, 

Trevor: no, I. I have heard him speak before. Years ago. He's sort of an opioid slash palliative care guru. And you one of the docs that I work with in Dauphin with, I would say cannabis patients, but a lot of patients go go to her because they have cancer and they are interested in cannabis. And then she sort of says, Trevor, do the paperwork for me and will you talk to them a little bit about it? So what are the docs that I sort of talk cannabis with? She's a big fan of of Dr. Daeninck because, you know, cancer, palliative care, cannabis, that's all his thing. So, yeah, I back to the why did we not interview him? I've definitely heard his name for 20 years now. He's he's one of the one of one of the gurus in the province. And, you know, you just heard why. 

Kirk: Yeah, I enjoyed that conversation. I also I hope you don't mind how I sort of discussed that, you know, and, you know, five years from now, you and I might actually be discussing psychedelics, not just cannabis, cannabis for reefermedness might, you know, it might cover all the stories in five years and we'll be moving on to psychedelics. 

Trevor: But, yeah, they are true to your acid tabs. Yeah. Any day. 

Kirk: Yeah. Yeah. No, I just thought that was a very fascinating interview and I really didn't want it to end. Like I said, I was I think five, ten minutes before the ending I was ending the conversation and my news feed. 

Trevor: Just just one more question Columboed him. “Just just one more thing.” 

Kirk: Yeah, yeah, yeah. One more question. But it was it was literally my my news feed came up on the computer and of course I should ask him that question and it just happened to come up. So somebody was watching out for me. This is already pushed into a long episode. Is there any any nuggets you want to pull out? 

Trevor: One. And it might sound and I'm not trying to be a downer, but he made it early. And I think it's worth mentioning cannabis isn't everything. It's not a panacea. It's not magic. You know, he talked about people who wanted to go just cannabis and ignore their chemotherapy, and they, frankly, didn't live as long. Now that's their choice. You know, patients should have autonomy in that kind of thing. But cannabis does lots of wonderful things. But, you know, it's not everything. It's it's just don't don't ignore everything else with it. You know, it's not it's not everything. It does lots of wonderful things. But think of it more as an add on. I thought I thought he stressed that nicely. And unfortunately, because he's been practicing long enough, he's seen what happens when people decide to go the just cannabis and ignoring like you said, there's one patient he was thinking of that had an eminently curable colon cancer and decided that didn't want to go that way. And frankly, life ended sooner than it should have. 

Kirk: Well, and I also found him very approachable. You know, I've shared often the story of my my friend in Alberta who hid hid his use of cannabis back in the 90s. He hid his use of cannabis. And we also heard the other story from Kieley about how they had to hide the cannabis use they were bringing in for one of her relatives. So I just found it very, very approachable. And again, it just reinforces that people should be ensuring that the health care professionals are involved with all aspects of the care. So if you're using cannabis, please declare it and hopefully your oncologist is for it. And I can't see I mean, how many times have we heard the doctor say, you know, there is research out there, you just have to know where to look for it. Right. 

Trevor: And more importantly, I think how many doctors and nurses and that we've talked to who started with frick, I didn't know anything about cannabis or I might even have been against it. But, you know, I had this patient who is so passionate about it that wasn't going to say no. And then they learn a little bit more. And so I know I was putting a lot of onus on you, the patient. But how I think of it this way, if you tell your doctor about it, you might be helping the guy or girl behind you in line the next time that that someone brings up cannabis to go to the doctor and the next time. So, you know, if you push your doctor or nurse practitioner, health care professional a little bit down that way, it might be a little easier for the for the next guy or girl down the line. 

Kirk: I just love the fact that he's got what I try to add it up. Twenty-three year experience using cannabis. Yeah, he was using it before. Before. And so I I like talking to this gentleman and I and I truly hope that we find another excuse to bother him. So sorry, 

Trevor: Dr. Daeninck, you're you're on our list, 

Kirk: so. Yeah, I don't have much more to say. It's already a long episode. And and I love this choice of music. I must admit, when he asked for Steppenwolf Magic, you 

Trevor: didn't you didn't picture him being Steppenwolf Guy 

Kirk: and Magic Carpet Ride. I mean, what would the Pot Doc pick? You know, he picked Magic.  So we're going to let Rene pick that one. And remember, people, this is Reefer Medness - The Podcast. Please check out our Web page. Our Web page will have, his papers are going to be there. We're going to have them linked as PDF files. He sent them to me, so I'll link them up with PDF files to the research will be there. The transcript will be up there. Check out our Web page and please give us a review on the podcast platform you using and maybe give us a heads up that you did it and you can email us and say, hey, check out my review. I gave you Reefer MEdness - The Podcast. I'm Kirk, I'm the nurse 

Trevor: I'm Trevor Shewfelt I'm the pharmacist. It was another good one. 

Kirk: Oh, and if you want to, you know, help us out and sponsor us, we're always looking for somebody to help help us pay for this little project. Right now, it's a passion project for us and we could sure use some help so we can promote it and get it going a little further. So, yeah. Reefer Medness, thanks a lot. See you next time. 

Trevor: You bet.