This presentation from a variety of UCSF specialists covers a range of practical topics, from how clinicians can easily meet the new DEA educational requirement for opioid use disorder to the current evidence on mindfulness meditation's capacity to alleviate physical, psychosocial and even existential distress in cancer patients. Learn why buprenorphine is an exceptionally safe and effective tool for managing pain in patients with an addiction history or for those who don’t tolerate full agonists. And hear one expert's perspective on the value of cannabis – and he doesn’t mean CBD – for easing cancer symptoms as well as on the medicinal use of certain mushrooms.
All right. Uh Welcome everybody to our Cancer Center Live Series Integrative Approaches to symptom management for cancer patients. I think this will promise to be a really exciting seminar uh with uh excellent presentations covering a wide gamut of areas and time for Q and A. So point out to everybody who's on that. Uh the zoom function has a Q and A button that you can see in your toolbar and you can put questions into Q and A uh type those questions in. It's better to use the Q and A button rather than the chat function if you can and then we'll try and answer as many questions as you put in live as we go forward. And the other ones will uh answer with text. Uh but definitely take this opportunity to put in questions. You don't have to wait till the end of each talk to put in questions, put them in whenever you're thinking about them. Uh That's the whole purpose of this is to have good communication backwards and forwards. I'm hope Roo, a breast cancer oncologist at U CS F. Um And I help to uh coordinate uh and uh organize the Cancer Center Live Series uh under the direction of Laura Corsitto. So who's our Chief Medical Officer of Cancer Services and with the tremendous help of Joy sen who organizes this and actually will give us the information about the link for the recorded session. This session is recorded, there will be a link afterwards that you can share. Um And Joy will put into the chat box, the uh website where you can find the recorded session in uh with a link. Uh So that's also really helpful if you happen to have signed up for CME credit. Uh That of course also occurs. Uh We have a fabulous panel uh today uh including Mike Grabau and you'll see everybody as we go forward. Um He's the Helen Diller Family Chair in Palliative Care and Professor of Medicine and Neurology as well as in the division of Palliative Medicine. Uh Janet Ho, who's the medical site director of inpatient palliative care Consult service uh at U CS F inpatient services. And also she works at San Francisco General Zuckerberg, SFGH uh in addiction uh consulting and is in the division of Palliative medicine as well. Donald Abrams, I think, well known to everybody here um who works in Integrative Oncology at the Osher Center for Integrative Health and is Professor Emeritus of Medicine. And then Kavita Mishra, who's a professor and Director of Clinical Programs at the Osher Center for Integrative Health and is also director interestingly in a separate area of proton ocular radiation oncology. Uh but has the Osher Foundation and Dow chair and clinical programs and integrative health. So we have really a fabulous panel today and uh I'm looking forward to having them come back again at another time because I think that there's just so much information here. It's really exciting. So Mike Reba is gonna start and tell us a little bit about the medication, a Access and training Expansion Act in terms of what you need to know and do, which is really important. And when, so this is really critical information, Janet will tell us about buprenorphine in cancer pain management. Very interesting area. Don Abrams is gonna talk about marijuana and mushrooms and cancer care and Kavita about mind body medicine and integrated cancer care. Keep in mind to put up your questions as we go along. I and don't wait till the end of each session because we'll try and answer questions with each session as opposed to at the end. And as Don pointed out to us, I mean, each of these talks could take up an hour or more. So keep in mind that really you're getting a top level overview of these topics and we'd love to hear from you if there are topics that you'd like to hear from more. Uh we can devote more time to specific topics over the course of our year with the Cancer Center live series. Um The just to keep in mind the cancer services referral center at U CS F with the telephone there and this uh and the hours listed here, uh this actually is a really helpful way of getting additional information for your patients and referring your patients for consultations. Uh You complete a referral form and fax it in and receive a fax within 24 hours confirming this. You can actually go into MD link as well. You don't have to call in during the days. So that's very helpful. Um And uh this can be for specialty services or any other topic that you need. Uh So it's a really, really helpful service. So our upcoming services, we have a collaboration with John Muir Health uh in education. And our big collaboration of the year is best of the year in 2023. That will be an evening web uh series on November, an evening web conference on November 15th. It's really great and it will include best of the year in the major solid tumor and hematologic malignancy areas with a speaker from both U CS F and John Muir. So this is a great program. Our second year of this uh be sure to tune in. And then we'll have two more uh cancer center live sessions in February and April of next year. And then CME if you signed up for it, there's a survey link in the chat feature now already posted copy and paste your link into a new window or scan the QR code below for a survey on your phone, you have to complete it by the end of day on October 11th. Receive CME credit. All right. So with that, I am going to uns share. Um and you can see our speakers on and I'm gonna turn the podium over to my doctor Rabo. Thank you very much. Let me see if I can get my uh powerpoint up and as he brings his powerpoint up, you can see that the video is uploaded after editing to med connection dot U CS F. Um It's in the chat now. Um U CS F health dot org. So it's pretty easy if you remember that, that uh connection um are my sides looking beautiful. Absolutely perfect. Perfect. Thank you. Thank you so much. Um Thank you all for joining. Uh I have probably the easiest job of uh all of us this evening in that I really just have to report to all of you and advise all of you about some legal requirements that we now have as physicians nationwide uh around the learning necessary for opioid and other substance use disorders. Uh The topic then is mate and I'm gonna describe what that is in a moment, uh what you need to do and by when so I have no uh disclosures. We're gonna look at three points uh in my uh time this evening, one is to recognize the clinical need for the mate requirement, sort of why we're doing this, understand what the requirement is and then learn how to meet the requirement. Um with the goal of trying to learn some useful information along the way. Even though this is a, a mandate, uh there's some good that can come of it for sure. So mate is the medication Access and Training Expansion Act and it's essentially a requirement for eight hours of education and opioid or other substance use disorders prompted by uh Sam sa the substance abuse uh mental health uh services administration's recommendation after a law was passed at the very end of 2022. So let's go into the details here. What's why are we being asked to do this? Why are we, we being asked to get eight hours of additional C and D uh credit uh for learning about opioid and other substance abuse disorders. So, uh it probably is not a shock to anyone that the setting of this is the opioid epidemic. A massive massive loss of life, uh loss of resources, loss of time, loss of family members, loss of loved ones uh that has gone on in our country for the last many years. Um And even though uh physicians are part of the problem that is prescribing physi physicians absolutely contribute to the opioid epidemic. Uh even while physician prescriptions are falling more recently, opioid use disorder deaths are increasing. So we are part of the problem. Not the only part of that we're gonna do our best by learning a little bit more about opioid use disorder. As you're gonna hear throughout the evening cancer care analgesia um has some particularities to it. It is not the same thing as acute pain, it is not the same thing as chronic pain. So, cancer pain may be a bit different partly because some of our patients with cancers uh metastatic cancer have uh much different prognoses than those with acute or chronic pain. Um And then also the reality that many of our patients with cancer also have coincident opioid use or substance use disorder. And we can quibble about the numbers, but it's somewhere in the 3 to 5% range that is across the country. All comers, um maybe around 5% of patients have opioid use disorder, substance use disorder. And of course, part of the challenge is that we prescribe a lot of opioids, a lot of pain medicines for our patients that then they might continue to take even after we've been able to control or cure their cancer. So there's ongoing opioid use among cancer survivors. And throughout I want all of us to pay attention to the terminology here that we often end up conflating opioid use, sort of the appropriate use of opioids to manage pain with opioid use disorder. These are important distinctions and one of the things that I think we can learn from more education around opioid use disorder. So here's the requirement, it was effective as of June 27th, 2023. So that's last June, um the D A is requiring all physicians in the United States to have a one time eight hour training uh in the treatment and management of patients with opioid or other substitute disorders. So, these are uh physicians who are uh registered with the DEA and able to write prescriptions for. So the requirement is that this requirement must be met either upon initial registration with the DEA or upon renewal. So for most of us, on this column expecting that most of us will have to comply with the requirement when our current DEA certificate expires and we are required to renew. There's actually three ways to meet the requirement. Uh For most of us, it'll likely be the third way that I'll get to. So pathway A is for those who are board certified in addiction medicine or addict in psychiatry. Um those folks are able to meet the requirement because they have um by virtue of their discipline training, they have the knowledge uh that's desired for all of us. Pathway B uh is for folks who have recently graduated from medical dental physician assistant or advanced practice nursing school within the last five years of that, June 27th, 2023 date with the idea that those folks who've gotten trained recently actually have had opioid use and substance use disorder training built into their uh education uh that may or may not be true in individual circumstances. But the idea is that recent grads have probably learned better about opioid use disorder than those of us who've been out of practice, out of uh training uh for a number of years. And finally, what applies to uh most of the rest of us is the pa the requirement can be satisfied by eight hours of additional training. And those eight hours can include training that you do specifically for the requirement currently or past trainings that you've participated in. And the training can be in a variety of different formats in the classroom. Uh Virtually, um some professional society meetings are starting to include trainings that count as part of the curricula of the meeting. So some of you may remember be aware that uh physicians in California are already required to complete 12 hours at one time, continuing medical education and pain management. Um and or in the treatment and management of uh folks who are terminally ill and dying. So it is absolutely the case that much of that training will qualify for this new m requirement. Also, if you've done X waiver training to be able to prescribe buprenorphine for uh substance abuse, uh that training typically uh counts as well. So again, you can count any training that you do moving forward, but also pass training uh that qualify uh for the requirement if your uh faculty at U CS F. Uh U CS F um has made um eight hours of training in the version of uh eight hours of videos from the fourth annual U CS F Addiction Medicine Conference offered this last year uh available for free to U CS F physicians to meet the requirements. If you're not a U CS F uh faculty, um you can go to the U CS FC and me site, see me California dot com and look up the course, the courses that meet ce uh for Nate. Uh I have the course number listed for you there. Um And it's not too much, more expensive than free, although it does cost $75 for those who aren't members of U CS S faculty. The U CS F has an easy and very, very um uh authoritative way to really learn this content. You can essentially recreate some of the um really successful uh U CS F Addiction Medicine conference from this year. Um And those eight hours would then count towards your mate and you would put that requirement. Otherwise there are lots of free courses. Uh The American Medical Association has more than 58 hours of free CME that can qualify to meet the mate requirement. Um The uh website highlighted in yellow is the one that will directly take you to that curricula. Um And you can see in the uh section titles, um A lot of these things would be helpful uh to many of us, the basics of opioid prescribing and management, you can get 47.5 of the eight hours required by just um learning about the basics of opioid requirements. And then there's much more detailed information about addiction treatment, management of addiction, special populations, et cetera. So that's the requirement. That's how you can meet the requirement. Uh And then how do you prove that you've been compliant with the requirement when you are um, registering uh for your DEA license or reregistering for your D A license? There will be moving forward a check mark, uh check box uh in uh the online um application where you'll be asked to sell the test that you've met the mate requirements. Um And this was somewhat ominous warning from the DEA you may be subject to random audits by the US Department of Justice and our DEA and we advise that you keep documentation of your training. And I think that that warning though, uh real um is probably not as uh uh serious as it might sound in the sense that really what you need is just proof of the CME coursework that you've done. If the CME coursework you've done was from long ago and you no longer have access to proof, you might consider retaking some of those hours. If it's been a long time, it might be beneficial to retake some of the hours because of new information that you might get. So my recommendation, final recommendations figure out when you need to comply. That is when your DEA license is expiring, determine how many hours you need if any. And if you are a physician in California, you may have already uh qualified for many of those eight hours and then choose free CME um or the inexpensive U CS FCME, that's of interest to you. This is a chance to learn more about opioids to learn more about addiction, which we're gonna be doing some of that during this uh evening. Uh But really, um see if we can get away from thinking just about how we have got this requirement. We have to meet, thinking about how this is really an opportunity to um think well and learn about modern management of paying for folks with opioid use disorder. Um how to screen for opioid use disorder and really how to do the best job we can caring for patients with cancer even in the context of the opioid epidemic. So I'm gonna uh stop there and thank everyone uh for your attention and, and your interest. Thanks so much, Mike. That was great. Um for anybody who's joined us after our introduction. Um Please put any questions you have in the Q and A box. And if you look in the chat box, you can see the link where the recording will be uh uploaded after editing and also the survey in case you requested CME credit. Now, Mike, I'll ask a question. Uh First um how do you document, how, what do you suggest people do for documentation? So probably the only documentation you need is a copy in some way, a PD FAA photo on your phone, something that you can share with the D A if you do get audited and questioned about whether or not you met the requirement, um official CME uh credits that you may receive um obviously would be uh useful as well. But um as far as I know, really, it's just saving some documentation of the coursework that you did, I don't imagine that there's going to be a ton of uh enforcement effort put into this, unfortunately. Um Partly because there's not funding for it. Right. So, uh no margin or mission. Uh I think that the DEA cares and I think it's an important requirement, but I think the D A probably won't have a lot of money to go after individuals. Uh So I think if we all act in good faith and do our best to keep documentation of our training, uh everyone should be fine. That's great. And um the training specifically, um is there a website that someone can go to, to better understand those? You just showed some very helpful information. Of course, you too, for sure. I, I think that the most helpful thing would be to go to the A MA website that I highlighted. Um that will take you directly to the A MA courses that they are certifying uh will count for the mate requirement. And obviously, um I am very supportive of U CS F um eight hours uh from the Addiction Medicine Conference this last year as well as another really wonderful site to learn. Uh and people can just go to the U CS F uh website to look for them. Absolutely. Actually, uh you can go to the, the U CS FCME website um and get all the information there. Also, since this is a national need, a national requirement, you'll find if you just Google Mate. Uh there's lots of information there for everybody to access uh really quite easily. And I would say, uh knowing that there are uh less than 1000 people on the, on the seminar. Now, if people have any particular questions, I'd be happy uh to be uh helpful if I can send me a quick email. Um and I'd be happy to address questions that come up after uh the Q and A closes. And one of the things that comes up a lot for our patients, for example, a patient I saw today has been on chronic long acting morphine and Percocet three times a day uh for many, many years and just got diagnosed with metastatic cancer for which she has no pain, but it was for chronic low back pain. I think probably the most common reason we see people on long term opioids. Um So for help with those kinds of patients, our symptom management program has been a really uh incredibly useful resource for us. Is that what you would suggest for people when they run into issues like this? Yeah, absolutely. I think that there's lots of expertise among folks with substance use disorder, uh addiction specialty. And I think palliative care as a general rule, really, really can be helpful and helping patients and uh their providers, their clinicians really be clear about what the goals of treatment are and what uh the various treatments that we're using are what the risks are. Um Thank God, we have so many miracles going on in cancer care that people are kind of graduating from cancer care. They're becoming survivors. They're um having a long term remissions or cures of the cancer, which means uh problems that they had going into the cancer are likely still existing. And then the problems that we create from the use of our medications and other treatments as well as toxicities and complications from our treatment um are really plaguing a lot of folks now. So I think the number of folks who have ongoing say peripheral opathy who lived with that for many, many years after cancer treatment that may require very aggressive pain management um are only increasing as we um are getting better and better at treating uh cancer. So I think that a collaborative care um including with palliative care um can be really important since there's a lot of people that um I think can weigh in on how to manage and balance. Um lots of things that are going on simultaneously. And I would say, you know, it's symptom management doesn't have to be for people who have metastatic cancer, you know, palliative care. These can be for survivors who have neuropathy, et cetera. But this was a really great uh talk that um our symptom management program or as well as palliative care all within the same umbrella are really tremendous resources and to talk about another area of pain management. Uh We're fortunate to have Janet Hogue here to talk about buprenorphine and cancer pain something I think most oncologists really aren't thinking too much about. Um So we're gonna take a look at buprenorphine specifically, um which is a large part of the mate requirement and um in particular its use on cancer related pain. I have no financial disclosures. I do have a land acknowledgment um for the remit a loni people um on whose land we work, learn and care for patients. So, objectives today are to do a rapid review of pharmacology um and summarize how that unique pharmacology can be really opportune to treat cancer related pain and then we'll touch on the broader context of how historical bias has really influenced and shaped our poor understanding, our poor use and familiarity with buprenorphine until now. So we're gonna jump right in and start with a case. So we have a 65 year old man with metastatic prostate cancer mets to the bone, uh who's on treatment and has a relative stability of disease. He has pain in the back and the pelvis, which is pretty common keeps him up at night, shoots down his leg when he's walking or sitting. So he's a lot less physically, um, active than he used to be. He's tried numerous medications that have been nonopioid up until now. And physical therapy, acupuncture as non pharmacologic treatments. Um and you have offered him traMADol 25 mg as needed, which he tried and which caused constipation and mental fogginess such that uh he's really not wanting to continue with that. So the question is what might you offer next? So basically, you have a 65 year old patient, metastatic disease that's pretty stable um with cancer related pain that is limiting its function. Um He happens to be opio naive and sensitive to side effects from the traMADol. Um And so would you continue the traMADol perhaps at a lower dose, try a little bit different, full opioid agonist. Um Would you stop the opioids and continue things as is um or would you try buprenorphine? And so maybe you're primed by my talk, but I would offer buprenorphine as the next step of an opioid based pain regimen that has a better safety and a better side effect profile for this patient. So let's take a look at how it actually does. That uh buprenorphine has three unique features uh that are important and unique compared to other opioids. So just as a brief orientation to this chart, on the X axis, you have the dose of the higher doses of opioids moving towards the right. And on the y axis, you have the new opioid uh receptor effect, which includes everything from uh sedation to respiratory depression, mental cloudiness, constipation, et cetera. And you see on the top, this green line are the full agonists that we're most familiar with. So, morphine, fentaNYL, methadone, heroin, et cetera. And basically the more of that opioid you give the greater the effect on the new opiate receptor. So the more morphine, the greater the risk of sedation, for instance, um in the middle on this blue line, you see buprenorphine. So, buprenorphine is a partial agonist um versus a full agns at the new opioid receptor. And what this means is that the more that you give buprenorphine, you'll get an increase in effect up until a certain point. And once you reach that threshold, buprenorphine hits um what we call a ceiling effect. And so this means that you could give higher doses of buprenorphine, but you're not going to get greater risk for things like respiratory depression, things like euphoria, things like sedation, et cetera. And at the same time, studies have shown that buprenorphine, it actually helps to recruit and make accessible more new opioid receptors when it's given. And so the analgesic effect um is that uh is actually that um equivalent to if not greater than oxyCODONE fentaNYL HYDROmorphone, et cetera. And this unique pharmacology of buprenorphine allows for analgesia um with a reduced side effect profile even at higher doses. Uh So, the second uh important feature of buprenorphine is that it has a high affinity for this receptor. So that means that if you put it into the same environment with a full Agnes like morphine, it's going to outcompete the morphine or it'll block it or it'll kick it off the uh new opioid receptor. Um And when you couple this with the third uh feature, which is the fluid dissociation, you have the potential for precipitated withdrawal. So if you introduce buprenorphine into a system that has full agonist present already. So for instance, a patient that's taking morphine and then you introduce buprenorphine, that patient is going to go from this green level of opioid effect down to the blue level. And this delta or this shift is going to feel like precipitated, withdraw. Um And this has really limited the application of buprenorphine and the use of cancer pain. Um For example, nobody could um really imagine asking a patient with cancer pain to stop taking oxyCODONE for instance, so that they enter natural withdrawal and then have buprenorphine introduced to um relieve or rescue them from that withdrawal. But that's all in the past, in the last decade or so. There has been myriad um reports in the literature of um new ways to rotate people onto buprenorphine that has essentially negated any risk of precipitated role and has negated the requirement that somebody stops their full agonous opioid and enter withdrawal in order to switch to buprenorphine. Um And so this has really revolutionized and made available this unique opioid for the treatment of people who need to con uh who need to be maintained on um opioid uh based cancer pain management. So, in addition to that unique profile, there's more. Um so bu buprenorphine is a mu opioid partial agonist, which is um how it provides opioid related analgesia. It's also a cap kappa opioid receptor antagonist. And what this helps with is it helps reduce cravings for opioids. Um which is how it is um very powerful for the treatment of addiction. It also helps to reduce comorbid dysphoria, depression, anxiety or hyper civia related to exposure to opioids, especially over the long term. And this helps to block central sensitization um or reduce risk for hyperalgesia. Buprenorphine also is an orl one agos which helps um again with analgesia and may reduce the reward of an opioid. Um Of note, it's analgesic half life is 4 to 8 hours. Um Even though it has a very long pharmacologic half life. So split dosing is the way to take advantage of this analgesic window just like with methadone, it is highly lipophilic, absorbed, um and not well absorbed um through oral methods. And so this has actually opened up uh a whole range of formulations that can be helpful for uh treating pain. You'll see in this lower left corner, there's a buprenorphine patch. So it's a transdermal patch like a fentaNYL patch. Uh This is actually a great way for clinicians to become familiar with buprenorphine. It's pretty low risk to use the patch. It's kind of like the gateway to buprenorphine. And in order to get you more comfortable with the use, um it also is um has a lot of buckle bioavailability. So there's a Buckle formulation, it's called BCA. Um and then there are the sublingual tabs and films um that you might know of as the box own or Subutex. And the difference is that the transdermal and Buckle formulations are approved for chronic pain. So they come in micrograms. Um The sublingual versions are approved in the treatment of oud and they come in milligrams. Basically what I think of this is as is a continuum. So you have very low dose of buprenorphine and then if you needed to because of greater pain, you could increase. Um and eventually somebody could be treated with pain through the higher sublingual versions. Um Lastly, there's no need to dose adjust for renal failure which um is always nice um to not have to consider that. So um a second case, we have a 60 year old man with esophageal cancer status of surgery and chemo radiation. Now with no evidence of disease. Um but lasting chronic cancer, pain related to treatment. He's been on long acting oxyCODONE 30 mg three times a day and short acting oxyCODONE 20 mg every three hours as needed, which he says he's using about 5 to 6 times a day. What you've noticed is that he's actually asked for early refills of the oxyCODONE three times in the last four months. Uh So at this point, what would you do with his medication management? So, basically, here you have a patient who's completed cancer treatment. Um and has no evidence of disease. He has a great prognosis. Um He does have ongoing chronic cancer pain and you have some concern for the overuse or the misuse of opioids. You might even be wondering if he has developed an addiction. Um in addition to the chronic pain. Uh So what might you offer in addition to increased monitoring and shorter um kind of prescription pills? You continue the patient's oxyCODONE taper them off the opioids entirely. Would you transition to methadone um or transition them to buprenorphine. So again, um I'd say that uh my recommendation is to consider a transition to buprenorphine. Um And part of this is that we know that once someone is on opioid, there's a momentum to continue with opioids. Um And so studies have shown that, you know, somebody is given one opioid prescription, um 20% will remain on opioids for a year later. And somebody's given a three month opioid prescription, uh 60% will continue to remain on opioids for two years after that at least. And this is no different from uh the pattern that we see with pan, with patients with cancer. Um of whom, you know, 80% or so are exposed appropriately appropriately to opioids for the treatment of cancer or cancer. Um treatment related pain. Uh So, at the same time, there's a lot of discussion and controversy about what to do with long term opioid therapy, especially with emerging evidence um of harms from long term opioid therapy. So, evidence shows that higher doses carry greater harms in terms of hyperalgesia, dysphoria, addiction, risk of accidental overdose immune suppression, endocrine dysfunction, et cetera. Um And that the risk of harm is actually 2 to 5 times greater, there are 2 to 5 times increased odds of harm for someone on 50 to 100 ome compared to someone on fewer than 20 up to 11 times greater risk of harm. Um for someone on over 100 ome compared to fewer than 20 ome. At the same time, there's limited evidence to show that being on long term opioid therapy actually improves function or quality of life. Um And so, you know, there's no real evidence to support um ongoing chronic uh especially high dose opioids at the same time there's building evidence that forced tapering just to get somebody off, to get someone off, um can also result in harm um and risk of suicide. So, um what can we do with patients? Um kind of in this situation again. Um buprenorphine has been studied for the use of chronic pain and it can be a tool that we use to then reduce the harm of exposure to full agonist. Over the long term, we can use buprenorphine as a safer tool to taper off a full opioid fulls opioid. We can also use buprenorphine and the treatment of comorbid pain and opioid use disorder or comorbid pain and complex persistent dependence, which is somebody where in the act of tapering down opioids, you might notice that this actually reveals more dysfunction um in that patient. So some patients um have developed a complex dependence wherein if you reduce the opioids are actually less functional, they have worse mood, they have worse sleep, et cetera and they actually rely on opioids to maintain some level of function. Buprenorphine can be used in the setting to maintain some opioid um therapy. Um With again, the lower risk of harm compared to fullin therapy. And from the chronic pain literature, we've seen that rotation with buprenorphine can reduce pain intensity, it can improve sleep mental health. There were no reports of uh overdoses and these findings have been found um in older adults as well. So the last case is a 50 year old woman with pancreatic cancer, um who is on chemotherapy and has abdominal pain on treatment. She also has a history of sustained recovery from opioid use disorder with uh fentaNYL and heroin as well as methamphetamine for the last 10 years. And it's important for her to protect her recovery. She has maximized non opioid management of her pain until the last month when things became excruciating. Um and the pain is constant and she's asking you what else you can offer. So, here we have a patient who has, um on who has active cancer, um who is in recovery from opioid use disorder with worsening cancer pain and is worried about opioid use. Um What might be a low risk opioid to start with? Again, the answer would be buprenorphine. Um So oftentimes in these situations, you know, I'll get a as pain or addiction and um when patients have both uh a history of addiction and cancer related pain and they're in physical distress, we try to parse out if it's cancer related pain for which we want to treat with opioids or if it's addiction, which we're taught not to. And the answer is yes, kind of like this guy with the arrows. It's both burning and sharp pain. It can be both. Um, one just might be more predominant than the other at different points in time. Buprenorphine is the gold standard office based treatment for opioid Use disorder. And it's a potent analgesic. And so you can use that one tool to treat both. Um Again, as Mike said that we know we know that having cancer and cancer pain are not protective against developing addiction with the use of opioids. Um And so, for studies amongst patients in oncology uh settings, you know, 3 to 8% have comorbid opioid use disorder. 20 to 40% um have been found to have some concerning opioid use. Um and 30 to 50% have found to have unexpected urine tox screens. Um And we know that cancer survivors have increased risk of adverse events due to opioids including accidental overdose just as a non cancer patient populations. Um So kind of enclosing the two buckets that I think about where buprenorphine might be a first line uh tool is um it's a schedule three opioid. Um It has a better side effect than traMADol uh side effect profile than traMADol. I would use it as a harm reduction tool. So always in someone with opioid use disorder, think about it and cancer survivors with chronic cancer pain. Um anyone who has risky substance use, um buprenorphine, I would also think about in terms of this better side effect profile for anyone who's very sensitive to constipation to respiratory concerns. Um Anyone with cognitive frailty, I like to use it in patients as first line if they're still working um and need to maintain alertness. Um And lastly, I just want to put you into the context of health care. Um and why we're so unfamiliar with it. So, you know, the US has a painful history as it relates to race and racism. Um And this is salient to opioids and addiction because of the war on drugs. Um and socialized drug policy that came from that. So for any clinician that manages pain and that manages opioids, it is an important part of practice. Um And, and uh providing equitable care to be familiar with buprenorphine and be able to offer it um appropriately. So I will one last thing is um we have a lot of questions. So OK, I just wanna keep this up with resources. The highlighted, the red ones are um resources that also uh would fulfill the mate requirement. So you can go to those sites. Um And it's really good to know that you can fulfill the mate requirement also with this, which I think is a really good point to make. Um So uh keep that in mind also, this will be on the website uh in addition or take a picture of it now. So uh the question, a lot of questions came in. Um one question that came in from two people was about insurance coverage for buprenorphine, which I've also had problems with as well. Um Is there a difference it, you know, what is the insurance coverage? Is there a difference um uh in between, you know, different patient populations, Medicare, et cetera. And then uh as a corollary to that, a patient who was on Suboxone uh which is buprenorphine and naloxone. Um And that was difficult to get covered by insurance. What is the difference between pure buprenorphine and Suboxone? Yeah. Should I answer these now or just answer them by? No? Go ahead and answer them. Ok. Um So insurance is a big challenge. Um The other challenge we found is with the pharmacist um or a different pharmacy. So at that level, also um some pushback to Bieber morphine. Um what colleagues and I have done is prepare some evidence from the literature um to send back to the insurance um arguing for, you know, just to get approved for this person. And because of this reason and the Department of Health and Human Services, actually, in their pain management guidelines, actually, um recommends buprenorphine as a first line opioid in the treatment of chronic pain. Um as a schedule three opioid with a safety profile that's better than any full agonist. And so we'll kind of provide this back to them and see, you know, if we can advocate for people to have access to this. And what is the difference between uh Suboxone buprenorphine and nin? Yeah. So, Suboxone is um the combination of buprenorphine naloxone product, the naloxone is there um to act as a deterrent for intravenous use um because it is not active if you take it. Um as prescribed. So sublingually, um the thought is that if you injected it, the naloxone would be, and then you would have either, but you would either have withdrawal or you would not feel any of the opioid effect from the buprenorphine that said people who are going to use um things differently from prescribed are going to do that regardless. Um And I've had patients inject the Suboxone and, and um and still feel what they wanted to feel um for patients, you know, the buprenorphine solo product um is often times less expensive than the um combination product. And so I will often use that um especially if I'm using it for pain and there's no concern for opioid use disorder. Um And then did you talk about the new center? Sorry. Oh, I didn't talk about the new center. Um The new center is um it's, I guess it's pretty similar. Um So you can use the buprenorphine Moor product. It does come in generic as well. So that's just buprenorphine uh uh brand name. Yeah. OK. And uh then do you see any differences in solid or hem cancers? And do you see delirium in elderly patients? Um So buprenorphine should be less Delio genic um for elderly patients or patients who are cognitively frail. And so if I have older patients, um especially those who've had kind of a bad reaction to the buprenorphine before or bad reaction to full agonist. Um I will use buprenorphine it is pharmacologically, uh pharmacologically similar in older patients as it is in younger patients. Um And I'd say the same thing for patients with hematologic um diseases as well. Um So with the new Center, um the new center is not actually buprenorphine, it is different. It is um it is not a partial agonist. And so I don't actually use minta all that frequently. It is um I think tidal um and buprenorphine is um I don't know, buprenorphine is buprenorphine. Ok. So basically that's where the information is. And um and you talk some about the CNS effects in elderly patients. Um and then uh what about if you can't get the drug or you can't get it approved? What's your, what's your next step? Yeah, I mean Medicare. Um So sometimes insurance will push back and not approve buprenorphine unless somebody has an opioid use disorder in their diagnosis. Um So what I will sometimes do is put a diagnosis of opioid dependence, especially if they've been on uh chronic opioids or opioids at some point for cancer related pain, opioid dependence is supposed to be a proxy for opioid use disorder. But literally opioid dependence just means that someone's been on it for a while. So I'll put that diagnosis and try again. Um And if somebody's not approved for that, then, you know, we'll switch to vagus good and I don't think there's been supply shortages yet of buprenorphine. So, um uh but obviously those things can happen. But this was really interesting and I think it'll be a great resource in the uh recording and your information about uh where to look for things as well. So, uh that's really great. And if you have more questions, put them into the link, the Q and A box and uh Janet will be happy to answer them in text as well. So, thank you so much Janet. And now we're gonna move on to Donald Abrams. Uh who's gonna talk to us about marijuana and mushrooms in cancer care? Donald? Thank you. And I do want to say that I'm in the process. One of the benefits of being Emeritus is that I read a lot of fiction and Barbara Kingsolver got the Pulitzer Prize for Demon Copperhead, which is all about the uh epidemic of opioid use in uh Appalachia uh stunning book. Uh Not for the Faint of Heart. So, yeah, so I am talking about a schedule one substance uh Unlike my colleagues, uh I do have some disclosures. I am an advisor to a number of companies and I did go to college in the sixties and I'll be discussing off label use uh of at least one federally illegal substance. Actually two. And I'm a friend of Paul Stamitz, a famous psychologist. So I just want to start by talking a little bit about cannabis uh which has been a medicine for about 3000 years and only has not been a medicine in the United States uh since 1942 and it was removed from the Pharmacopeia. Cannabis was placed in schedule one high potential for abuse and no accepted medical use. In 1970 the plant itself contains over 400 different chemicals including 100 and 2021 carbon tural phenolic compounds known as cannabinoids. But the plant also gets a benefit of pharmaceutical and physiologic from the turpis which give each strain its characteristic odor and the flavonoids, which are also bio active delta nine tetrahydrocannabinol or THC is the most psychoactive of the cannabinoids. Uh CBD which is catapulted to the top of the most favored cannabinoid list uh is felt not to be psychoactive. Although the largest studies, other than epilepsy of its benefit have been in people with anxiety and it's useful for sleep. So it is psychoactive but it doesn't get you high. Uh other uh cannabinoids that are also being investigated individually. Personally, I do believe that the plant is the medicine and nature. Did it best we and all animal species down through sea squirts have a whole system of cannabinoid receptors. One and two CB one and CB two present throughout the body. The CB one receptor is the most densely populated G protein coupled seven transmembrane receptor in the human brain. And we don't learn about that in medical school showing the degree of reefer madness that we live in. Uh cannabinoids receptors are present because like our own endorphins, we do make our own endogenous cannabinoids. And it's felt that this whole system of cannabinoid receptors and endogenous cannabinoids is to help us to forget and predominantly to help us to forget pain. So, there are a number of cannabis based medicines that are available. Dronabinol and Nabilone were both approved in 1986 for treatment of chemotherapy induced nausea and vomiting. So certainly, if these uh synthetic and uh delta nine TH DS are useful, you would consider that the plant might be of benefit as well. Uh Nebi Alls is the product that's licensed and available throughout the world, but not here. Uh It's a whole plant extract with the 1 to 1 ratio of uh THC to CBD. Um originally approved for multiple sclerosis, uh hasn't really done too well in studies in the US, I'll show you in a second. Uh Epi X is a highly purified plant derive uh cannabidiol pro product that has been approved for treatment of Children with refractory seizure disorders. And then there is of course, uh cannabis or marijuana which is available in 37 states now but remains uh scheduled one by the federal government. So many people always want to know the best way to use cannabis. I tell patients if they want better control over the onset, the depth and the duration of the effect that inhalation is probably better than oral ingestion because it's rapid onset and rapid decline when you ingest delta nine THC by mouth, first, past metabolism through the liver, changes it into an even more psychoactive 11 hydroxy component, which does allow for people to overdose uh when they eat a quarter of the cookie and nothing happens and they eat the whole cookie, I think. Right now, some of the best options are actually the tinctures that are available. When you put a liquid under your tongue, you immediately absorb some sublingually which reproduces the kinetics of uh inhalation and then you swallow the rest. Uh So you get hybrid kinetics between inhalation and oral ingestion. I was one of the 16 members of the committee at the National Academies of Science Engineering and Medicine that reviewed 10,000 papers on uh cannabis uh in 19, in 2016. And in the document that we produced 500 pages on the health effects of cannabis and cannabinoids, we had one chapter on therapeutics in which the strongest evidence was that in adults with chemotherapy, induced nausea and vomiting, oral cannabinoids are effective antiemetics. And in adults with chronic pain, patients treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain. And I must say it was my study of cannabis in patients with HIV neuropathy that had such a large effect size that it pushed us to add cannabis uh to this. And when we look at cannabis use in cancer patients, this is a survey that was published. Now two years ago, the 612 women with breast cancer responded, 42% said that they use cannabis for medical purposes. Only 23% strictly medical. Uh The majority reported that it was extremely helpful in relieving their symptoms and the symptoms most commonly uh relieved were pain, insomnia, anxiety, stress, and nausea. Uh Unfortunately, 50% also felt that cannabis was being used to treat the cancer itself. And although there is much preclinical evidence that cannabis may inhibit cancer in many different ways. There is no clinical evidence of efficacy at this point. And this is a paper that was just published uh last week. Uh looking at 1200 patients in New York at Memorial Sloan Kettering with nine different cancers. Here, 31% reported using cannabis after their diagnosis, ranging from 25% of lung cancer patients to almost 60% of the young men with testicular cancer use prior to diagnosis was strongly associated with use afterwards. And again, very high reports of improvement of symptoms. Uh only a quarter of these patients discussed their use of cannabis with their providers. And Elana Braun, who is the uh chair of the AS O committee that I'm currently a member of that will be publishing soon guidelines from as O published this survey of 400 oncologists who responded a 63% response rate. 80% discussed medical cannabis with their patients. Two thirds viewed it as a helpful adjunct to Stanford pain, to standard pain management. And two thirds thought it was equally or more effective than standard therapy for anorexia and Kia. And when I kept saying at the, as O meeting, isn't this evidence? No, you know, we oncologists demand evidence coming from randomized placebo controlled clinical trials and you cannot do those with cannabis, the botanical because it's a schedule one substance. So I'm I'm not enthusiastic about the guidelines that you're gonna see coming from. Uh as o the, the I mentioned neuropathy and there have been five studies in patients with uh HIV related uh peripheral neuropathy that strongly suggests that cannabis is useful. There has only been one published study of Nabis, the 1 to 1 whole plant extract in patients with chemotherapy induced peripheral neuropathy. 16 patient crossover study showed no actual benefit, the Israelis. Uh every time a patient gets cannabis in Israel, they get a license and they get to be surveyed. And this, it was a very interesting study that I think is worth noting 513 cancer patients about to start uh F fox. Uh half of them use cannabis and the other half they served as controls, again, not randomized or placebo controlled. And the cannabis users were divided into those who use cannabis prior to receiving the oxalic platinum and those who used it afterwards. And as you can see, grade 2 to 3 chemotherapy induced peripheral neuropathy developed in almost half the number of patients who were cannabis exposed to compared to the controls and the protective effect of cannabis was more pronounced among those who used it uh before they received oxalic platinum. Now, with regards to non uh neuropathic pain and cancer patients, what's mostly been studied is the pharmaceutical product Nabis. And unfortunately, in the six studies that have been published, there is actually no difference between Nabi and Placebo for the difference in the average uh pain score. And that's shown in the Forest plot. Personally, I believe that CBD detracts from both the high of cannabis of THC as well as from the therapeutic benefit. And with regards to uh pain uh in our patients, uh I was funded by NIDA because Nida only funds studies looking at safety or harm. Uh to look at a study of cannabinoids in patients was on sustained release, morphine or sustained release oxyCODONE. And we saw no real change in the plasma concentration of the opiate after five days of exposure to vaporized cannabis on the bottom. You'll see. However, even though we weren't supposed to look at pain, we did and we saw a 27% reduction in pain in the overall cohort of 21 people. But the study was not powered for pain as an endpoint. But it does suggest what we've seen in states where cannabis is available, that opiate use can decline. I just want to say uh about CBD again that uh there's a lot of uh expectation and placebo effects with CBD. And this was a study published last year in the JCO phase two randomized placebo controlled dose escalating study of CBD oil versus placebo for 28 days. In patients with advanced cancer having symptoms, 70 patients receive CBD at a median dose of 400 mg a day and 72 received placebo and there was actually no effect CBD on quality of life, depression, anxiety, feeling better or much better. And this meal was reported to be more common. So CBD really adds nothing but it is a $28 billion business. Another big business is mycological nutraceuticals or medicinal mushrooms. There are about 14,000 mushroom species known to men. 3000 of which are edible and probably 700 exhibit some medicinal properties with only 1% of all species being poisonous. Again, at the global medicinal mushroom market is about 18 billion a year. Not quite that of CBD. Mushrooms can be considered as functional foods as well as supplements. The, the mushroom itself is mainly water, 90% with a little protein fiber carbohydrates and that, but they also do contain uh biologically active compounds. Phenolic acids, flavonoids, tr turps, et cetera. They're rich in potassium, calcium phosphorus. And if you put fresh mushrooms out in the sun, they will make ergocalciferol or vitamin D two mushrooms are also prebiotics and they're non digestible carbohydrates. Uh they become fermented into short chain fatty acids by our microbiome. Uh So, mushrooms, as we all know, uh start out underground ashy feet, one cell thick organisms that are very large and usually affiliated with some sort of a tree and then suddenly they sprout up the fruiting body above the ground. And some mushrooms also have an additional life stage of a spore that gets released from the mushroom with the strength of a rocket launch. Apparently the way the mushrooms generally work in cancer is the cell wall. Beta glucans resemble bacterial cell walls. And so when ingested, the body thinks it's being invaded by a bacteria and it mounts a non-specific immune response that we hope will also be able to target cancer cells. So the top four mushrooms on this list are edible mushrooms. A Garriga species are the white button, their brown cousin, the crimi and their giant cousin, the Portobello. Uh all mushrooms must be cooked, slicing white buttons and throwing them in a salad is a no, they have a cancer causing compound in them. There is some suggestion that they may have aromatase inhibitor activity, mata and shitake and Horii are all edible mushrooms. Uh The bottom three are the ones that I use. The most, uh particularly tred versicolor has been studied the most as an adjunct to chemo and radiation in patients with cancer. But as we're talking today about symptom management, the two that I'm gonna focus on are corps Sensis Corps is actually a fungus which parasitize the caterpillar that lives in the Tibetan Highlands. In traditional Chinese medicine, it's used as a lung and kidney tonic and it's used for vigor and stamina as well as male vitality. And in fact, uh the the uh Chinese women relay team in the National Games in Beijing in 1993 broke all sorts of uh records and they were tested uh for doping and the only thing they were taking was cortic. Now, recently, I've learned that cortic in vitro does increase testosterone production. So, although it's something I have been recommending to patients with prostate cancer, I'm not sure that that uh should be done or maybe we need to do a study to see if the mushroom actually does that in men. The other mushroom that I like for symptom management is Lions Maine, which is edible and quite delicious. Uh It's felt to perhaps uh stimulate brain derived nerve growth factor. So it can be considered as a neuroprotective agent or something to use that to treat patients who have peripheral neuropathy. And I think it's also quite useful in chemo induced cognitive impairment. Uh Preclinical studies suggest that Lions Maine may be protective against the effects of ischemic stroke, Parkinson's disease as well as Alzheimer's. And there have been a number of studies done more so than with Cortic, with Lions Maine suggesting that there are benefits uh with cognition in elderly people. And again, my patients uh who benefit from uh li Lions men do say that they get sharper lions. Maine is also part of the micro dosing uh recipe that people are using uh with uh psychedelic mushrooms. Uh There's been quite a rage recently looking at the potential health benefits of psychedelic mushrooms. And there have been a number of studies looking at uh psilocybin, particularly in patients with uh cancer. The first study was a very small study in patients with advanced stage cancer and anxiety. And again, it showed that uh there was improvement in anxiety and also depression that persisted six months after a single dose. And since that time, there have been two larger studies. Uh 1 29 patients and 1 59 with cancer related anxiety and depression, double blind placebo controlled crossover trial. One used niacin as a control and the other used a low and high doses of psilocybin and again, what they show and what I find in patients that I see who have had a psilocybin assisted psychotherapeutic session is that they become much less phobic about impending death and they embrace life and uh let go of their depression and anxiety. It's quite, I am a a psychedelic virgin, I must say. But you know, I am quite uh amazed at uh what happens to patients that I see. So, in conclusion, despite a dearth of published evidence related to barriers to research, I believe botanical cannabis is a useful adjunct to standard treatment in alleviating the side effects of cancer earths treatment. And I do believe it's superior to the more widely studied isolated cannabinoids as I mentioned. But I didn't show you there is as yet no conclusive evidence that cannabis or cannabinoids have any significant clinical anti tumor activity. Medicinal mushrooms are primarily utilized as immune enhancing adjuncts to conventional cancer therapy. But cortic steps may have energizing effects with caution, perhaps warranted in men with prostate cancer and hoium or lines may may have a role in nerve related issues secondary to cancer treatment. And psilocybin does appear to promote sustained psychological benefits when used in guided therapy sessions in patients with advanced cancer. And with that, I will stop. That was really great a tour de force and I think you covered a huge amount of information, which is really great. Um There are a couple of questions in our Q and A for, I think you have like a couple of minutes. But um just on, there was an interesting question uh about fruiting bodies versus mycelium grown on grain. Um And uh uh Natalie Ledezma talks about Paul Stamitz. Um and the mushrooms use rice mycelium. This is way beyond anything I would think about. So. Yeah. No, it's a, it's a big controversy. In fact, labs gave Paul Stamitz a slap on the wrist because on the bottles, he showed the fruiting body when actually he's using mycelium grown on a grain. Uh So uh the mycelium is a single cell organism that it lives and becomes the fruiting body. So, obviously, it has an amazing potential. The fruiting body I think is a good food. But if you're looking at a medicine, I think the fruiting body or the mycelium or even the spores, you might remember, Alan Vanu, our own. Alan Vanu reported on two patients with hepatocellular carcinoma clearing it using a Chinese racy spore product. And Mark Schuman and Alan and I try to study it, but the company that produced this product would not tell us their good manufacturing procedure. So we never could study that. So, yeah, there is a bit of a controversy. Do you use Mysia? Do you use fruiting bodies? Do you use for? I think, you know, you just have to, if you go with the flow and see what, what's been studied and isn't um U CS F do having program with psilocybin or some sort of psychedelic, I think for patients who have chronic pain syndromes. There, there are one of my patients came to me and she said she's working with a guy at Langley Porter uh as one of his research aides and he's studying psilocybin name escapes me. But Bree uh uh Bell in palliative care uh has a study uh that she's doing with the psilocybin investigator as well. Uh That will be launched when she comes back from maternity leave. So that's something that we can think about for our cancer patients. Yeah, I have a patient who did the program at U CS F. So it's really interesting. Somebody said it's Josh Wooly's lab. Um Susanna Benningfield said so really interesting. And I, I don't want to take up too much of uh cta's time. So, but it's so interesting if you have more questions, put them into the uh Q and A because I know Donald will be happy to answer any. And uh obviously we can do another session, taking more time with this in the future. Uh So thanks so much Donald. And uh we'll move on now to uh Kavita uh Misha who talked to us uh about another interesting topic. Mind body medicine. Can you see my slides? Yes. OK. And is it going forward? Uh Yes, it looks beautiful. OK, perfect. Um All right. So yes, if your brains aren't fried already. Um Let's see if we can get another 15 or so minutes in today. We're gonna talk about mind body medicine and innovative cancer care. And this hope that I have a few different hats and ra ra on and at the Oser Center, no financial disclosures. And I just want to start with this cartoon which I think describes many of us probably in the webinar. Uh What the hell is that? Oh, it's just my mind. I think all of us know that sense of having about 50 million things going on in the mind at any one point. Um And our mind is a complicated instrument. We, you know, I live, I have lived in the world of radiation oncology with really big machines, protons. Um but there's nothing more complicated than the mind. And so when we talk about mind, body medicine and cancer and hope I just want to make sure I am on the right slide which says mind body medicine, I can't tell you are perfect. So mind body medicine is um trying to work with this thing up here. And there are lots of different definitions. I like this simple one, which is diverse practices. Literally hundreds of different practices can be considered mind body medicine and they focus on the interactions between the mind body and behavior to promote health. And so you see a list here. These practices can include breathwork, body awareness, compassion training movement, which is really important for our patients with cancer. And that can be Qi Gong tai chi yoga, dance, walking, you know, all kinds of different things, relaxation, expressive arts, including art, um writing, music and being out in nature and the symptoms. When I see folks in integrative oncology side that I might be thinking about various practices, could be physical symptoms, like sleep, fatigue, pain, nausea, it could be psychosocial symptoms like stress, depression, anxiety, fear of recurrence, and it can be existential cognitive kinds of questions, um awareness of meta awareness, uh sort of the questions of life, self compassion, gratitude, reflection. I'm gonna start with this, which is the NCCN guidelines and some of the work that's been done prior to it. Now, this is based on randomized control trials, meta analyses, systematic reviews kind of the uh gold standard of data that we like to see. And you can see that in the latest NCCN guidelines, meditation and M BS R which is mindfulness based stress reduction as X is pretty much all the way down, which means that they are NCCN part of the NCCN guidelines for things like pain, fatigue, sleep, anxiety, depression, cognitive dysfunction, sexual dysfunction, the lack of XS doesn't mean that it may not be helpful. It just means that the data is not to that sort of gold standard MC CM level yet. Um But I just want us to notice that, hey, we can look at some of the data. We, we won't have much time today, but we'll look at a few little tidbits but really experts who have looked at all of the data out there say that yes, there is enough data in the way that we like to think about data. Don't worry about the thousands of years of experience. But in our modern language, we know that this makes a difference for patients. This actually is hot off the presses literally last month. Um A few of our own were part of this uh as Oio Guidelines Society for drive on college Chloe Atreya from G I on and Chelsea Suart from uh psycho on what part of this. And Linda Carlson has done quite a bit of work in uh mindfulness based interventions and really um named the Mindfulness Based cancer recovery program, which is based on M BS R and other long standing traditions. Um And this talked about anxiety and depression in patients and adults with cancer. And basically, these are probably small to see. But the idea is that mindfulness based interventions, which is the topmost category here with a high level of evidence quality is known to be useful based on data for active treatment, folks, as well as posttreatment, folks who are experiencing depression and on this side of the slide who are experiencing anxiety. So this is literally from this past month, coming up with an expert review of all the data that's out there. And so then we beg the question. OK. Well, we have some good clinical data that's saying something's happening. We have thousands of years of data saying something must be happening. We sort of kept on uh these practices, what might be causing these changes, adaptations, uh ability for patients to um grow in certain ways. There are a lot of different theories. One theory is that meditation may be affecting our natural stress response. And so we live today in this kind of chronic stress uh on uh all the time we used to maybe 1000 years ago. Live with acute stresses where we had to have that stress response. And then we go away and start walking around the grasslands and then we have an acute stress, a tiger to deal with. And then we go away and work from les. Now we live in a sort of chronic stress situation. And that's where we think meditation, mindfulness may be helping us. Uh And the idea is that it may actually be helping us deal with those chronic stressors to bring our autonomic balance into better space between our sympathetic and parasympathetic. It may actually be affecting our inflammatory markers, um our immunity, you know, CD four counts, soloist activity, many of our own who have done some good work here like Melissa apple, um and others that you see stuff have looked at long race activity, the enzyme levels and how it may be manifesting differently from meditators versus non meditators. Um A lot of interesting functional uh MRI data showing the differences even with short meditation stints of some minutes or for uh young meditators versus, you know, obviously those with experienced meditators, you can see an atomic as well as functional changes and then epigenetic changes. I have a few slides here that we can go through, but I won't sort of list out all the details. But you can see this is actually a slide bar from uh Daniel Lowenstein and he talks about all of the different bodily tissues and uh markers that may be effective and decreased or increased in, in a positive direction when we meditate. Um Here's a study that looks at uh Mbis or mindfulness based interventions and it may be aiding the immune system, uh affecting IO four and um interfering gamma. And here's another one looking at um MRI data and the altered brain structure, in fact. So again, anatomy as well as functional changes and network changes that we're seeing, This was a meta analysis um and review looking at specifically fear of cancer recurrence, which we can understand maybe where pa patients carry. And so uh Mbis are really found to be helpful in this space. I'm gonna shift over from some of the data that folks are collecting in the field to the amateur philosophers in us and in the audience, you know what may be happening with patients that might be leading to some of these developments. And there are some philosophical models, one of which has this kind of triad of wisdoms that may be coming for patients. And it's in three attentional, constructive and deconstructive and so intentional wisdoms that patients or we may gain with meditation. It may be something like increasing our ability to focus, be aware. Why if the mind be able to be in the present moment without kind of living in the future or past, which is where we tend to be in our mind. Um That's attentional. Another kind of wisdom is constructed and that's around kindness, compassion, loving, morality, gratitude, um community that can become a really important piece for patients and especially I'll talk about this later. But in some group work that we're doing with medical visits, this is a really important piece of that common humanity and compassion that can come forth from the experience of meditating individually as well as together. And then finally, there's a group of wisdoms that are called deconstructive. And this is a bit more existential talking about what are the wisdoms that we might be doing through this process of meditation, not mind body practices. What are the uh interconnectedness that we're feeling some of the actual work that Donald was talking about with psilocybin? There is some congruence with maybe what's happening with things like Psilocybin and meditation where we're uh restructuring parts of our mind in a way to be able to understand um internal and externally in the world. And so attentional constructive and deconstructive are a way to think about the wisdoms. So, going practical from existential to practical, um how do we like to do this with patients? And so obviously, we see patients one on one, we also see patients in groups and then we have a whole system with digital health resources online. There's obviously a lot of um resources with meditation, yoga, qigong, et cetera. And so this triangle is how we think about what kind of resources we need and how many patients we can serve so individual care groups and digital health resources. And we've tried to put resources into all of these three, but particularly in the last couple of months, really growing out our group medical visits at the Oser Center. And part of that is to increase accessibility, um reduce wait time for folks to get in and to really try to be inclusive um of folks that may not be hearing about these services. And I just want to point out the Jetsons had telehealth understood way before any of us did. Um for those of you who are out there who know the Jacksons. So group medical visits, uh you can go to our web page. I placed it here so that you can go check it out, know what you may be able to offer to patients. You can give this website to patients and they can explore and see if there's something that they want, you know, to be a part of. And um we have some new ones coming up. One is by actually Stephanie who works with a couple of our speakers, Stephanie Chang in palliative care. She's doing one around nature therapy and actually doing a virtual um forest therapy experience, which includes meditational experiences as well. Those patients being able to be in nature, whatever that means, either actually in a park in their backyard or from hospital bed, looking at a picture of something uh in nature. And so she's really working through her palliative care lens to bring nature into people's lives. And I won't list all of these. But you can see that we have a number focused on both advanced cancer as well as survivorship, um narrative medicine, nutrition, movement medicine. And then we have uh doctor Rey and I run one for diverse patients in advanced cancer inactive treatment. These group medical visits are built through insurance. They're usually 3 to 4 weeks, sorry, 3 to 4 sessions usually either weekly or every other week. A couple of these are eight weeks long or 7 to 8 weeks long. And then we also have public classes which just as a practical way for you to help patients. Um If you, if a patient is interested or if you want patients to check out more about it, they can go to our OSHA website and look at my influence case stress reduction, both for English speaking and Spanish speaking, which just got started as well as restorative yoga and LA for yoga. So these are again, resources that are right here in that brochure and these are some of the ones that I just mentioned. And this is Nature therapy. There's a little video that a patient can click into and get an understanding of what that's all about. Uh the one that I did just to give an idea of how these group medical visits can work. It's usually about 6 to 10 patients on average eight and ours is a four week passage which includes um individual as well as group material. And week one, we talk about mind uh MBIS or mindfulness based interventions in the context of emotional balance, mindful eating with a lot of our patients and who have really much share loss of appetite. This becomes really relevant meditative movement and of fatigue and sleep. So we really try to use the NCCN guidelines and pinpoint, which kinds of practices may be used to work. And something that I've been working on recently is you know, we all live in this era of personalized medicine. I like to think about an integrated oncology. How do we assess personalized meditation and how do we give a prescription for something to patients? And so you can see this is kind of an example of what I or my colleagues, we give a patient, uh the kind of practice that we may discuss with the patient and the kind of smart phones that we may discuss with the patients very specifically to give um to develop together duration, frequency time of day location. And a term that some patients have started to catch on to is this idea of mind body medicine snacks. So just like we go into nutritional snacks, um we try to get some exercise in, we also try for mind body snacks. So if they're in a waiting room, waiting for a scan, um if they are waiting for doctors, one if they're at the grocery store, whatever, 1 to 5 minutes, they start to practice these skills. And the idea is that it is a practice such that when you need those skills in the chaos at the moment, you practice it, it's in your toolbox. And then this is the MVSR mindfulness based stress reduction at the Ocean Center. And again, uh I really do want to emphasize the newest one which is for Spanish speaking folks. If you do have patients who might be interested, please do send them along. This one is eight weeks. Um There is a cost but there is also funding for those who cannot pay for it. So, so um there are ways that we can help patients and with that, I'm gonna bring this to a close because I know that um we are heading into the final minutes. So I wanna thank uh everyone on my rat on side as well as as the osier side. And I think we made it in time. You did a great job and that was really, so interesting. That's really great. And I think that one of the big things about mind body medicine when we talk about it um really has to do with uh access. And one of the questions that was asked here, I think is really important and patients who are not getting care at U CS F attend the group medical visits and classes and how would they access uh the uh link for understanding when there are classes that they could sign up for. So great question, the M BS R, the mindfulness based stress reduction class is for open to anyone. So anyone anywhere across the nation can actually take those. Um And if you just go to that website, if you just search OS RM BS R, it'll pop up. Um and patients can go and see the different classes. There are some different instructors about five instructors and each has different timings and so the patient can figure out what time of day and separate works for them. Um Those are for the public facing classes and actually the restorative yoga and laughter yoga are also open the group medical visits for now. We have been keeping that. So basically within U CS F as kind of the, you know, um a program that cancer patients here have access to. Um it's also just the reality of having providers who have limited bandwidth. And so as we are able to grow, that may be something that we can think about for patients who are not getting care of use. But for now, the good medical visits actually uses like f um in terms of insurance. Yes. Uh The team looks through the cancer center and OSHA Center work together on some of these visits and we have a whole process where we look at the, you know, insurance authorizations. We try to, we make sure that patients um have everything in place and I believe and each patient is different. So in terms of medical, yes, there are certainly some patients that have been able to be um served with me. But to say blanketly, I have to have my insurance folks make sure. So if you have a patient, please send them, you know, through and then we can double check and make sure that's great. Yeah, I wonder, you know, there's just um so much in terms of people being able to afford, you know, mind body work and access it. Uh I think that really does end up being one of the biggest uh issues but insurance will cover a little bit of this, right? For a short time. Mhm. And actually insurance, well, it depends on deductibles and co-pays. But yes, all of the medical visits are billed to insurance and so generally we have not had patients um uh built any major extent and with many of the pilots, we actually told patients that we're getting even if you're getting some something odd in your um bills, please let us know and we haven't had major issues with them. And uh so the I guess really the biggest question is how we integrate all of these things together. So uh you know, mind body uh care I think is really important and uh is not so focused on having chronic pain, right? Um and the issues the um treatments that um that Donald talked about are also, I mean, some are pain, but many are other symptoms that people have um that he talked about, you know, clarity of thinking, anxiety, uh many different areas. Um And then we talked about buprenorphine and um issues related to chronic pain. I think that these are all such important uh issues that come up for oncologists and for patients um in the oncology area. How do we integrate our integrative approaches? And uh maybe all of you could comment a little bit on that, including Mike. And uh just to uh mention that Donald, do you wanna start with just a comment about that? Well, I mean, you know, just being aware of what's available and directing our patients to uh the right places is one way to, to start. I mean, you know, so many people come to us at the Ocean Center and say, you know, they didn't tell us about the cancer center doesn't know about you. They still tell us that I've been there for 18 years and they say the cancer center doesn't know. I mean, you, I'm not talking about you hope pretty good. I just saw one of your new patients. I just, yeah, but I mean, being aware of who we are and what we did, I do want to say that uh Kavitha made an excellent point about uh I read Michael Pollen's book also how to change your mind. I usually prefer uh fiction, but I read this nonfiction book about psychedelics and he does equate psychedelics, the psychedelic experience to meditation, the meditative state and says that they're very similar, which I thought was, was interesting. Also Buddhism and psychedelic seem to, you know, converge as well. So, yeah, how to get people to take advantage of these things is making them aware that they're available for me, Brenno buprenorphine. However you say it is, I'm, I'm sorry, I'm not prescribing anymore because that would have been a fabulous thing. And I'd like to Sprinkle it all over Barbara Kingsolver's characters in her. Not a scary book. Uh So that's important. And uh Mike, do you have a comment? I mean, one of the things I will say to add in is one we did have a frustration and this is true just of, you know, across the board in medicine, it's hard to get patients in to see providers. Uh But we are really able to get into the Osher Center more easily now than we were in the past. And there are classes available for the public um in addition to U CS F uh patients uh where there are a few as we heard about specific types of offerings. Um So that's great. And our symptom management, palliative care service again, symptom management is not uh you know, for only patients in a palliative mode. Uh So there's a lot of different aspects, Mike, do you want to comment. Yeah, I, I actually think that the integration comes from the combination of science that we've been talking about tonight and referencing tonight as well as Kavita. Beautiful point about the person and personalized medicine. So we're taking truths that are universal and asking people to, I'm getting in touch with who they are and uh quiet uh themselves and we really feel what's really going on. So I, I think that that's what we're all pointing towards. And I really loved uh everybody's comments and I don't know if Janet's on or not because her video is not on. Um But Kavita you wanna make a comment about? Yeah, I'll just uh move up here. We just have two minutes. So, yeah, I'll just riff off. Uh the other two Michael pollen. One of the theories that Eva really many researchers have been thinking about is this idea that we get into habits and we sort of ski down the same slopes and we have these ski runs that are set in our mind and perhaps some of these meditational or suicide and other techniques are actually allowing us to, rather than taking the same black diamond of anger or sadness or whatever down, maybe to have a moment reassess and then actually take a blue or a green hill down and end up in a different place. Um As we assess where we are in our relationship with others in the world. And so anyway, I find that concept. Very interesting in terms of how we may be remodeling or shifting my mindset. Um in terms of how to bring it all together hope. Uh we're, we're depending on you or depending on you. It is interesting. I mean, I think that um you know, we do need to use our referral services and work together. Uh and, you know, maybe someday what we could look for is that we would consolidate some of these services within a, you know, where you could uh check up various areas of support for a patient within a single referral service. But right now, we don't have that. But I think something that's something that we all would like to see over time is that we really integrate our integrative approaches to provide the best support possible. We also have a question about whether to list this as a support service through my chart in patients with a cancer diagnosis. And I think that, you know, we do actually in the breast care center have specific things that pop up. You know, if you're young with triple negative breast cancer genetic counseling pops up and you have to delete it if the patient's already seen a genetic counselor. So that is something that maybe um we could all work on to collectively so that things do pop up that there's a referral to specific areas. And we're actually working with the apex team on that in terms of getting some of that direct patient facing information. That's wonderful. Um So, uh, yes, uh Janet did mention that she had to step away for childcare. She just is still up there. So I forgot about that. Uh, but we really, uh all appreciate and I appreciate so much everybody's talks this evening. This was such a fabulous session. I think the recording will be, uh, listened to many times. It's gonna be really useful and I hope that we can circle back again and talk about some of the additional aspects of all of your topics as we move forward. I hope that you, the audience have enjoyed this. I'm really appreciative that everybody was here uh listening and we've already gotten a comment saying that there's an excellent session. Thank you and I just will reiterate that many times. Don't forget to take the survey if you want CME credit and look at the video um uh uploading link there med connection dot U CS F health dot org after the editing. So it won't be immediate, but it's usually within a week or a few uh shorter days. Uh Remember that we have a another session of our uh cancer Center live series on November 15th in the evening, starting at 5 30. I think we're starting at 5 30. This will be a collaboration with John Muir. Best of the year. It's gonna be fabulously useful. It'll talk about in major cancer, both solid and liquid tumors. Uh the major advances of the last year and how we're applying those to clinical practice. Definitely stay tuned. You'll see more about that very soon and then we'll have two cancer center live sessions next year in February and in April and we look forward to seeing you there. Thanks so much and thanks Joy for your help and to all of our speakers. Take care.
