Neuro-oncology, Functional Medicine, and Medical Cannabis in Brazil
(This transcript has been slightly edited for linguistic clarity)
Project CBD: I’m Martin Lee with Project CBD, and today we’re having another edition of Cannabis Conversations. Our guest is Dr. Paula Dall’Stella. She is a physician in Sao Paulo, Brazil. We’re going to talk about her practice, which involves something called ‘functional medicine.’ So maybe you can explain to us, Dr. Dall’Stella, what is functional medicine and how does cannabis, or cannabis therapeutics, relate to that?
Dall’Stella: First of all, it’s a pleasure to be here, Martin, your work in the Project CBD is amazing. Congratulations.
Project CBD: Thank you.
Dall’Stella: Yes, I work with functional medicine. It’s an area of medicine that we, as doctors, are searching for what is wrong in the lifestyle of the patient. Science is showing us that 80 percent of disease is very related to our lifestyle and less related to our genes. So this is very important. It’s very powerful, actually – knowledge. When you know that your lifestyle is causing or promoting disease, you have the power of changing it, right. So, functional medicine is looking for what’s wrong, what are you doing wrong. It includes exercise, diet of course, which is the basis of our health, vitamins and supplements, how is your hormone balance, how is the power of your detoxification. All combinations of those things create and promote disease.
In terms of years, it’s very interesting to observe that when patients get a chronic disease, they don’t look in the past and they don’t identify – they say, ‘yeah, but I’m eating this bread or this thing or this food for years, and I never felt anything!’ Yes, but now you’ve got a disease. We don’t pay attention to what we are doing every day, how we are creating the seed of what we’re going to have in the future. So through functional medicine you can change your future. Instead of having a chronic disease and have to use medications to treat your symptoms you can have the power of changing your lifestyle right now, your life, and then changing your future.
And how is this related to cannabis? I am one of the first doctors in Brazil to prescribe cannabis. I’m doing that since five, six years ago. What I realize is that it’s about two things: One it’s our endocannabinoid system – and it’s related to our lifestyle. So what means creating disease? Creating disease means, for example, if you are a negative person and every day you wake up and you have negative thoughts – you are expressing types of genes. If you are a positive person, you are expressing different types of genes. So, if you have good relationships, you are expressing types of genes. If you have bad relationships – this goes for every part of your life. But we never relate that to our disease.
And the correlation, going further, means our endocannabinoid system is co-related to our all systems in our body, right. So, when we are creating stress – and creating stress means not just creating stress about thinking, it’s also about food, for example, too much bad food creates high stress in our body. This stress causes inflammation. And when we have inflammation, or we have a disturbance in our endogenous [cannabinoid] system, we are more open to have disease. So, what I do in my practice, it’s focused very much on lifestyle, and using cannabis as a tool to treat in a more gentle way the symptoms that those patients still have. And, of course, you cannot just drop the medications from one day to another. We have to do it through time – and cannabis is a tool to help those patients to pass through this modification.
Project CBD: So, you found that cannabis can help patients wean off of pharmaceuticals, or lessen their use of pharmaceuticals? And in what particular areas, or conditions, are you finding in your practice that cannabis seems to be particularly helpful for, or most helpful?
Dall’Stella: I have a lot of experience with patients that arrive in my office using 5 or 10 medications – polypharma we call them. Because, of course, with 10 medications nothing is working properly, right. We don’t even know what is working or not. It’s very hard actually to treat those types of patients, and I’m seeing much more it’s very common. They are changing doctors, and doctors don’t change their prescription of the doctor before, and they are accumulating a lot of medications. So, yes, cannabis is a very great tool to help those patients to take off many of them. Sometimes, the patients keep one or two instead of 10. But, then again, it’s about lifestyle modification and cannabis. Because probably the 10 medications they’re using are very related to their lifestyle. For sure. As for what I see that is very common in my office – well I did my post-graduation in neuro-oncology, and because of it, I receive a lot of patients related to oncology. So functional medicine is a very wide field for patients. Oncology is one of the types of patients that I see very great results.
Project CBD: Cancer patients. And you said “neuro-oncology.”
Project CBD: So that’s a specialty among cancer patients, implying cancer of the nervous system, of the brain. Maybe you can talk a little bit about that. What have you found with patients when they begin to use cannabis, or particular cannabinoids like CBD or THC, and they’re dealing with the cancer in a neuro-oncological perspective, maybe a brain cancer. What have been the results? Because this is very serious disease.
Dall’Stella: It’s a very serious disease. I just recently published in Frontiers in Oncology the results of two case reports where we introduced CBD in a certain type of a moment in the treatment of those patients. So, both of them, they had GBM (glioblastoma), the most aggressive form of brain cancer. Also, they had a very similar profile in age and they both were men. And it was very interesting to observe the response of both of them. They both went to surgery, they were biopsied again, and it was confirmed it was GBM. After they were going through chemo and radiation, and then after chemotherapy alone, a type of very aggressive chemotherapy actually, then we introduced CBD in that moment. And we let them, actually, tell us how much they could stand. We didn’t tell them how much they should use. One of the patients used 450mg [of CBD] and the other one used 200mg. It was interesting to observe that the one that used 200mg actually had a better response.
Project CBD: Is that the idea that maybe less sometimes has more of a response? Is that something you’ve seen in other applications with patients – this kind of “less is more” approach” for cannabis therapy?
Dall’Stella: Yes, actually I try to put my patients in the lowest dose with the best benefits, therapeutic benefits. Yes, I really believe that with chronic use we don’t need too much. In some types of disease, of course, you have to be specific as with certain children using CBD for convulsions, for example. If they use a little bit more they get a seizure or if they use less they get a seizure. So, it must be precise.
For cancer patients we don’t have answers in terms of how much. I do see a difference in response. And I think it’s related to the endocannabinoid system of the patients, too, the genetics of the patient – how the patient metabolizes [the cannabis oil] – and the interaction of the cancer with his system. It’s a very complex thing. Here’s what we observed in those [GBM] patients. After the first month of the radiation and chemo together, they had a very strong inflammatory response. What was impressive for us was how very quickly they had this response. It was a very robust response. When we saw this after a month, we thought oh my God, they are having a progression [of the cancer]. But instead of having a progression, they were having a pseudo progression – it means it’s not a real progression. It’s a very intense response to the treatment. It’s very good actually. They were clinically performing very well, actually. They were doing exercise, they were bicycling. I was really impressed to watch it.
And after, they follow up with chemotherapy. And the chemotherapy they were doing, as I said before, was a really aggressive one, with three types of different drugs, a very toxic type of chemo. Some patients can’t go until the end because of the toxicity to the brain, the liver, the blood cells, so it’s very intense. Both of the GBM [in our case study] vaporized THC flowers during that moment, and they keep using CBD. And what we noticed that was really impressive was that the clinical performance of them improved. Of course, they had fatigue, they had nausea, they were laying down in the bed, but compared to other patients they had moderate side effects. Sometimes one of those patients could work and have a social activity.
That’s impressive, from my point of view. I think that with cannabis, for oncology specifically, what I see is that patients have more energy. They perform better. They are more resistant to the stress of the treatment – even psychologically speaking, not just physically. They sleep better, they are in a better mood. Cannabis promotes the quality of life. The whole thing is creating an ecosystem that is better for them.
Project CBD: So, you were seeing not just positive results in terms of the cannabis helping the difficult symptoms that arise because of chemotherapy – the nausea and so forth – were you also seeing impact on the tumors, the brain tumors themselves, that were showing positive signs?
Dall’Stella: Scientific research has proven that what happens in a culture of breast cancer cells happens in our brain, too (for glioblastoma I’m speaking). We don’t know the answer about those patients, in terms of survival. We need more patients to observe. It was a very small population. But GW Pharmaceuticals just released their phase 3 (if I’m not wrong, 2 or 3?) study of the combination of Sativex [a CBD/THC tincture] with the treatment of GBM. And what they say is there is around 83 percent (if I’m not wrong) improvement in the survival time. It’s really nice actually to have these results because then, yes, we are seeing that it can really have an anti-tumoral effect in combination with the [chemo] treatment. The last time when I spoke with the team of the researchers, they said to me something really important and we are seeing it in the results of research: There is a positive interaction between the chemotherapy and the treatment with cannabinoids. For some doctors, they are afraid because of the antioxidant properties of cannabinoids, it could damage the [chemo] treatment and could not be a good combination. But no, instead there’s actually a synergic effect on tumors when you combine those.
Project CBD: You mentioned GW Pharmaceuticals and their product Sativex, which is a 1:1 combination of CBD and THC as a tincture, a sublingual – is this generally available to medical patients in Brazil? Are there other cannabinoid remedies available to patients? What is the situation if one just wanted to get a cannabis-based medicine and use it on their own, as you can in California and other U.S. states. Do the laws permit it? What’s the situation in Brazil?
Dall’Stella: In Brazil, it’s California 20 years ago, let’s say. It’s becoming popular. The doctors are getting their education slowly. But the patients are coming – they want to use it. What I’m seeing right now, in terms of what’s going on legally – you asked me about Sativex. Sativex in Brazil it’s called Mevatyl. It’s a different name. And we should have this in the pharmacy. But it’s not easy to find. I just had a problem with a patient two weeks ago. He’s an MS (multiple sclerosis) patient. And we were trying to find medication for him, and we couldn’t find it in any pharmacy. And I called to the pharmacy and asked why you don’t have it? And they said, yeah because it was here for two years and nobody prescribed it. So we delivered it back. So, yes, we have Sativex. We don’t Epidiolex of course. I don’t think it’s even available in the U.S. Is it already available?
Project CBD: That’s basically pure CBD for children with very severe epilepsy. I do think it is available as a prescription.
Dall’Stella: So, it’s already in the pharmacy.
Project CBD: But only with a doctor’s prescription.
Dall’Stella: In Brazil, we don’t have Epidiolex yet, but what we have in Brazil are a lot of companies from abroad bringing CBD made by hand to Brazil. So, we have a combination of THC and CBD in the pharmacy – very expensive – very expensive for the Brazilian economy. And then we have products made by hand, CBD made by hand, into the country with these international companies. So for a doctor, we have a very limited prescriptions in terms of cannabinoids and compositions, everything that it could do, it’s very limited, unfortunately. Brazil now is getting a public consultation – our FDA, our ANVISA (the name of the organ that regulates medications in Brazil) has opened a public consultation to understand what we think about having our own [cannabis] cultivation as a country, to produce our own medication. Because what we are receiving – it’s not a medication. We’re even not sure what it’s saying on the label.
Project CBD: With the CBD products?
Dall’Stella: Exactly. What’s already inside the products. We are in a moment right now that we need to force some quality control, education, manufacturing, and the whole process to be able to produce a quality controlled human consumption product. We still are not there yet in Brazil. We need to improve it as a country. We don’t have [product] regulations yet. So for a doctor – I prescribe what we have. We have the CBD products from abroad.
And you ask about the illegal market. The illegal market probably is [much] bigger than the regulated. What is regulated? For a patient now to receive medical cannabis in Brazil he must go through the bureaucratic process: it means going to a doctor who knows how to prescribe cannabis and make all the documents for this patient to get and apply for authorization. After 52 days the authorization arrives and then he can buy and use those company’s products. So, can you imagine for a person with a very bad condition, – he cannot wait for 52 days, plus 10 days to receive his medication. It doesn’t make any sense. So, normally what everybody does, they go to the black market because in 24 hours you resolve your problem.
Project CBD: I think what you describe about Brazil is not uncommon, even still in the United States. The black market exists along with the not-so-black market. It’s kind of all helter skelter and happening. But fortunately, there’s an increasing number of options that patients have and hopefully, that will happen soon in Brazil. We thank you Dr. Dall’Stella and good luck in your work.
Dall’Stella: Thank you so much.