Purpose of this paper

This paper will discuss some of the challenges faced by patients and adult users of cannabis in terms of inadequate guidance and counseling from qualified health providers, the less than clear scope of practice for dispensing agents and caregivers, and some of the negative impacts this lack of clarity presents for many of the players in the cannabis space. A discussion of the discontinuity of care between recommending healthcare providers and the medical marijuana dispensaries will be included. Recommendations for possible solutions to some of these issues and challenges will also be discussed.

The dispensary experience

It’s a common occurrence in the cannabis space — patient or adult user visits a dispensary. The product menu reads like a doctrine delivered from a foreign planet. Kush, cookies, OG, haze, indica, sativa, hybrid, oils, topicals, vapes, tinctures, edibles, flower, terpenes, vaporizers, water pipes, papers. To a cannabis naive patient, one glance at such a menu may be all things overwhelming and confusing. Realistically, a menu like this can be all things confusing for even the most experienced users, especially if they are seeking relief from symptoms. Which products help with pain? Which products work to relieve insomnia? Are there any products that can help someone experiencing anorexia related to chemotherapy treatments? These are just a few of the common medical questions that patients and adult cannabis users alike bring into the dispensaries.

For patients who registered with the Medical Use of Marijuana Program, they may have spent a short time with a recommending healthcare provider discussing what some of these terms mean. They may have come away from their recommending healthcare provider consultation with a brief guide to choosing cannabis products and have a few suggestions for choosing cannabis products jotted down. But then they enter a dispensary and their help guides from their qualified health provider are insufficient to help them negotiate the menu and make decisions that may benefit them.

Enter the dispensing agent

Also known as budtenders in other states, dispensing agents are dispensary staff members responsible for helping patients and adult users to decipher the menu by providing information about the various cannabis products. Whether or not the strain or chemovar leans sativa or indica, the lab testing results, how a product is best consumed, the terpene profile, patient experiences with the product may all be discussed in the span of a few minutes. Dispensing agents may also fulfill the patient or customer’s order, and complete the sale at the register. They are often not healthcare professionals, more often they are people with retail, customer services, and sales backgrounds.

Here’s where their role gets tricky — in order to help patients and adult users make decisions about which products to purchase based on symptoms reported, dispensing agents very often give medical advice that is far out of the realm of their skill set, training, and knowledge-base. It’s not the dispensing agent’s fault that they are in such predicaments, but the fact that the majority of dispensing agents are giving medical advice in some way, shape, or form is disconcerting from a medical and health perspective. Conveying unauthorized medical advice without a license is also a criminal offense. For the purposes of this article, we’ll stick with the risks faced by patients. There are valid risks associated with cannabis use, just as there are risks with the use of any substance, drug, or medicine. Some of these risks can certainly be perpetuated by inaccurate advice conveyed by a non-medical person, in this case, dispensing agents and caregivers.

What are some of the valid risks associated with cannabis use?

In the medical marijuana dispensaries, dispensing agents may have access to a very limited list of conditions from which the patient suffers. That’s it, there really isn’t any information regarding the patient’s health history which presents risks in itself. The unknowns about a person’s health background can be a veritable minefield in terms of keeping a person safe. Basically, how can a patient be adequately helped without such information? How can safety be prioritized? How can harm truly be reduced? From this nurse’s perspective, it’s not feasible without this sort of information. And more than this, it is really not possible without the guidance and oversight from a knowledgeable healthcare provider — one who understands cannabinoid therapeutics and conventional health and medicine practices.

For one thing, cannabis does interact with other drugs. Cannabis may impact the way most pharmaceutical medications are metabolized in the body, in some cases speeding up metabolization, in other cases slowing metabolization down. Cannabis may have a synergistic effect with medications, or it may have an antagonistic effect. In all of these cases, the risks to the person consuming cannabis with medications may range from rendering the prescribed treatment ineffective, to an experience of severe interactions that require emergency medical attention.

Another major risk — patients may think they can simply replace their prescribed medications with cannabis. And too often, unknowing dispensing agents relay anecdotes from other patients who have successfully weaned off of this medication, or that medication. This is unfortunate because no patient should wean off of any medication without the oversight and guidance from a qualified health provider as the effects of doing so may be very harmful.

A dropped ball for patients that places them at risk

As stated above, it’s not completely the fault of the dispensaries or the dispensing agents that these businesses sort of profess medical advice. Most states have developed cannabis programs that are disjointed. In Massachusetts, it’s a conflict of interest for recommending healthcare providers to have any affiliation with the dispensary businesses. On paper, this makes sense. A recommending healthcare provider who develops a relationship with specific dispensaries has the propensity to engage in questionable business practices and vice versa. However, in practice there are aspects of these restrictions that put patients at risk, mainly because the patient is provided their certification from their qualified healthcare provider then left to navigate the cannabis space on their own with only the help and guidance of the dispensary staff who are typically not qualified to help them in any medical capacity.

Per the state cannabis laws and guidance documents established in Massachusetts, recommending healthcare providers are explicitly not allowed to counsel patients at dispensaries. And because of the potential conflict of interest that is specified in the laws and guidelines, dispensary staff do not contact recommending healthcare providers on the patient’s behalf.

To better understand this issue, consider this hypothetical scenario — a patient goes to their physician with a medical problem or illness. The physician writes a prescription that will help the patient improve their symptoms and hands it to the patient. The patient then brings the prescription to the pharmacy to have it filled. The pharmacy staff experiences difficulty reading the physician’s prescription order and requires clarification to fill the order. But the pharmacy staff can’t have any contact with the prescribing physician because the physician is not allowed to counsel patients at the pharmacy. So then the pharmacy staff guesses what the patient needs, fills the order, and wishes the patient the best. No this is not something that would happen in the conventional medical system. Pharmacies regularly ask for clarifications on physician orders to maintain the patient’s safety which just makes sense.

Bottom line, the way many medical cannabis programs have been developed in part creates these issues where dispensing agents are put into situations where they are helping patients with significant medical issues because the recommending healthcare providers are not allowed to provide the continuity of care that the patients really need to make informed decisions about cannabis use. It’s the patients who get caught in the middle.

What needs to happen to improve patient safety?

Simply put, patients deserve to have oversight and guidance from qualified health providers. It would be better if the recommending healthcare providers had the opportunity to advocate for their patients as they would in conventional practice. Unethical business practices are one thing. Forced discontinuity of care for the patient is also unethical and can result in harm to the patient, which is exactly what the law promotes at this time.

Perhaps the easiest solution to this problem is to require dispensaries to hire nurses to fill these gaps. Nurses are charged with the care and safety of their patients, have a well-defined and understood scope of practice, and act as liaisons between patients and their medical teams. Nurses do exist in the cannabis space and should be involved to reduce the risks to both the patients and the dispensaries. After all, every patient deserves a nurse.

Another solution could be a standardized training program for dispensary staff. Such a program could include a well-defined scope of practice for dispensing agents, competencies to determine practice readiness, required periodic learning updates, and regular recertification requirements. In effect, the dispensing agent role should be considered that of an allied health professional with appropriate training and licensing standards.

Last but not least, the federal laws need to change, prohibition needs to end. Every healthcare provider needs to have an in-depth understanding of the endoCannabinoid System and cannabinoid therapeutics. This shift in the medical, health, and science fields would have the most profound impact in improving patient safety. As it stands, this industry and the programs that have been implemented to allow legal access to the public have remained immature and risky because of the restrictions enforced by maintaining cannabis as a federally illicit, schedule 1 substance.

What about the role of caregivers?

In Massachusetts, registered patients can identify and register two caregivers with the state. Caregivers can visit dispensaries on the patient’s behalf and transfer cannabis products to the patient from the dispensaries. Caregivers can also grow cannabis for their patients. Caregivers also run the risk of giving unauthorized medical advice, or making unsubstantiated medical claims. Such claims run rampant on the Internet and social media. To this end, it would be advantageous for the caregiver role to be well-defined with standards and scope of practice, required training, and applicable competencies. The aforementioned solutions for developing scope, standards of practice, and training protocol for dispensing agents could apply here.

It’s all about community

In closing, it’s important to note that patients and adult use cannabis users are helped by the staff at dispensaries and by qualified caregivers available in the community. There is a lot of good that happens in this cannabis space and that cannot be discounted. It’s imperative to be fair and unbiased, and realize that as wonderful as it is to see people actively improve their quality of life and heal with the use of cannabis, there are inherent risks associated with cannabis use also. There are a great deal of flaws in the way these programs were developed. For the sake of all of the participants in this burgeoning cannabis space — the patients, the adult users, the healthcare providers, the dispensaries, the caregivers — it’s time we seek functional solutions to these problems so that we may all benefit to greatest extent possible.

References

https://www.mass.gov/service-details/massachusetts-medical-use-of-marijuana-program-snapshot

https://mass-cannabis-control.com/wp-content/uploads/2018/08/GUIDANCE-AGENT-REGISTRATION-FINAL-ELS.pdf

https://www.mass.gov/files/documents/2019/02/09/Medical-Regs-501-PDF-Converted_0.pdf

https://healthcare.findlaw.com/patient-rights/what-is-the-unauthorized-practice-of-medicine.html

Start low and go slow. It’s a phrase that’s thrown around in the cannabis space like a Nerf ball at recess, but what does it really mean? And do cannabis consumers understand it? Let’s explore the answers to these questions and get down to the basics that encompass the concept of microdosing — another term often heard and misunderstood in not only the cannabis space, but also our culture.

Ask any cannabis user when they began to use cannabis and the answer from most people will fall somewhere between their high school and college years. Reach a little further to determine what that use may have looked like, and most people report that the goal at that time was to become as high as possible by consuming as much cannabis as possible. A typical Western culture occurrence that centers on the underlying (or perhaps overtly accepted) premise that more is more is more. This is simply not true when it comes to most substances. Certainly not cannabis. To use cannabis therapeutically, it’s imperative for cannabis consumers to find the least amount of cannabis that helps them to achieve the maximum desired effect.

To further explore the concept of microdosing, we’ll use the consumption method that gives the most feedback quickly — inhalation. This method of use also happens to be the most popular way to consume cannabis. Whether inhalation happens via smoking, vaporizing, or dabbing cannabis, it can be helpful to the person needing to relieve symptoms to track the effect with a journal, or these days, there are a lot of great apps one can put on their phone instead of utilizing a paper and pen.

For example, if the desired effect is to reduce pain while maintaining the ability to complete daily tasks, then the consumer must explore with cannabis to find the lowest possible dose that effectively reduces pain, but doesn’t impede or impair the person’s cognitive abilities. It’s best to start with the lowest dose, more can always be added slowly. But too much can lead to an unproductive experience.

Here’s the process I recommend.

Review symptoms and answer these questions — what ails you? What symptoms are you trying to relieve? What is the desired effect?

Sticking with our example — If you are struggling with pain, rate your pain on a scale of 1 to 10. 10 being the worst pain you’ve ever experienced (in which case, you may want to seek emergency medical attention!) 1 being a nagging tension, but nothing that you can’t deal with. Remember that this is just an example, everyone is different. Pain is subjective.

Once you’ve answered these questions, you are ready to explore to find the therapeutic dose that works best for you.

Start low — take one puff. Breathe in and out. (It’s a myth that the “hit” will be more effective if held in for as long as possible.)

Go slow — Track the effect over the course of a few minutes. Take five minutes you are cannabis naive, or new to cannabis. In the case of pain, rate your pain prior to use. And then a few minutes after.

Still in pain after those few minutes have passed? Take another puff. Track the effect again. This time, wait ten minutes to see if your pain is reduced or relieved by rating it again. Remember, the effects are cumulative. You can always add more, but taking in too much may cause you to have an experience you weren’t seeking.

Continue this process until you have achieved the desired effect. Document in your journal or app if this strain and method of consumption worked for you, or if it didn’t at all.

Keep in mind that finding the therapeutic dose hinges on a lot of different factors. Some strains of cannabis may help you reduce your symptoms, some may not. The terpene profile, whether or not the strain leans indica or sativa, the ratio of cannabinoids, the cannabinoid profile, the processing methods used to create cannabis product, how long the consumer has used cannabis, and a whole host of other factors may play a role in helping you achieve the desired effect. Be prepared to explore with multiple products — using cannabis to effectively reduce and relieve symptoms is a discovery process.

If you’re completely new to cannabis, ask your dispensing agent or budtender at your local dispensary which products have been reported to help other people with pain. This is typically a good place to start. There are also several great websites that review strains — such resources are free and available to you via Internet search.

Last, but certainly not least, make sure you are setting yourself up for success. Nourish yourself — a diet comprised of vegetables, fruit, lean protein, and 80 to a 100 ounces of fresh water daily is essential to staying well, or helping your body return to a healthy state. And also, move your body. The best way to reduce symptoms and relieve suffering is to make regular deposits into the self-care bank. Cannabis can be a part of that self-care plan, but it won’t work nearly as well if the body is devoid of the proper diet and regular movement it depends on to function optimally. Good luck in finding the therapeutic regimen that works best for you! Here’s to your health!

Brandy (not her real name) is a 30-year-old woman who will tell you that she once had the world at her feet. Always an overachiever, she had been working in her career as a marketing manager in a large advertising firm for about five years following her magna cum laude finish from a local university. Everything was going remarkably well for her until she veered her car at high speed into oncoming traffic — she was checking a text on her cell phone while driving. She wanted to respond to her best friend who was confirming dinner plans for that fateful evening when she looked up through her windshield in time to witness her own disastrous mistake. She struck an SUV head on, causing the hood of her small compact car to xylophone. Airbags exploded from her steering wheel and dashboard, burning her face and hair. She blacked out at that point and had no recollection of anything until she woke up in an ICU bed two days later.

The accident left Brandy with a head injury, whiplash, and a broken left ankle. Her life was spared, as were the lives of the four people in the SUV that she struck. The family of four included two small children — all were alive and well with only a few scratches on the parents who occupied the front seats of the vehicle. They didn’t press charges. Brandy cried when she received this news. She was relieved to hear that everyone was alive, thanked her lucky stars, and decided that she would never make such a significant, life-threatening mistake again.

While in the hospital, Brandy was placed on a pain pump. She was able to administer a dose of morphine at regular intervals to reduce the pain she experienced post-accident. All with the push of a button, directly into her vein. She noted how well the morphine worked and was grateful for the pain relief. On her way home, the nurse who discharged her provided a couple of prescriptions written by the attending physician — oxycodone for pain, another for Ativan as Brandy had been experiencing anxiety and panic during her time in the hospital. The nurse recommended that she use the oxycodone for as long as she needs, but to switch to Motrin when she’s starting to feel better.

“You don’t want to use those pills for any longer than you have to,” said the discharge nurse.

Brandy’s head injury left her with constant headaches and vision changes. Her ankle was held together with pins and screws now — she had orthopedic surgery shortly after being transferred to the hospital following the accident. She didn’t remember anything about that. She was released from the ICU within a few days and spent another day on a step-down unit until she was discharged the following morning. Brandy’s parents brought her home to her apartment — she was ready to get back to her life and move on from this horrific event. Her mother stayed with her for a couple weeks until she was a bit more stable. Little did she know that this accident would be the start of a new life that was unrecognizable to not just herself, but everyone who knew her.

Within a few days of being home, Brandy attempted to dig back into work and realized that for one reason or the other, she couldn’t find the solutions her team was seeking from her. She couldn’t see a task through to completion, nor could she communicate well via email. It took her a half-hour to write one email.

Concerned, she deferred to her Mom who reassured her, “You have a concussion sweetheart. You shouldn’t be thinking about work or looking at computer screens right now. Just rest. Don’t worry right now.” Brandy’s Mom always found a way to make her feel better.

Several weeks later, everything was a still a struggle for her. It took her twice as long to get up and ready in the morning as it had prior to the accident. She not only had to negotiate using crutches to get around, she also couldn’t force herself to work through any particular task in an efficient manner. She would start the coffee pot only to realize after a few minutes that hot water was dripping into the pot — she never placed a filter or coffee in first. She left the faucet in the kitchen sink running for an entire day at one point. Brandy also forgot to close the refrigerator door before leaving for work on a particularly bad day, causing an entire grocery shopping’s worth of food to spoil. And the worst part was finding her rental car in the garage after work. She would walk around and around and around, clicking the key remote in hopes that it would cause the car to beep. She had this car for weeks and she could never seem to remember where she parked it in a familiar garage.

When she visited her primary care doctor, she expressed her concerns about these lapses in memory, but her doctor brushed off her concerns and stated that head injuries take time to heal. He suggested seeing a neurologist if she didn’t see any improvement in a month. Unfortunately, Brandy’s employer didn’t feel the same way after nearly two months of what they considered an unproductive, lack-luster performance. Brandy tried her best, but she admitted her best post-accident was pitiful compared to her performance pre-accident. Ten weeks post-accident, Brandy was laid off from her job.

Brandy didn’t know how to move forward. She updated her resume and sent it off with a cover letter to all of the marketing and advertising firms in the vicinity. No one responded, not even an email to say “thank you for your interest” was received. She continued to take her oxycodone and Ativan daily. Sometimes she took more than the prescribed dosage on the bad days, but didn’t think much of it. These medications made her feel better and so much in her life was upside down, she felt she needed to take both on a regular basis. So she frequented her doctor’s offices for refills on her prescriptions. Her primary care doctor referred her to a pain clinic when he realized Brandy was not about to accept “no” for an answer. At the pain clinic, she was able to acquire a regular supply of oxycodone as long as she agreed to regular physical therapy for her ankle. She rationed the ativan, splitting it up into tiny pieces so she could take little bits with her oxycodone.

Brandy collected unemployment and put an ad on social media for a roommate. She made going to physical therapy and the pain clinic her job, committing herself to every appointment without fail. She did this to ensure her supply of oxycodone would continue, a realization that came much later she admits.

Four months post accident, Brandy’s bills were piling up. Her parents paid her rent in an effort to help. Brandy still couldn’t afford to pay anything other than food and utilities with her unemployment check. She had to return the rental car because she couldn’t afford it any longer, nor could she afford to buy a new one. And as far as finding a roommate, Brandy cancelled every appointment that potential applicants made in favor of sleeping. Depressed and anxious, Brandy repeatedly turned to the only things that made her feel better — oxycodone and Ativan.

A few more weeks passed and Brandy’s parents said that they could no longer afford to pay her rent. Upset, Brandy demanded to know where she would live. They offered their basement to her and agreed to help her move out of her apartment in a month. She agreed and felt it was the best option she had.

Brandy admitted that she would hole up in her parent’s basement and sleep for days at a time. The only time she would emerge from her underground lair was to fly up the basement stairs in a rage over someone making too much noise during the day, or if she had a pain clinic appointment where she would basically demand that one of her parents cancel their day to get her there. The once vibrant, strong, unstoppable girl had become an irritable troll who hated her life and everyone around her. Brandy blamed the accident, the head injury, and the loss of her job on this behavior until her parents found her unresponsive in the bathroom nine months after her accident. Brandy had overdosed on a deadly combination oxycodone and Ativan. She had stopped breathing. Paramedics administered narcan and revived her. And she got to spend another few nights in the hospital.

“I was taking handfuls of pills all day long. I don’t even know how much,” Brandy admitted when she reached out to me following a white-knuckled experience in detox, “I’m still in so much pain. I haven’t had so much as a Tylenol since I detoxed, but I can’t live like this. It’s constant.”

Brandy’s suffering was legitimate, but for a person who had just entered recovery, treatment options are sorely lacking. “I can’t get hooked again, I can’t believe that happened! But I can’t live like this!”

“What is your experience with cannabis? Have you ever tried it?” I inquired.

“Yeah, in college. Wasn’t really my thing. I don’t want to smoke…”

“You don’t have to. You don’t even have to be high, but a little THC may benefit you.”

Brandy considered this option for a few minutes. We reviewed the endoCannabinoid System, how nourishing this system with whole plant medical cannabis could potentially help her relieve pain and improve her overall quality of life.

“It’s not addictive?” I could hear a glimmer of hope in Brandy’s voice.

My response — “Every substance can be addictive. There are support groups for people who are addicted to chapstick to give you an idea! Compared to many prescribed medications, the addiction rate for cannabis users is low. It’s much safer than many prescribed medications and of course, illicit street drugs. If you do abuse it, it won’t kill you. And you can come off it without needing medical oversight.”

With that, Brandy decided it was worth a try. She acquired her medical marijuana recommendation and visited a dispensary. With my recommendations, she acquired a high ratio CBD tincture with twenty parts CBD and one part THC. She also picked up a vape pen that the dispensing agent recommended for sleep, and a pack of low-dose edible fruit chews recommended for pain management. Along with her therapeutic cannabis regimen which we planned together, Brandy agreed to eat a diet rich in plant-based foods, drink plenty of fresh water, and to drastically cut processed, sugary foods.

During our last follow up phone call, Brandy reported that she was feeling much better. Her pain was greatly reduced, and her parents seemed to like her again. She wasn’t out of the woods citing constant cravings for the oxycodone she had become dependent on, but she noted that the cannabis definitely helped.

“This cannabis is helping me stay in recovery. I go to meetings and I tell people about it. I don’t know why doctors don’t prescribe it. I am very grateful that I reached out to you. I am getting my life back — still in pain, but I can manage it with the cannabis. And I think my brain is working better! But yeah, when I want a pill so bad, I use some cannabis. It helps.”

“That’s all so great Brandy. Keep doing what you’re doing — keep up the good work.” I happily responded.

“Oh and one more good thing happened! I went on an interview today and got the job!” I could hear how elated Brandy was to report this positive event.

“That’s awesome Brandy! Congratulations! You did it!” I exclaimed while smiling on the other side of the phone, I shared in Brandy’s excitement, “Such wonderful news!”

As I ended the call and pulled up my notes, I could only sit for a second in a moment of pure gratefulness. Another beautiful soul, that was almost extinguished by bad decisions and abused prescription medications, was now able to move forward and carry out her life with the help of a little cannabis. Thank goodness for “this cannabis.” It really can be a life-saver for people struggling with addiction who require a solution to chronic pain and relentless anxiety. According to the National Institute on Drug Abuse, 30% of opioid related deaths from overdose involved benzodiazapenes like Ativan. Bottom line, cannabis is a harm reduction tool, it should be on the table with every other treatment for substance abuse and addiction to combat this drug overdose epidemic. The proof is in the stories shared and yet to be told.

Special thanks to “Brandy” for allowing me to share your story. It will help others!

For nearly twenty years, Marissa Fratoni has helped people walk their own healing paths while accounting for each individual’s own biological, physical, psychological, social, and spiritual needs. She is a multi-disciplined, holistic nurse and health practitioner specializing in women’s health and behavioral health, further specializing in substance abuse and addiction. Marissa is well-versed in complementary and alternative healing modalities including primary, patient-focused nursing, massage therapy, yoga and mindfulness practices, integrative and functional nutrition, and cannabinoid therapeutics. She truly believes that the integration of conventional and non-traditional care techniques is essential for healing the whole person. Her written work can be found at HolisticNurseMama.blog.

A Disastrous Account of Addiction Based on Many Truths, But a Work of Fiction

Kate drove like a madwoman in her usual way, weaving her old vehicle through rush hour traffic, speeding up to the next vehicle’s bumper, slamming on the brakes, and narrowly filling in the gap between the cars in the neighboring lane. With each jerking maneuver, this junkyard ready vehicle from the last century would scream, whine, and squeal. Kate was really pushing it this time. She realized her exit was coming up and immediately clicked on her indicator to let others know she intended to depart the highway. Once the blinker was on, she proceeded to navigate her rusted, shaking, bumbling box of mechanical mystery behind the pick up truck in the right lane, clearing his bumper by an entire inch. The truck driver slammed on his horn and pointed fingers while swearing loudly enough for Kate to hear him through the crack she left in the window for her cigarette smoke to clear. The truck driver called out “crazy bitch!” and proceeded to drive on. Kate exited the highway without flinching at his remark. She glanced at the broken digital clock in her car’s dashboard and determined it was five o’clock. Gram would be home in a half-hour.

Kate was in a rush, there was no time to lose. She ran to the backyard and grabbed the spare key that was stashed under a terracotta pot in her Gram’s garden. She let herself into the most well-organized basement in the history of home ownership. Her Gram didn’t save everything, but everything she did save was stored inside a plastic bin, each bin adorned with a detailed label of bin contents. Kate glanced across her Gram’s basement to see the variety of plastic storage containers her Gram had collected over the years. Some were a half-century old, some had been purchased last week at the local department store. An empty one sat at the base of the stairs and Kate noted that her Gram had already made a space for it to reside next to the other ones. Kate shook her head thinking that she would never be so organized. She walked up the basement stairs and pushed the door open into the kitchen. A waft of the morning’s coffee and a sweet scent of dish soap filled Kate’s nostrils.

“Hello? Anyone home?” Kate asked with anticipation. No one answered. No one was home.

Relieved to be alone in the house, Kate swiveled her head around. She was looking for something, anything. It had to be valuable. And it had to be easily missed, not obvious. This process was getting more difficult. But Kate was not one to give up, so she took to the stairs and headed toward the bedrooms. She knew there would be something there.

But first, Kate thought to check the medicine cabinet in the bathroom. Kate wasn’t in the habit of looking in the mirror these days. Mainly because the young woman who looked back was underweight with ghostly white skin and large dark circles accenting her brown eyes. She tried to smooth her brown hair without much success. With a groan, she dismissed the diminished reflection as she opened the medicine cabinet. A bottle of Tylenol, bandaids, a jar of petroleum jelly from 1952. Kate quickly moved out of the bathroom into the room her mother and she had shared when Kate was very young. She opened the closet where her old school uniforms, a few costumes from dance recitals, and a plastic container labeled “Sara’s Toys — 1970” stared back at her. Kate tore the plastic lid off and peered inside — there were a few Barbies, a small bag of homemade doll clothes, and an old Mystery Date game. Kate took out the Mystery Date game and set it on her old bed. That might fetch a few bucks on Ebay, but wouldn’t help her now. With a grunt, she stormed across the hall into her Gram’s bedroom.

Kate literally and figuratively hadn’t crossed this threshold before. She had come to her Gram’s house to “borrow” things before, but she hadn’t actually entered her Gram’s room. She was in new territory, a fact that bothered her for all of a thirty seconds. She scanned Gram’s dresser for a jewelry box, but there wasn’t one. She turned around and noticed the quilt that Gram was using on her bed — it was the one she had made with her Mom and Gram when she was in the second grade. Her first time sewing on a machine. Kate patted the bright yellow quilt and reached out to open the closet. Inside, she eyed an old cigar box stashed on top of a stack of shoe boxes and pulled it off the shelf. She lifted the lid and peered inside — an old tobacco smell emanated from the box. She found a gold pocket watch that needed to be repaired, a crumpled up letter that had been smoothed out, a broken brass lighter that needed to be cleaned. Kate quickly replaced the lid and shut the closet door. She had what she needed. She quickly ran out of her Grandmother’s house, got back in her car and drove to her next stop.

“Hi — You’ve reached Kate. I’m not able to answer your call. Leave a message.” Beep.

“Hi Katie. It’s your Gram. I was just wondering if you stopped by today. The basement door was left open and the key is gone. Call me back sweetie. Okay, bye bye.” Beep.

“Hi, You’ve reached Kate. I’m not able to answer your call. Leave a message.” Beep

“Hi Katelyn. It’s your Grandmother again. I need to ask you a question. Call me back as soon as you can.” Beep.

Kate watched her phone ring over and over. She silenced her phone so she wouldn’t have to listen to the voicemails as they were left, one after the other. Averaging six minutes apart. All from her Gram. This was the only time she felt any remorse for her actions.

She was starting to get cold, her car was without heat and it was getting late. She had to figure out her evening. She pulled off the road into a small dilapidated shopping plaza where only a laundromat and a pawn shop remained open for business. She took the cigar box in her clutches and walked up to the pawn shop.

Kate’s nostrils receded as she entered the pawn shop which wreaked of tuna fish, moth balls, and possibly mold. She looked across the small, crowded shop and saw a very large man in a ripped t-shirt with a tattooed head and thick, hairy arms. She meandered over to where the man was sitting and placed the box on the glass case he was sitting behind.

“Yeah, do you want something?” the man garbled over a mouthful of tuna salad sandwich.

Kate slid the cigar box closer to pawn shop man in response. He flipped the lid onto the floor and started digging through the box with his filthy, fish-stinky hands.

“The watch is worth $60,” said the pawn shop man, “it needs to be cleaned and I have to call a guy to get it working again.”

“It’s gold! No, I need more than that. Damnit,” Kate balled her fist up and gritted her teeth, “I need more than that for this. It’s a family heirloom. What about the lighter?”

“I can give you a few bucks for that, but again. It’s old, it doesn’t work. I need to put money into that to sell it.” The pawn shop owner wasn’t about to start negotiating and Kate knew it.

Kate looked around the pawn shop for a minute and tried her best to muster a counter-offer that the owner would agree to — “Give me $80 for the watch and the lighter and I’ll get out of your hair,” Kate said in her toughest negotiation voice.

The completely bald pawn shop rubbed his tattooed head and chuckled, “Ain’t got no hair. I’ll give you $70 for both. That’s it. You’ll have to leave my shop if that doesn’t work for you.”

Kate nodded and agreed to the $70. The pawn shop owner counted out the bills on a glass case and scribbled some illegible words on a receipt pad. He ripped off the top receipt and handed it over to Kate with the money.

“Thanks,’ Kate said as she pocketed the money and the receipt. She noticed there was something occupying her pocket. She removed the brass key for her Gram’s basement door.

“Damnit,” Kate said as she turned the key over in her hands.

“You keep saying that,” remarked pawn shop man.

Kate looked up at the shop owner, nodded her head, and started to push her way out of the musty store.

“Hey lady!” pawn shop man called out, “Take your cigar box. I don’t want your trash!”

Kate stepped over to the counter and took the box from pawn shop man’s grimy, stinky hands. She pushed her way out of the musty pawn shop and got into her car. One try, two tries, three tries — Kate fought to get her clunker started. The engine finally turned and Kate’s mind moved onto the next step in her evening’s plan. The same plan she had every night for the last few years. Kate pulled her car into a fast-food restaurant parking lot, haphazardly rolled it into two spaces, and threw the car into park. She thought it best to keep the engine running. She lit a cigarette and rolled down her window. She mindlessly grabbed her phone and reviewed the screen — eight voicemails sat waiting to be heard. All from her Gram. Kate didn’t bother listening to any of the messages. She instead started scrolling her contact list so she could call Becks.

“Yeah,” Becks always answered in a way that conveyed his apathy and lack of concern for human beings.

“Hi Becks. It’s Kate. I have $70. I was wondering if I could do five tonight?” Kate took a deep breath and tried to get her hand to stop shaking. She was starting to feel sick, sweaty and nauseous.

Becks responded by screaming, “For fucking $70 you can have three and I’ll throw you a fourth one since you’re desperate as usual. What happened to everything you bought yesterday?”

Kate’s lower lip started to quiver, tears streamed down her cheeks. She responded, “I…ah…I used them already. I need more. I’ll take the four,” she took the phone away from her face so she could catch her breath. An anxiety attack was starting to ensue, “I’ll be there in a few minutes.”

Becks hung up without responding. He didn’t give any confirmation that he’d be available. He never did.

Kate put her car in reverse, pulled out of the two parking spaces her beat up car was occupying and proceeded to drive like a bat out of hell to her dealer’s apartment. As she was driving, she realized that her car needed gas. She would only make it to get her drugs tonight. She’d have to sleep in her car. Again. Hot tears formed into rivers that flowed off of her face. Kate pulled over, opened her car door to vomit, and quickly closed the door. She screamed at the top of her lungs. She was freezing. She hated herself. She hated her life.

Her cell phone lit up — another call from Gram. Four rings, five rings, six rings. “Gram?? Gram??” Kate’s terrified voice penetrated the call, “Gram! I’m so sorry!”

“Katelynn! Oh Katelynn. Look — I need that box back! The cigar box belonged to your Grandfather. The watch belonged to his Grandfather. The lighter was my wedding gift to your Grandfather. The letter was the first letter I received after not hearing from him for over six months during the war,” Gram expressed herself in a rapid fire fashion. Every bit of her fear, frustration, and absolute anger was dispatched, “Katelynn — I can’t let you do this to me. And I can’t allow you into my home any longer.”

Kate started to shake and weep. She couldn’t handle hearing her Gram convey such distress. She could barely muster a response. She especially couldn’t handle her Gram calling her Katelynn. Her name was Kate.

“KATELYNN! ARE YOU THERE???” Gram screamed through the phone, “Katelynn! Please! What is going on? I know why you keep stealing from me. We’ve been through this before. You and me. I don’t know why you would make these same choices!”

Kate buckled.

She had done it again. She had hurt her Grandmother. This time hitting really deep. Because of her addiction to pills — opiates.

“So what happened? Did she die?” I looked up from the podium to figure out where the query had come from.

“I’m sorry. Who asked those questions?” I scanned the room, but no one moved.

“Did she die?” inquired a young woman standing in the back corner of the room, “I mean, how does this end? This is just another stupid, sad story about an addict who fucked up her life. It doesn’t help us.”

I gathered my papers into a pile and placed them back into a manilla folder. I cleared my throat and responded, “Yes, you’re right. I know how often you’ve heard these stories before and…”

“Yeah, it’s just more depressing crap. Doesn’t help us. Doesn’t help us with our problems,” the young woman interrupted.

I placed the folder in my shoulder bag and set it aside on an old wooden school desk. I glanced around the space. We were collected in the basement of a Catholic church. Seven of us. Most were seated wherever they wanted to sit. A couple of the attendees were standing.

I walked over to a stack of chairs and lifted one off so that I could place it on the floor. I sat down with the other support group attendees as the young woman in the back continued with her tirade. Audibly upset, she was nearly shouting now, “So what? You’re done talking? You’re not going to tell us what happened to Kate? She died of a horrible drug overdose and killed everyone who cared about her. Right? Did Grammy die of a broken heart?”

I simply sat in my plastic chair, knitted my hands together, and placed them in my lap. I didn’t want to interrupt this young woman who clearly needed to be heard. By someone, by anyone. She proceeded to get closer to the front of the room where I sat. I could see her young face, anguished in misery, rage, and pain. An older man who was seated near the back of the room grabbed his jacket and left.

The young woman watched as he left the room. Through clenched teeth and fresh tears, she asked “How does this help me? How does hearing this story of another tragedy help me?”

I got up from my seat and gestured for this young woman to sit down. She couldn’t have been 25-years-old. Her jeans were faded, stained, and ripped. She wore a men’s hooded sweatshirt that swam on her lean and lanky frame. She agreed with a nod and walked by me. I could smell cigarette smoke waft over as she removed the hair tie from her long, black hair. She tried to casually wipe the tears and knotted her hair into a bun before she sat down in the seat I offered her. Her stained tennis shoes had holes around the toes, one was held together by five or six safety pins.

She was me, ten years ago.

I grabbed another chair off the stack and brought it over to sit next to my new friend. I sat down and cleared my throat again, “This story has a happy ending. It’s not a tragedy, although it has its tragic moments. Gram did pass away a few years ago. She passed peacefully, in her sleep, in her own bed. I spent the evening previous to her death with her — we were rummaging through her plastic bins, pulling out old photo albums, and reminiscing about my Mom…”

“We?” the young woman’s eyebrows nearly leaped off of her forehead.

A young man and an older woman glanced at each other from across the room and took their seats to the front where myself and the young woman were seated. Both sat down so that a small circle had formed among the four of us. Everyone else had left.

The young man asked, “How do you kick this?”

The older woman nodded and said, “Yes, I have been addicted to these pills since my knee surgeries two years ago. I can’t get off!”

Gulping back tears, remembering where I was just a few years ago, I responded, “I kicked this with my loved ones holding my hands and never giving up on me. More than anything else though, I didn’t give up on me. I wanted better for me than my own Mom wanted. She died of this addiction. I chose not to die. That’s how you kick this. You decide to live every day. For yourself first, and then your loved ones.”

The young woman mumbled and shook her head, “No one cares about me. I don’t have anyone to hold my hand.” The young woman started sobbing. I reached out for her hand and held it while she cried.

“I am holding your hand now. I will continue to do so if you decide to live. I have walked in your shoes. I absolutely care. My name is Kate.”

Featured Photo Credit: Pixabay

According to the Anxiety and Depression Association of America, Depression is the leading cause of disability in the United States among people ages 15–44. In 2015, 16.1 million American adults over the age of 18, or 6.7% of the total adult population in the United States, had experienced at least one depressive episode. A recent report issued by the United Nations and the World Health Organization (WHO) revealed that depression is the leading cause of illness and disability for children aged 10 to 19 years old. And according to the WHO, 350 million people, or 5% of all human beings struggle with depression globally.

Depression is a mental illness that impacts every walk of life, regardless of social status, race, age, ethnicity. If you’re human, chances are you’ll have a go with depression at some point during your lifespan. If you’re a woman, those chances increase. In fact, 1 in 8 women will experience clinical depression at some point in their lifespan, according to the National Institute of Mental Health. According to the American Psychological Association, 1 in 7 women will suffer from postpartum depression or some type of perinatal mood disorder. All of these figures and statistics are based on reported diagnosis, and don’t account for the un-reported cases in which stigma associated with mental illness plays a serious role. So these figures realistically may be higher across the board.

To say that we have a pandemic of depression is an understatement. The problem is only projected to increase according to the WHO — by 2030 the amount of disability and loss related to depression will exceed any other condition including stroke and cancer.

Depression is a multi-faceted condition that may or may not cause full disability. Regardless, it certainly encumbers and dampens life for those who do suffer from this condition. Diagnosis usually hinges on symptoms perpetuating for more than a couple weeks. Those symptoms vary greatly from person to person and may include a persistent sad, anxious, or “empty” mood, feeling helpless, feeling worthless, lack of energy, fatigue, feeling restless, inability to rest, oversleeping, increased or decreased appetite, pain, digestive issues, difficulty focusing, memory issues, ineffective decision-making, loss of interest in typically pleasurable events and activities, suicidal ideation, intrusive thoughts, and thoughts of death.

Causes of depression are as varied as the people who suffer from it, and the symptoms that comprise the condition. There are genetic, biological, environmental, and psychological factors involved. And the effects of the condition may permeate into every facet of the struggling person’s life.

Indeed, I am one of those struggling persons, and depression does impact just about every aspect of my life. Depression causes me to have insomnia, causes me to lose my appetite completely, to have absolutely zero focus, and basically fight all day long to stay on task and stay present. In addition to the above, I get to battle the fatigue left from not being able to sleep. Interactions with my family are not exactly sitcom silly when I’m depressed, and the guilt I feel for being a sad Mommy is more than I can bear most days. It’s a sick, sad, not-so-merry-go-round. A ride that I’ve ended up on too often in my life and one that I am slowly but surely learning how to get off of more efficiently.

So what does this nurse do to help herself with bouts of depression? First of all, I have to cultivate awareness for where I’m at because being stuck in a depressed mood makes everything clear as mud. It also amplifies stressors and in the face of depression, I have no energy to deal with unnecessary stressors. I start by getting quiet and detaching from the electronic world. A holiday from my phone, from social media, from my laptop where most of professional life resides is just what I need to start fresh. If you are struggling in any way shape or form with stress, I recommend trying this! Detach. See how you feel. Also note how many times you go on autopilot to embrace your little glowing box of power, light, and information — you may be really surprised how often your brain asks for that device. Admittedly, I go through a little detox each time, but it’s not uncomfortable because I realize how much time I have to care for myself. Plug in the good things that your devices take you away from — spending time with a child, taking a walk, taking a nap, journaling, drawing, creating art, creating music, practicing yoga. If you gave up your phone for even a few hours, what would you do with those hours? For me, detaching from electronics literally frees me up for self-care. It may do the same for you.

Next — move! Move your body. Most people who are struggling with depression also struggle with tension and pain. The physical body literally becomes depressed, slow, sluggish, clumsy, not well-functioning. Thankfully, we have built in healing chemicals that help to relieve all these icks. When you move (or for those of you familiar with this four-letter word “exercise”) your body releases it’s own kind of morphine called endorphins. These endorphins bind to the same receptors that opiates do, but they’re created for your body, by your body. So they’re completely safe and guess what? They will make you feel better. Start with a walk. I am a yogini, a practitioner of yoga and I am also a teacher. I tend to work stuff out on my mat, but when I’m really depressed and fatigued, I push for a walk outside for 10 minutes. This 10 minute walk always ends up being longer, but my soggy brain seems to agree that a 10 minute walk is feasible in a depressed state. Trick your brain, it’s okay. When you have endorphins flowing through your body, you will have effectively used your own body’s healing properties to relieve symptoms.

Lastly (but not least), I prefer to medicate with cannabinoid therapeutics to stimulate another healing entity in my body — the endoCannabinoid System. This network of receptors is found throughout the body in the nervous and immune systems. It is homeostatic in nature — its purpose is to regulate all of the other physiological systems. Just like our bodies create its own supply of morphine, our bodies create its own supply of cannabinoids too. My endoCannabinoid System does well when it’s nourished and upregulated with whole food nutrition, meditation, yoga, movement, and sweet sleep, but when I’m depressed, it really benefits from plant-based cannabinoid supplementation. I find that cannabidiol (CBD) oil provides a calming effect that allows me to be present. CBD turns the volume down and allows me to focus. I typically vape quality CBD oil, or administer CBD oil under my tongue — sublingually. Tetrahydracannabinol (THC) helps too in very low doses— It lifts my mood, helps my brain process pain differently so it’s no longer the focus, and allows me to smile which is no easy feat in the face of the depression I struggle with. I use THC sparingly when depressed because I don’t want to escape my symptoms, I want to treat my symptoms. And in the past, THC was certainly an escape. (There’s that awareness piece again!)

In closing, it’s important for me to note that everyone is different and everyone who is struggling with their own depression needs to choose the methods of healing that best serve them. Perhaps that’s the best piece of advice I can provide here — There are many avenues to healing from any chronic condition, including depression. What may work for me may not work for someone else. But healing won’t happen without effort. If you are struggling with depression, I implore you to take out your own map and try walking down the avenues that interest you. Maybe conventional medicine holds the key to you feeling better. Maybe cutting out sugar and process food would help. Maybe meditating at a silent retreat for ten days is what you need. (Worked for me at one point.) Keep trying different things until you find the elements that make you feel better, that help you feel whole again. After a while, you’ll have your map memorized and you may come into another obstacle of depression, but you will remember that you can find your way home. You’ve done it before. It’ll get easier. One breath, one step, one decision to prioritize self-care at a time.

If this article resonates with you and you’d like help from me, please reach out via email — marissa@greennursegroup.com. Or check out GreenNurseGroup.com to learn more about how we can help you find your way onto your own healing path.

If you or a loved one are struggling significantly with intrusive thoughts, suicidal ideation, or thoughts of death — please know that there is help, you are not alone. Call the National Suicide Prevention Lifeline 1–800–273–8255.

The Elite Gel is comprised of hemp-derived CBD, several terpenes — limonene, B-pinene, B-Carophyllene, purified water, some natural fragrance, and the PLO gel — a pharmaceutical grade transdermal gel. The pen is discreet and easy to use. I was able to keep the pen on my person and apply it without needing to find a private place to medicate.

Per the product instructions, twist the end of the pen clockwise to unlock, remove cap, and depress end to dispense product. Apply product to clean skin in a veinous, not fatty area of the body. Examples of these regions of the body include the temples, inner wrists, ankles, top of the foot, and behind the knees.

I explored with different sites of application. Initially, I wasn’t a fan of the smell, so I applied it to the top of my foot. I wasn’t sure what to expect, so I sort of forgot that I had applied the gel and moved on with my morning. While I was driving, I realized that the foot that had been bothering me no longer bothered me. I had a touch of plantar fasciitis in my right foot — inflamed connective tissue on the bottom of the foot near the heel. And that pain usually makes itself known when I press on the accelerator in my vehicle. This pain was completely resolved by the transdermal gel. The 2mg dose lasted for the entire day and I didn’t remember my foot was sore until the next morning. I was impressed and surprised to say the least.

I was still struggling with anxiety and didn’t find relief from that symptom by applying the transdermal gel on my foot. So I tried another site. I decided to deal with the smell that I wasn’t too keen on. I applied a 2mg dose of hemp-extracted CBD to my temple in the morning and went about my workday. The smell bothered me for about ten minutes, but then I didn’t notice it. I did notice that tension in my face was relieved and I did feel more calm. I could definitely deal with the smell in exchange for the symptom relief. The morning dose kept me symptom free for a few hours. I reapplied in the afternoon on the opposite temple and once again, pain and anxiety were relieved for the rest of the day.

It has been a few weeks since I started using Mary’s Nutritionals Elite Gel Pen. It is definitely a product that I have integrated into my self-care repertoire. In that time, the smell has really grown on me. I really like it now despite typically being very sensitive to anything with a fragrance. And I have found that an application to bilateral sites (both wrists, both temples) works best for longer, more effective relief of symptoms. For the transdermal gel to be effective, I would apply a 2mg dose to each side. And I would repeat on average 4–6 hours later. For anxiety relief, I found that I had to apply the gel to my temples. For pain relief, the gel was most effective when applied to the veinous site closest to the tension. Hence the reason why this impressive transdermal product relieved the symptoms of plantar fasciitis when applied to my foot.

For anyone who values discreet methods of cannabinoid application, I highly recommend Mary’s Nutritionals Elite Gel Pen. I also recommend that anyone seeking relief from symptoms should work with a qualified health provider for guidance in using cannabinoid-based products, or when integrating cannabis with conventional, holistic, or alternative therapies. It’s the best way to keep yourself safe, and to manage symptoms efficiently and effectively.

To this end…The information provided is for educational purposes only and is not meant to substitute for medical or health advice, diagnosis, or treatment. The information provided is not intended to replace consultation with a qualified health provider. And now that the disclaimer is done, I lift my Mary’s Nutritionals Elite Gel Pen to you — May your symptoms be relieved, may you be well. Here’s to your health!