Flu season, COVID updates; marijuana in cancer treatment: Upstate Medical University's HealthLink on Air for Sunday, Oct. 30, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air:" an infectious disease doctor provides an outlook for this year's flu season. She also talks about COVID-19 and the potential for a "twin-demic."

Elizabeth Asiago-Reddy, MD: ... When we think about the combination of COVID and flu rearing their ugly heads together is that influenza is less contagious than COVID, and so it has been a little bit easier to suppress influenza with the measures that have been taken for COVID ...

Host Amber Smith: And a radiation oncologist explains how marijuana can help patients in cancer treatment.

Karna Sura, MD: ... The nice part about medical marijuana is, although classically most people try to smoke marijuana, you can obtain it in a powder form, vaping form, lozenges. There's a lot of options. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll get an update on the pandemic going into fall/winter. Then, a radiation oncologist shares his research into the use of medical marijuana among patients in cancer treatment. But first, the best way to guard against influenza this season.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." As the weather turns cooler in Central New York, it's time for picking apples, raking leaves -- and scheduling flu shots. Here with me is Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate University Hospital, and she's here to talk about this year's flu season. Welcome back to "HealthLink on Air," Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you for having me, Amber.

Host Amber Smith: Is it true that incidence of flu decreased during the pandemic?

Elizabeth Asiago-Reddy, MD: Yes, it did. And it was quite significant and very much related to the degree to which people were masking, as far as we can tell.

Host Amber Smith: So what about this season, then? People aren't really masking that much.

Elizabeth Asiago-Reddy, MD: Yes, we have reason to be concerned that the flu season this year will be more difficult than it has been for the last couple of years. And one of the major concerns that we have is because we have the data from the Southern Hemisphere, where they've already experienced their flu season. And it was quite a difficult flu season, for example, in Australia, with a lot of young people getting sick in particular, because those young people likely had not been as much exposed during their early lives to circulating influenza due to the reductions we just talked about.

Host Amber Smith: Does the continued presence of COVID -- because that's still in our community, and it's overseas, it's everywhere, still -- does that impact, or will it impact, flu rates?

Elizabeth Asiago-Reddy, MD: So I think, like I was mentioning before, the most likely impact is going to be on any mitigation strategies that we use to kind of keep people apart from each other during the flu and COVID season. So I already brought up masking. Of course there were others, where we reduced the amount of gatherings that people were having, or the number of people who were attending gatherings. That really seems to be the major driver of whether or not we experience high levels of flu, as well as high levels of COVID. So both of them are infectious viruses. Both of them are transmitted through respiratory routes. So when you get a bunch of people together, then you could experience high levels of one or the other.

Host Amber Smith: If a person is sick with flu, does that make them more susceptible to catching COVID, or does it protect them from COVID?

Elizabeth Asiago-Reddy, MD: These are two completely different viruses in terms of their lineage, how they're structured. They have different ways they interact with our immune system. So it's not thought that one would confer immunity to the other. Whether or not our immune systems responds to one -- so, say if I just got over COVID, am I more susceptible to another virus? -- I don't think we have enough information to say that for sure. Basically you would see this as the risk of anything that you come in contact with, you could potentially get it. You know, if you don't have immunity to it, you could potentially get it.

Host Amber Smith: Could you get both at the same time?

Elizabeth Asiago-Reddy, MD: Yes, unfortunately. And that was seen during the flu season in the Southern Hemisphere, that there were, especially, young people who were getting both at the same time.

Host Amber Smith: Most people who get the flu will recover from it, but each year, the flu kills thousands of people. Can you explain why it can be a deadly disease in some people?

Elizabeth Asiago-Reddy, MD: There are two main factors, and we've gone over some of the very similar things with COVID. So the first is the immune status of the individual who is experiencing the infection, and anyone who has immune compromise is at elevated risk of severe complications. That includes very young people as well as older individuals and people of all ages with immune-compromising conditions, including pregnancy. And then the other factor is whether or not your immune system has experienced this particular virus in the past. As it relates to COVID, we saw that a lot of the infections were particularly severe when the virus was new because, basically, no one had experienced this particular virus before.

And influenza has the capacity to shift the proteins on the surface. When those proteins shift, it may become a virus that looks more or less similar to viruses that people have experienced in the past. So the goal of influenza vaccination is to try and keep up with the shift in the virus, which I know we'll talk about a little bit. But whatever viruses end up predominating, the extent to which people have been exposed to similar viruses, either through past infection or through vaccination, will play a major role in the degree to which people get sick.

Host Amber Smith: I wanted to ask you about the reliability of the flu vaccine in preventing people from getting the flu. So let's start with who needs to be vaccinated. Are we talking about children, pregnant women, the immune compromised? Do they all need to be vaccinated?

Elizabeth Asiago-Reddy, MD: Yes. All of those individuals are recommended for influenza vaccination, and that is starting from 6 months of age. Prior to age 6 months, the infant is expected to have some immunity transmitted through their parent, hopefully, especially if immunization was received during pregnancy. So after age 6 months, all the way up, it is recommended to get an annual flu vaccine. Babies who are 6 months of age, they will need to get two vaccines to get started because it takes more to generate that initial response to the vaccine. After that, individuals would receive a single dose of vaccine every year.

Host Amber Smith: You and I are speaking at toward the end of October. This is flu-shot season, but when is it too late to get your flu shot? You want people to get them now, right?

Elizabeth Asiago-Reddy, MD: Yes. September and October are the ideal times because what you want is a nice peak of antibodies at the time when the season is really peaking itself. So if you get vaccinated in September or October, you'd be anticipated to have high levels of antibody throughout the flu season. If you're vaccinated too soon, the antibodies might wane by the time the season is still in gear, and so you might miss out on some degree of protection. The only exception to that, in terms of early vaccination, is pregnant women. So people who are pregnant in their third trimester during the summer, if they have access to the vaccine, it is recommended that they be vaccinated during that period of time because those antibodies could nurture their infant during the flu season.

Host Amber Smith: Is it safe to get a flu shot at the same time you get the COVID booster?

Elizabeth Asiago-Reddy, MD: Yes. And CDC (Centers for Disease Control and Prevention) is recommending that. Obviously it's much more convenient to get the two of them at the same time if you're recommended for one, or either, or both.

And the other thing I want to mention is that if you miss out on being vaccinated. During September or October, that doesn't mean that you should skip the whole season. It would still be recommended that you should go ahead and get your vaccination whenever it is that you happen to be seen by your provider, or you happen to have the opportunity to go and get vaccinated. And that recommendation would last all the way up through the early spring, potentially as late as March, because we continue to see circulation of influenza virus all the way through the end of April.

Host Amber Smith: We've been talking about flu shots. Is there a nasal, or inhaled, option this year?

Elizabeth Asiago-Reddy, MD: There is, although it is less available because of a lot of stipulations and restrictions related to its use. So it's only available for certain age groups, age 5 to 49, and it's also only available for individuals who do not have immune-compromising conditions, pulmonary conditions, cardiac conditions, and who are not in contact with any immune-compromised individual. Given all of those different features, many of the places that offer flu vaccines do not stock that one, although some practices do stock it.

Host Amber Smith: I understand there are a lot of different brands of the flu shot on the market. How should someone go about choosing which one is right for them?

Elizabeth Asiago-Reddy, MD: Generally speaking, all of them will have similar efficacy in looking at the accumulation of trials that have happened over the last several years. It is important for people who are age 65 and older to have either the high-dose vaccine or adjuvanted vaccines, because those have shown to increase the efficacy of the vaccine in older individuals significantly. And, I think the practices, pharmacies, etc., that are stocking these vaccines are well aware of that and will typically be stocking the doses for younger individuals and those for age 65 and older. But certainly that's an important question to check on if you are in that age group.

Otherwise the only other thing to consider is, potentially, someone with a very severe egg allergy. There are certain kinds of flu vaccines that are prepared on eggs, whereby someone with a very severe allergy has a theoretical risk of having a reaction to that vaccine. And there are others that are genetically engineered, which do not have, they're not created in eggs. So anybody who has an egg allergy could seek out one of those specifically. Interestingly, however, because the proteins are so incredibly broken down, even in the egg-based vaccine, there are no data actually to show that people who have egg allergies have a reaction to that vaccine. So CDC actually recommends to go ahead and get whatever one is available to you, but that if you do have a severe egg allergy and you're getting one of the egg-based ones, you should do it in a clinical setting where you can be monitored afterwards.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago-Reddy.

She's the chief of infectious disease at Upstate University Hospital, and we're talking about the 2022/2023 influenza season.

I know people should stay home from work or school when they're sick to avoid spreading germs. So let's go over the symptoms of flu. Is there distinguishing characteristics that can help with the diagnosis?

Elizabeth Asiago-Reddy, MD: You know, any respiratory virus is going to have a variety of symptoms, right? So all of the typical respiratory symptoms -- cough, sore throat, nasal congestion, fevers -- are going to cross over for most of the respiratory viruses. If you look at some features that might be more classic for flu, it's the sudden onset and high fevers are kind of classic, compared to some of the other respiratory viruses. So it tends to have more severe symptoms, and more lower respiratory tract symptoms with cough and pneumonia, compared to some of the other respiratory viruses, which may present more with the nasal congestion and not be as likely to cause high fevers and severe coughs. But that having been said, you truly can see the whole spectrum of illness with influenza.

Host Amber Smith: I know there are COVID tests available over the counter. Is there anything like that for flu that a person could take to tell them whether it's influenza or not?

Elizabeth Asiago-Reddy, MD: As to my awareness, these have not been approved for, in-home use at this point. And that really gets just to, the demand and need for the test, which was so high for COVID that the processes were in place to try and make them available. Rapid tests are available for flu. They're administered typically in a clinical setting, so the possibility exists that that could move into the home setting in the future.

Host Amber Smith: Now if someone is feeling a little bit under the weather, but they live alone, they need groceries, would it make sense for them to wear a mask to guard against them spreading disease and run into the grocery store? Because during COVID we were masking kind of to protect ourselves. So this would be kind of the opposite of that. Would that be helpful?

Elizabeth Asiago-Reddy, MD: I would say absolutely it is helpful. I mean, everyone has to kind of weigh the pluses and minuses of the different decisions they're going to make. But, if you're known to be COVID-negative and as far as you're aware, and you're concerned that you have respiratory symptoms, but you need to interact with others, absolutely. Wearing a mask is a very viable way of protecting other people. And in fact, that is what in the past we would typically ask even health care providers to do if they had influenza. So for example, if a health care provider was infected with influenza, after their fever was gone for two days, they would be required to wear a mask until all their symptoms had been completely resolved. So that's definitely a known phenomenon and way of protecting other people.

Host Amber Smith: In terms of treatment, how would you advise someone to take care of themselves at home if they suspect they have the flu?

Elizabeth Asiago-Reddy, MD: As with any infection or any concern that you have healthwise, if you are concerned about how you feel, your symptoms are significant, obviously touching base with your primary care provider is very important because some individuals might be eligible for treatments. They might be recommended to get testing done to assess which treatments they might need. So that's always very important to keep in mind. And otherwise, once you have determined your treatment status, then there are no specific home remedies for influenza. Similar to other respiratory viruses, this is symptoms management, so things that make you feel better -- rest, hydration, and possibly over-the-counter medications to reduce your symptoms.

Host Amber Smith: How long might it take to recover from influenza?

Elizabeth Asiago-Reddy, MD: This is variable, but, it can definitely, on average be about a week before someone is recovered, and it could be shorter or longer depending on their vaccination status and immunity and overall health, et cetera. But it oftentimes can be about a week.

Host Amber Smith: If a person is infected with the flu in October, early in the flu season, does that protect them for the rest of the season from catching it again? Or do they still need to look at a vaccination maybe?

Elizabeth Asiago-Reddy, MD: So it may not protect them because, the vaccines that we receive are targeting a number of different influenza viruses to include two different versions of influenza A as well as two different versions of influenza B virus. So, you would still actually be recommended to get your vaccine. And unfortunately, somebody could experience an infection with a different virus, particularly, the possibility of influenza B, if you started out with A. B tends to peak later, which is why I chose that order in my head as an example.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but when we come back, we'll be talking with Dr. Elizabeth Asiago-Reddy about what's expected to happen with COVID-19 this fall and winter.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith, with my guest, Dr. Elizabeth Asiago-Reddy, the chief of infectious disease at Upstate University Hospital. We've been talking mostly about flu season, but now we're going to shift the conversation a little because some health officials are worried that the United States could see a "twin-demic" outbreak of flu and COVID at the same time as we get into the winter months.

Are you one of those health officials?

Elizabeth Asiago-Reddy, MD: Yes, I'm definitely concerned, and I think the main reason behind that is that we've seen a huge change in people's behaviors over the last six months with respect to the degree of social distancing or masking that's happening. There's been a huge reduction. And some of that is very much reasonable in the sense that we have seen that there has been, on average, a significantly reduced risk of hospitalization overall from COVID in the last several months. And we have not currently been in a flu season for the last several months. So I don't think that it's unreasonable that people have started to get back to their lives, but, we are worried about this upcoming winter season. We typically will see peaks of COVID, over the last several years, during the winter months.

And, I think what's different, when we think about the combination of COVID and flu rearing their ugly heads together is that influenza is less contagious than COVID. And so it has been a little bit easier to suppress influenza with the measures that have been taken for COVID thus far. But with those measures dropped completely and the fact that many people have not experienced any exposure to influenza over the last several years, it raises the possibility that we will see a lot more flu. So if we see a lot more flu, then of course a certain proportion of those individuals are going to unfortunately be sick enough to go in the hospital. So that is the concern, that we would have our typical peak in COVID, or at least some degree of peak in COVID, with a peak in influenza, which we haven't seen for the last couple of years.

Host Amber Smith: COVID has killed more than 6 1/2 million people worldwide, including more than a million in the United States. Are you still seeing people who are severely ill with COVID?

Elizabeth Asiago-Reddy, MD: I am. And in fact, I've been seeing it more this fall as I've been covering the inpatient service in the hospital. And we have seen our hospitalizations tick up a little bit over the last couple of weeks, putting us into a high-risk zone for the last several weeks. So yes, I am seeing that. And it's not the way that it was at our most severe. So we haven't breached the heights of what we saw, for example, in the winter of 2021 or early 2022. But yes, we are seeing some significant increases, and we are still seeing people, unfortunately, really sick enough to end up in the ICU (intensive care unit) and to even die from COVID. It is still happening.

Host Amber Smith: Are these people who never got vaccinated?

Elizabeth Asiago-Reddy, MD: Certainly the risk overall of death and hospitalization remains markedly increased for people who have never been vaccinated from COVID, and the data are available on the CDC (Centers for Disease Control and Prevention) website as well as several other websites. So you're looking at anywhere from a five to 20 times reduced risk of hospitalization associated with vaccination, some of which depends on whether or not the individual has recently had a booster vaccine. So recent booster vaccine is going to decrease your likelihood of severe illness significantly. And then also whether or not the individual has experienced past episodes of COVID infection. So it is true that there's some cumulative immunity from illness that has occurred as well.

Host Amber Smith: So what about the risk for people with compromised immune systems? Is that still very real?

Elizabeth Asiago-Reddy, MD: It is very real. Andthese individuals form a large proportion of the individuals who I see in the hospital with COVID. It's true that still with both COVID and flu, there are cases where somebody becomes extremely, severely ill and requires hospitalization with no known medical problems. We don't know why it's happened. It still happens. That is happening less than what we saw at the beginning of the COVID epidemic. We are seeing more of individuals with higher age groups as well as immune compromising conditions as a risk factor for severe COVID.

Host Amber Smith: Are infants and elderly still at higher risk for COVID?

Elizabeth Asiago-Reddy, MD: Absolutely, yep, on both counts, but particularly, increasing age is a very significant risk factor for severe COVID. For the youngest individuals at this point we are actually, potentially, even more worried about flu, although we're worried about both, because the rates of COVID vaccination and infants have been very disappointing. So there is, for sure, concern for those young age groups as well.

Host Amber Smith: In the early days of the pandemic, there were public testing sites, contact tracers, and it seemed like everyone who got infected was being counted by someone. But now with home testing and milder infections, thanks to vaccinations, it seems like health officials no longer have an accurate count. Does that affect how the pandemic is being managed?

Elizabeth Asiago-Reddy, MD: Yes, absolutely. It is well recognized that we are not able to fully count COVID infections for two different reasons. One is that we don't have access to information about home tests. In the large majority of cases, people don't report those. And then the other is the recognition of the number of people who are having asymptomatic COVID infections, which is extremely high. So some data suggests that up to 50% of omicron infections may be asymptomatic, and yet those individuals could still transmit illness. So we really don't know the exact numbers of people, so what we've started to look at to get a better sense is actually the hospitalization rates. So, hospitalization rates have become a critical component of making a decision as to whether an area is high risk or not high risk.

So as we see overall the level of severe illness declining, even when numbers of cases are high, what becomes most important is have we preserved our ability to hospitalize those who need to be hospitalized by having room in the hospitals and adequate staff to care for them? And then No. 2, do we have adequate staff and room in the hospitals to care for people who have other medical conditions that need care aside from COVID or other respiratory illnesses?

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate University Hospital, and we're talking about where things stand with the COVID-19 pandemic.

So let's talk about the COVID vaccine and its boosters. If an adult got vaccinated as soon as the vaccine was available, how many boosters should they have had by now?

Elizabeth Asiago-Reddy, MD: So definitely up through the last couple of months, it would've been recommended that they had at least one booster and possibly two. So the primary series for your mRNA vaccines is two vaccines. Most individuals did receive mRNA vaccines, so I'll focus on that. And then after that, all individuals would've been recommended for a booster, or a three-dose series if they're a child. And then, depending on their health conditions and age, many would've been recommended for an additional booster of the same formulation as the initial series of vaccines.

Now starting approximately one month ago, we had the availability of the new bivalent boosters, which we can speak more about. So up until the time when those were available, like I said, most people should have had at least one or two boosters. And, that's with the mRNA vaccines. With the Johnson vaccine, either a second dose of Janssen (Johnson & Johnson) or a booster of an mRNA vaccine was recommended.

Host Amber Smith: What is the bivalent booster that's available now, and how does it differ from the earlier boosters?

Elizabeth Asiago-Reddy, MD: The bivalent booster contains the original, so it contains a message for our body to create -- again, I'm speaking about the mRNA vaccine -- so, a message for our bodies to create a spike protein of the coronavirus, and it contains two messages. One is to create the old version of the spike protein that was circulating initially when the epidemic first began, and then also to create an updated version of the spike protein that more closely matches omicron strains that are currently circulating. And that offers us the opportunity to really create a very robust immune response that is more likely to protect us against what's actually out in the community right now.

Host Amber Smith: So if someone never got a vaccine and they go to the pharmacy now, are they going to receive that bivalent as their vaccine?

Elizabeth Asiago-Reddy, MD: No. It's still recommended to start out with the primary series of vaccination. And a big part of the reason for that is that we have an understanding of how many doses one should receive before a full immune picture is realized within our immune system. So if I started out with the mRNA series, I would still be recommended to get two baseline doses, followed at least a month later by the bivalent booster. So I actually would be recommended up front to receive a three-dose series of vaccine. The booster would really be included in that initial recommendation.

There are other vaccines that are available. So I wanted to mention that Novavax is the vaccine that is available now, which was not previously available, which is a protein based vaccine. So there's no mRNA in it. It's not an attenuated virus, which the Johnson vaccine is more similar. The Johnson vaccine is not exactly an attenuated virus, but it's taking a weak virus and putting the message for the COVID spike protein inside that weak virus. The Novavax is strictly a protein, and a lot of people may feel more comfortable with that because it's the basis for the vast majority of the vaccines that we typically administer. So, that is a possibility for someone who has been waiting for that type of vaccine to go ahead and get their primary series. But yes, you would start out with the primary series and then from there one would move to a booster.

Host Amber Smith: At this point, if someone develops symptoms -- fevers, chills, cough, headache -- and they test positive for COVID-19, what advice do you have for how they should treat themselves at home?

Elizabeth Asiago-Reddy, MD: You should call your health care provider to see whether you're eligible for any treatments. There still are a number of treatments that are beneficial to people with specific health conditions who are at high risk of the possibility of severe COVID. So that's No. 1. Make sure that you have discussed whether or not you would be eligible for one of those treatments. That information is also online, so you could try to make some sort of a determination. But of course, speaking with healthcare provider is your best course of action.

And then from a symptomatic perspective, it's a matter of continuing to rest, adequate fluids and keeping an eye on symptoms that would be concerning to you. So certainly if you are experiencing severe symptoms, you're severely short of breath, or you're concerned that you're not able to hydrate yourself, for example, those would be emergencies that would need to be addressed either, again, with a call to your health care provider, or even a visit to the ED (emergency department).

Host Amber Smith: Well, Dr. Asiago-Reddy, I really appreciate you making time for this interview.

Elizabeth Asiago-Reddy, MD: Thank you so much.

Host Amber Smith: My guest has been Upstate University Hospital's chief of infectious disease, Dr. Elizabeth Asiago-Reddy. I'm Amber Smith for Upstate's "HealthLink on Air."

Why don't more people in cancer treatment seek relief from medical marijuana? -- Next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air". Almost half of patients in cancer treatment never obtained medical marijuana that was prescribed, and a team of researchers from Upstate wanted to understand why. With me to talk about the study that was published recently is Dr. Karna Sura. He's an assistant professor of radiation oncology at Upstate. The study was called "Experience With Medical Marijuana for Cancer Patients in the Palliative Setting," and it was published in The Cureus Journal of Medical Science. Before we get into the goal of the study and what you found, can you first tell us what palliative setting means?

Karna Sura, MD: Palliative setting is usually for patients in pain, or, classically,in stage 4 (late stages of cancer) settings. But I think the idea of palliative medicine has actually expanded across every patient just to kind of help with pain and discomfort, as well as just symptom management.

Host Amber Smith: Regarding medical marijuana, why might it be used in cancer treatment?

Karna Sura, MD: Marijuana in general, people use it for that euphoric feeling, but it can be used for nausea, vomiting and the munchies. Those different options are very effective for cancer patients, because usually that's the biggest problem is weight loss, nausea, vomiting. So, marijuana, being a natural substance, may be an option for these patients and actually fix a lot of problems with one medication.

Host Amber Smith: Does it have to be smoked?

Karna Sura, MD: No, it doesn't have to be smoked. Actually, the nice part about medical marijuana is, although classically most people try to smoke marijuana, you can obtain it in a powder form, vaping form, lozenges. There's a lot of options for patients, and usually dispensaries have a variety of choices, and the pharmacist at the dispensary will discuss different options for the patient and what would be beneficial for them. So I think that's one of the misunderstandings about medical marijuana that everyone thinks, "Oh, you have to smoke it, and I'm not a smoker," but you could use many options.

Host Amber Smith: Does medical marijuana differ from regular marijuana in other ways?

Karna Sura, MD: Medical marijuana, the main difference is, when people purchase on the street, you actually don't know what percent marijuana you're getting or what you're actually obtaining. With medical marijuana, there are very strict regulations. The bottle, basically everything has to be tested and approved. The amount of THC (tetrahydrocannabinol) and CBD (cannabidiol) is all very regulated and has to be approved and tested by the dispensary. And so the New York State department of medical marijuana (Office of Cannabis Management) that regulates this is very strict about this. So you know you're getting very pure marijuana, and what percentage of each -- CBD and THC -- you're obtaining with anything that you take.

Host Amber Smith: And CBD and THC are the more active ingredients?

Karna Sura, MD: Yes, that is correct. Yes. So, although marijuana has multiple different components or ingredients in it, the CBD and THC are probably the most well known, of being the most, or the strongest or the potent parts of it. THC is more of that high euphoric feeling, usually used for eating and the munchies and nausea and vomiting, as well as some sleep. And CBD helps with more like neuropathic pain. Actually over the counter, you can find CBD now and buy it. But usually, the type of CBD you're getting under the medical marijuana is usually much more regulated and much purer than you would get really over the counter.

Host Amber Smith: Now, why did you decide to research this topic?

Karna Sura, MD: I think it's a really interesting topic. You know, patients really want kind of non-pharmaceutical methods of treatment, and I think medical marijuana is one of those really, potent non-pharmaceutical that we could potentially use for patients. And I think there's a lot of questions and stigma, and there's not enough information about this. And the big problem is federal research is kind of limited on medical marijuana. And obviously it's not a prescription drug, so there's no money for trying to find information or trying to actually study it in a randomized fashion. So I was really interested in just our patient population. Does it work? Are people using it? You know, these are questions that we actually didn't know, and it was very helpful to actually get the basic data so that we could better inform our patients as well as think of future studies that we can actually use and try to get more information.

Host Amber Smith: So you focused on patients that are treated at Upstate from Central New York?

Karna Sura, MD: Yes. The goal was to look first here because we use medical marijuana quite a bit for our patients here in Upstate. And actually a lot of the providers are in the palliative care department that actually will prescribe it. So we have a very focused method, a multidisciplinary method that we all work together in a framework, but our palliative medicine providers are the ones who do the pain management and medical marijuana. So it's really nice, and it was an easier study because there's not too many bodies that are involved in this. There's only a couple people (providers.) So we can kind of focus on those patients and the patient population.

Host Amber Smith: So how did the study work? I'm curious how many patients enrolled and how long this was underway.

This was a retrospective study, so we did like a retrospective chart review of the patients. The goal was to kind of start when the database was, whatever information it kind of started from. And our endpoint was just basically when we data collected. And so the goal was to see 1. patients enrolled in the database, or people who obtained a certificate. And then actually chart check them and see how did they do during this time period? So, the hope is from this retrospective study that we can actually do prospective studies and collect patients and have more direct impact and understanding as they're going through the process. But retrospective studies are kind of our first level of, to learn of the information that we have so far.

Host Amber Smith: This is Upstate's HealthLink on Air with your host, Amber Smith. I'm talking with Dr. Karna Sura. He's an assistant professor of radiation oncology at Upstate, who, along with a team of researchers, examined the experiences of cancer patients who were prescribed medical marijuana during treatment.

What did you discover, and were you surprised?

Karna Sura, MD: One of the discoveries was, as you pointed out, the number of patients who did not use the medical marijuana program, even though they were enrolled. I think we found a lot of different reasons for that. And, I think the biggest issue is, a lot of times, is patients are referred too late, or they may be going into hospice care, where medical marijuana is not easily obtained in that setting. This has changed since then, but medical marijuana, the biggest problem is that you can't go to a pharmacy. You have to go through a dispensary to actually obtain it. And so these dispensaries are limited at certain places, but you have to either send yourself or caregiver to obtain it. Now the regulations have started to ease a little bit, so there's more ability or more access, but it will take some time for patients to have more access to obtaining medical marijuana.

Host Amber Smith: Well, walk me through this, if you would. If a person is prescribed medical marijuana, what happens after that? What do they have to do to actually fill that prescription?

Karna Sura, MD: So the first step is, patients come and are identified for being accepted for medical marijuana. We talk about the reasons, the rationale, pros and cons of them with the patient. Once that happens, how the New York state program works is, we enroll them into the database. So, we accept and say as a prescriber, that this patient would be eligible for medical marijuana. We have to write the reason, the rationale behind it, fill their information. Once that's done, we give them the certificate saying that they are acceptable for medical marijuana, and the patient actually has to go to the database themselves and fill in their information. They're then sent an ID card, actually, in the mail, which is a medical marijuana card, and the card is what they need to actually go and get the medical marijuana. So once they have the ID card, they go into the dispensary with the card, and the dispensary will have a pharmacist there who will actually talk through them about the different options. And then the patient can buy the medical marijuana right there. So it's a little bit of a different process. We don't really, the doctor is not giving them a script to say that you need to take so much medical marijuana. It's usually more so the patient and pharmacist driven. We're just giving them the barrier to access it, basically.

Host Amber Smith: So are the dispensaries inside existing pharmacies, or are they separate structures?

Karna Sura, MD: They are all separate structures. There're a bunch of dispensaries in Syracuse. There's a couple in the outskirts in, around the area, but they're all separate structures and separately regulated. And the worst part is they're all cash. There's no credit card, nothing like that, because of how the law works. So everyone has to have an ATM there that you can use. But you have to pay everything in cash.

Host Amber Smith: Is it covered by health insurance, generally?

Karna Sura, MD: No. Nothing is covered by health insurance. Like I said, it's basically a cash transaction. It's pretty expensive, or can be expensive, for patients who are on fixed incomes. There's really no options. No insurances will cover it. And again, part of this has to do with the federal laws behind it. Part of it is the medical marijuana and the DEA (Drug Enforcement Administration) classification, but part of it is the federal banking classification that basically certain activities are regulated. So it gets complicated. And a lot of credit card manufacturers and banks don't want to get involved with it, so there's a little bit more of a restriction on that.

Host Amber Smith: How do you counsel patients who are reluctant because they fear becoming addicted?

Karna Sura, MD: The biggest problem with addiction is, in general, even with pain medication and medical marijuana, I think we are trying to fix a specific problem with a goal in mind of an ending, OK? And I think a lot of times with addiction is that you're kind of trying to fix a problem with not actually fixing the underlying issue. So a lot of times with cancer treatment, it's a symptom control for a reason, meaning the cancer pain or nausea, vomiting from chemotherapy. So once you stop the chemotherapy, that goes away, and we really don't need the medication anymore. Or usually the patients are less reliant on that. So it's a little bit different, I think. And, and I think there's a lot of stigma for that, like, "Oh, I'm going to use it, and I'm going to be addicted to it." But I think that with patients who you have an endpoint, addiction is really difficult because you basically are monitoring that, and you're actually changing the values or changing what you would recommend based on the symptom that you're trying to fix goes away. So I do try to counsel them to say that we want to put you on this to get you better so that you can do your normal activities, but then we will try to take it away, over time, so that you, again, you won't be addicted to this.

Host Amber Smith: Among the people in your study who did use medical marijuana during their treatment, what were their experiences?

Karna Sura, MD: The experiences are really positive. One part of medical marijuana is that, patients who benefited, benefited pretty well. It's usually helped their symptom management, so like the nausea, sleep, vomiting, weight gain. I think those are the big ones that actually helped a lot. Pain was one of the things that we were looking at, which seems like some people benefited while others didn't. And that may be related to how much they were doing or what they were taking in. And so that needs to be better clarified. And the other side of it is that there's really not that much side effects that we could see from medical marijuana. So I think it's a good drug that, if you compared it to other medications that we can use or prescription medications, it would be pretty much on a very high benefits for low risk, and so it would be a pretty useful medication overall.

Host Amber Smith: Does it replace the need for narcotic pain control?

Karna Sura, MD: Right now, how we are prescribing it, it's supposed to be like a supplement for narcotics, so it's not supposed to be a complete replacement. Now, some patients can benefit and have a complete risk replacement. Like in the study we did find a couple patients who basically did not need to take opioids anymore after starting medical marijuana. But for right now, how it's supposed to be prescribed for patients is as a supplement.

Host Amber Smith: Is there other research you would like to see done on medical marijuana usage in cancer patient?

Karna Sura, MD: A lot of people in the United States want to see randomized clinical trials done with cancer patients. I think actually the good news is yesterday, president Biden released some information that they're going to change the whole marijuana classification as well as to change the federal law behind it, which will change a lot. So once they move the DEA classification down for marijuana, actually research can be done on it, and federal dollars can go into research. So that's going to be a huge difference. And I think that's the biggest problem is, once we get access to federal dollars or even state dollars, that would allow us do research, it's going to be a whole game changer. And so I think that's kind of the biggest hurdle right now is the finance part of it, not the actual enthusiasm to do it. I think a lot of people want to use medical marijuana, and I think that patients really want to understand what's the benefits of it before using it.

Host Amber Smith: So with the previous restrictions on studying medical marijuana, do we even have a consensus among doctors about the best dosage, or the best delivery to get the best results for patients?

Karna Sura, MD: We have none of that information. That's the biggest problem, is that we don't know what is the best delivery, what is the best dose. Is there a dose response to pain or nausea, vomiting? What's better, THC or CBD? These are all questions that we want to know answers, because the biggest problem is how do you counsel patients what's better for them? Unfortunately at the dispensaries, there's a lot of different options, but we don't have the data to say which one is better for each patient or customize it. And, there's a lot of frustration because you can spend lots and lots of money to get each different thing. But if you're not using it, it's a lot of money wasted. So, I think it's really hard for patients to decide which one's better. Usually my recommendation is to start with a kind of balance, and then move away and see which one you like better. This is the biggest problem is that even the pharmacist, they try to give them counseling, but each patient's a little bit different. And, it's really hard to know for right now, what's beneficial for them.

Host Amber Smith: Would medical marijuana potentially be able to help people with earlier-stage cancers?

Karna Sura, MD: Yeah, medical marijuana could be used for anyone. It's perfect for any type of patient as long as we're aiming for a specific symptom to kind of improve. So I think I've had a couple patients who benefited. They were going under treatment for head neck cancer, where we have a lot of weight loss, and, unfortunately, because of the weight loss, they need medical marijuana, and they maintained their weight with that.

Host Amber Smith: With more and more states legalizing marijuana, including New York, is that going to change the accessibility or the usage, do you think, among people? And will they still need a prescription for medical marijuana?

Karna Sura, MD: I'm not sure how that's going to change in the New York state system, in terms of, will there be a more access or more dispensaries available? I do think it's going to be a good thing that it will remove the doctor a little bit out of the system and allow people to go and pick it up themselves. But I also think that will be a barrier for certain patients because of the fact that, patients may meet not as easily accessible for that becausedoctors may not bring it up because it's available. So I think we need a better way to maybe incorporate it or use it in a better fashion.

Host Amber Smith: Well, Dr. Sura, thank you for taking time to share your research with us.

Karna Sura, MD: Thank you so much for having me.

Host Amber Smith: My guest has been Dr. Karna Sura. He's a professor of radiation oncology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Poets have a way of finding the truth of an experience, even in the seemingly quiet, undramatic moments of illness. Mary Beth O'Connor from Ithaca, New York, recalls the moments of sitting vigil with a friend who can no longer communicate in her beautiful poem "what is time to her?"

time that passes so slow

for us visitors

reading to her, holding

her hand, longing for her

to open her eyes,

to smile at us, trying

to coax her back ...

maybe all those months

seemingly sleeping, she's been

busy beyond interruption

weaving a shroud

like in the fairy tale

getting ready

the way creatures

know how to prepare

nests, store black walnuts

learn to fly ...

and we, so well-meaning

and bereft, cannot seem

to just let her

David Dixon is a physician and poet from North Carolina who describes the ache of sitting with a parent who is slowly dying in his poem 'Still Life with Dad and Shade Tree."

After he's gone, what is it we keep?

What is it we scoop and carry like apples

in apron folds

clutched tightly to a chest?

And where would we even store

such a harvest? For surely

it's written somewhere that

both the plucked and the fallen

are gathered, one bushel at the time,

then taken to the same prepared places

of light and laughter. Sorted by size,

separate from the rotten fruit

so they don't spoil the lot,

hidden in cool cellars.

Such a tasty, sweet metaphor for memory,

is what I think,

even as there is still an answer on the phone,

still the welcome of your crooked hug

in the doorway,

still no idea what I'm missing:

no better than half-a-peck

of pretense,

trying to write this poem

as we sit here together.

Waiting.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": clinical research happening in Syracuse that you might want to volunteer for. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.