May 31, 2023 • 39 mins
Today we are talking to Dr. Vincent Paolone, for the second time. He is a board-certified psychiatrist in Ohio and also holds a certificate to recommend Medical Marijuana in this state. We discuss Delta 8, using cannabis for PTSD and other mental health issues, and the use of telemedicine for recommending medical marijuana. We end with a disagreement about whether this therapy is appropriate for patients in their 60s who have never used cannabis.
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Episode Transcript
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(00:00):
Not every mess cooker had the skilland diligence of Walter White to produce his
excellent product. You know, it'sthe same thing with Delta eight, you
know, but and unlike Walter White, He's Delta eight cartridges gummies are being
(00:23):
sold in gas stations everywhere. Youare listening to the Plant Wise Pharmacist with
Joe Jeffries. We talked to expertsin the cannabis field, from growers and
scientists to doctors recommending this treatment.Our goal is to bridge the gap between
(00:46):
using cannabis as a drug and understandingit as a medication. Today we are
talking to doctor Vincent Poloone for thesecond time. He is a board certified
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psychiatrist in Ohio and also holds acertificate to recommend medical marijuana in this state.
I do invite you to go backand hear our first podcast from June
twenty twenty two with doctor Poloane tohear more about his education and practice background.
That episode also gets into his uniqueperspective on recommending cannabis and requiring his
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patients who test positive for THHC tohave a medical marijuana registration. I think
it's a really great discussion on theimportance of having the recommendation if you are
testing positive for TC obviously, sothat you're not getting it from the black
market. So please go back andlisten to that. Today we're going to
be discussing Delta eight, the cbedthat's showing up at CBD shops, and
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doctor Polone has seen this in hispractice, using cannabis for harm reduction and
opioid addiction, using cannabis for PTSD, and the use of telemedicine for recommending
medical marijuana. In fact, let'sstart there. First off, welcome doctor
Pullo, How are you I good? Even Let's let's kind of set the
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table with a little background on telehealth. You know, obviously it became very
popular during COVID. In fact,most people listening to this podcast may have
had a telehealth visit. I knowI have. So those rules go back
to COVID. But in February Februarytwenty twenty three, actually Ohio passed their
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Telehealth Guidance to carry Telemedicine forward.It allows healthcare professionals to provide telehealth services
to a patient located in Ohio ifthey can meet the standard of care for
the patient in their medical condition.It explains when a healthcare professional must see
the patient in person or refer thepatient. So if a healthcare professional determines
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at any time while providing telehealth servicesto a patient that the standard of care
for in person visit cannot be met, kind of up to the practitioner at
that point. Allows for remote monitoringobviously, blood clue ghost monitors and the
like, and the rules get alittle more fuzzy. Now with controlled substances.
There's a lot of information in thenews about prescribing adderall and other stimulants
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and opiates, so they're kind ofcracking down there. But you know,
from my perspective, it's you know, it's potentially more patients that are able
to obtain medical marijuana, and that'sI think we're going to get into that
discussion here a minute. But onegood article that's out there right now on
telemedicine and cannabis specifically is in CRXmagazine, And I'm going to quote the
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positive side of things from a positionand then I'll I don't hand it over
to doctor Polone to kind of talkto talk about what he's seen. So
this is quote, telemedicine has thepower to remove so much of the stress
and the burden on patients. Thisdoctor says, I have quite a few
patients who are disabled and coming tophysically see me as a big production.
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It requires wheelchairs and coordination with theircaregivers. I even had one patient who
had to schedule an ambulance transport justto be able to see me in person
and fulfill that requirement. Had Ibeen able to see this patient via telehealth,
it could have spared a thousand dollarambulance ride. So, doctor Polone,
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why do you think we need moreface to face meetings with doctors in
order to obtain medical marijuana. Well, I was doing telehealth before the pandemic
because in psychiatry there's a shortage acrossthe state, and if I were treating
someone who was from an hour ormore away, or I had a relationship
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with someone who then moved farther awayin Ohio, I would do telemed,
And so I was. I wasfamiliar with telemed before the pandemic, and
I was familiar with the rules oftelemed before the pandemic, the rules being
that, especially with controlled substances,the very first appointment had to be in
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person, and then there had tobe at least one in person meeting per
year, and the means of thetelemed had to be an approved medical kind
of telemed, something that is encrypted, not just using like FaceTime. Then
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we had the pandemic and all therules went out the window for good reason,
because it was so necessary to dotalimed and it was so much safer
to do talimed, even for apsychiatrist. As a psychiatrist, we were
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relatively safe, being able to positionour chairs six to nine feet apart in
our office. But still, youknow, talimed is one hundred percent safe.
During the pandemic, they allowed FaceTimeto be used. They allowed to
do Tealimed to be done across statelines. Normally, the patient has to
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be physically inside the state where thedoctor is licensed, which is interesting because
the doctor doesn't have to be physicallyin the state during tlement. So I
could be on vacation in Florida anddo talimed with the patient who's physically in
Ohio because I'm licensed in Ohio.However, if the patient is on vacation
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in Florida and I'm in Ohio andthey're physically in Florida, I'm not supposed
to do telement or if I havea patient who lives literally fifteen minutes away
but lives across the state line inPennsylvania. Since I'm in northeast Ohio,
they would technically have to come acrossthe border and be physically Ohio in Ohio
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during telement. But they removed thatrestriction. They even removed you know restriction
restriction that it had to be faceto face. It could be just you
know, literally all audio. Andthere was a good reason for that,
because many people have limited technological skills. And then during the pandemic, when
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so many people all at once wereusing telemet, the system was breaking down.
I think the servers for the telementservices were overwhelmed because you know,
I had used telemed fairly successfully before, and I noticed just how much of
a problem there was, especially inthe first year of the pandemic. Now,
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as there are fewer telemet appointments,and I think the telement providers have
up their game, it's gotten alot better again. I always tried even
during the pandemic, I was stillseeing many of my patients for the first
AVAL in person, but I diddo some of the first AVAL videos,
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especially during the pandemic, before wewere vaccinated. Now, I still do
telement. I try to go backto the rules prior to the pandemic,
where I really want to see theperson face to face the first time.
You know, definitely not audio only. You know, there's just so much
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more you get from video, thefacial expression. What you can't get from
video is you know, sense smells. You know, um, let's face
it, if in face to face, if a patient comes into the office
stone, you're gonna smell it usuallyare are there drunk? Are there specific
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conditions that uh, you're you're mostlyconcerned about in terms of psychiatry, that
that may be more affected by thisproblem of not seeing someone in your office.
Well, you know, you can'tassess someone's grooming very well if you
know you can't see them close up, or you know, if they're really
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not bathing, you wouldn't be ableto tell just with audio or even video.
UM. You know, as faras you know, if you're doing
a medical WANTA evaluation UM for pain, you know, quite often UM the
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person will you know, you'll beable to see their body, see the
scars. I mean you can dothat on video UM, but on a
pure audio call you can't see scars. I mean, you know, for
a lot of the patients that I'vedone who have chronic pain, I mean,
you can you can easily see,you know, the scars on their
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wrists, knees, um. Ifthey're wearing a shirt, they could pull
their collar aside and you can seethe scars on the shoulders from their shoulder
surgery. You know, that's that'suh, you know, uh, face
to face, you could have themraise their arms. You can hear their
their joints crackle. You know,you can do somewhat of that kind of
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physical exam. Um. But moreeven more than that, I don't think
you form as good a bond witha patient if it's all audio. Um.
And the thing I've gotten concerned withis I've interviewed patients who have gotten
their medical marijuana recommendation from pure audiosources, is that they seem to really
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be lacking in having got appropriate informedconsent. When I see a patient,
even by video, patients can accesson my portal the informed consent material and
electronically sign it and then review itanytime they want on the portal and in
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person. You know, I givepeople written forms which they sign, we
scan them in and then they cantake the written forms home. And I
think conformed consent is extremely important,not only for medical marijuana, but with
any kind of controlled substance certainly.And what I've seen is that, you
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know, I've discovered my patients whowere, for example, getting a franquilizer
prescription or getting a prescription for attentiondeficit, in which I'm required to check
the database for controlled substances. I'vechecked this database and all of a sudden
seen medical marijuana show up, becausein Ohio it is reported to the database.
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And I tell them, well,wait a minute, you're you're on
medical marijuana. Now. Um,you know, first of all, you
should have, you know, runthis by me first, you know.
The second of all, you know, whoever did give you the recommendation should
have pointed out to you that ifyou're seeing another provider and that provider would
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ever start or continue a controlled substance, they're going to know by seeing your
dispensary purchases that you're on medical marijuana, and it would behoove you to warn
them so you don't get a veryangry action. I'm a slow to anger
individual, but there's a lot ofdoctors, you know, I tell them
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a lot of doctors they'll see somethinglike this kick you out of their practice
right away. I could start somethinglike that that interacts with my meds and
not put me in the loop.Yeah, most patients that I talked to,
it's definitely the story ends much betterwhen they've been honest with their their
physician on taking that they're taking medicalmarijuana. Let's let's define informed consent real
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quick, so the patients understand orpeople understand, you know, I'm presuming
it's most practices have a list ofrules of of of how I want you
to take this medicine, how I'llbe testing you for these types of medicine
that you're prescribing. Is that amI right? Or yeah? I mean
informed consent especially revolves around getting informedabout common side effects that you're likely to
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have, but also rare side effectsthat could be serious. And with medical
marijuana, there's the added aspect ofenlightening them that this is not FDA approved
medical treatment. This exists since moreof an experimental realm and it's you know,
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it's to work, And you alsohave to extra warn the patient of
things like the fact that with medicalmarijuana they could lose their job. You
know. That is the other thingthat I noticed that people weren't realizing or
weren't being informed over the phone,or at least weren't picking up that they
have been informed that because marijuana isfederally not legal, there can be no
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accommodation that's mandatory in the workplace.So if you are a drug free workplace,
you know, if you're a nurseworking on a medical unit and it's
a drug free workplace, it doesn'tmatter, and your subject to drug tests.
It doesn't matter if you have amedical marijuana card. It's thought an
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accommodation that's federally mandated. You wouldbe terminated unpotentially reported to the nursing board.
If you're at a factory and workingwith heavy equipment, there's the same
thing. You know, if you'rein a drug free workplace and you test
positive for marijuana, have it,and doesn't matter that you have a card
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and it came from a dispensary,you can be terminated. So that's you
know. I always tell my medicalmarijuana patients who are employed, you know,
and a lot of them have alreadydone this themselves, which is investigate
with their employer what your employer's attitudeis but if they haven't, I say,
you really need to investigate, especiallyif they're in any kind of a
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job that involves operating equipment. It'sso much better just let them know ahead
of time and figure out where theystand in. And it's kind of refreshing
to see some employers changing from afive panel to a lower panel that doesn't
even test for THHC. Obviously,like you said, it depends on the
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job. But the other thing Isaw coming I saw an article about it,
is they may for marijuana, theymay be moving to a saliva test
because it is not as sensitive asthe urine. So if you're testing positive
and your saliva, it indicates thatyou used much more recent, more recent
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use, which is more applicable towhat they do with alcohol. I mean,
alcohol is the ideal example where youcould be legally drunk and if you
stop drinking five hours later, yourblood alcohol level will be zero and you
can verify that by blowing into abreathalyze, you know. So unfortunately it's
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much more complicated with marijuana. Buta step in the direction of letting people
have recreational use but not get introuble at the job just to have some
sort of a test that gets anidea of what how recently they've used,
what's going on in their body atthat time. I mean, that's a
big issue with driving, you know, especially with medical marijuana. The other
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aspect of informed consent was medical marijuanais the issue that I tell people in
my form and verbally. I alwaystell them, you know, technically,
if you buy plant material, you'renot supposed to burn it. I tell
them that, you know, weyou and I had this discussion that you
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know, how many people are actuallybuying a vaporizer and heating it and boiling
off the tac rather than just stickingit in a bomb piper bowl. Um,
but I do tell them, youknow, and the law in Ohio
is that if you have plant material, it is not to be burned.
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And then they do with that whatthey will. Yeah, I guess the
dispensaries do the same thing. Youguys, don't make people produce a vaporizer
before to show proof of purchase rightwhen you give them plant material. And
quite frankly, the number one itempurchased as flower is bud for fifty percent
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of the purchases in Ohio. Um, you know, and one thing that
some people don't realize is the paraphernaliato use to smoke marijuana, is you
know, potentially hire I hire misdeanmisdemeanor fine as well. So you see
a pipe or papers or that,that could be a bigger fine than actually
the amount of of cannabis you mighthave on your person. Oh yeah,
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paraphernalia. Yeah. So actually,if you don't mind a segue into uh,
you know, being tested for cannabisat the workplace and patients that are
going to CBD shops. Another thingthat has kind of proliferated over the last
few months a year maybe is thethe the amount of THHC that's in these
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products and CBD shops and uh.And I think some people go into them
assuming that they're they're not going totest positive or TC by by getting something
from a CBD shop, but theycertainly will. They it's this weight weight
problem that the farm bill had.So if you know, if it's a
it might say it can't be morethan point three percent THHC, but that
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that could that based on the weightof the product, that could be a
lot of THHC approaching I mean,the whole delta eight issue has exploded,
as things tend to do in theUnited st. States. We're fad based
country, you know, and whensomething catches on, it tends to explode.
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And Delta eight has exploded in away bigger than anything else I've seen.
And as you mentioned the Farm Bill, Yeah, in twenty eighteen,
the Farm Bill said that hemp waslegal, and hemp is a cousin of
cannabis, and CBD comes from hemp, so CBD is legal. And then
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but what these manufacturers are doing arebasically cooking delta eight out of CBD,
you know. And by cooking,I mean cooking as in breaking bad cooking,
you know. It is It's likecooking meths from suda fat. It
is applying heat and organic chemistry andcreating a new compound from something else.
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Now, since the delta eighth theycreate is derived of the CBD, which
is derived of how it's technically legal. It's subject to control, but technically
legal. Now the problem arises inthat you might assume that someone is looking
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over the shoulder of these manufacturers tomake sure they're doing it right, and
that would be a false assumption.You know, the article I read said
this lab took twenty seven samples ofcommercially available gas station CBD products and analyze
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them to see, well, okay, I mean not CBD Delta eight products,
and analyze them to see, okay, is the amount of percentage content
of Delta eight what's they're according tothe package? And not only that,
is there Delta nine in there?You know? And other things. And
what they found was that the advertisedpotency could be much much different, much
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more Delta eight than was advertised.That there could be significant amounts of Delta
nine THC. There could be otheryou know, byproducts of cooking CBD that
are also also related to THHC andpsychoactive and able to cause side effects and
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intoxication. And they found fun thingslike heavy metals like lead and mercury.
Yeah, you know, so youknow, And as we know with Mess,
not not every mess cooker had theskill and diligence of Alta White to
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produce his excellent product. You know. It's the same thing with Delta eight,
you know. But and unlike MaltWhite, he's Delta eight cartridges gummies
are being sold in gas stations everywhere, yes, you know, health food
stores, babe shops and you canyou can imagine how frustrating it is for
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somebody in my position. You know, there are so many hurdles to get
somebody in our doors at a medicalmarijuana dispensary, the black market, the
CBD shops. Uh, you know, it's just not it's still not.
It's it's certainly not promoted in Ohiomuch by the Pharmacy Board. And then
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you know the regulations that we haveto abide by and the testing that has
to be done before that product everenters our building. Heavy metals like you
said, Uh, you know,the funguses. Uh, you know,
anything that could be harmful to thelungs is tested, and that you can
make the price more expensive than theblack market, but at least you know
it's safe. But man, they'renot doing anything. It doesn't seem like
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they're doing anything. And you know, well, you know that's ironic because
with real marijuana, it's federally illegal, and state by state, more states
are making it legal for medical andeven recreational. For Delta A, it's
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going the opposite direction, whereas federallyit's it's legal. So the DA and
the fans aren't doing anything. Butas the problems from it pile up state
by state, they're starting to banit, you know, So if anybody
in Ohio is thinking of opening aDelta A shop, they have to watch
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that investment because it could become illegalanytime, you know. And the bad
events that are piling up are thatkids are getting ahold of this and getting
intoxicated and sick bringing it to school. You know, people who are of
age are getting intoxicated and sick.Because Delta eight is THHC. It's just
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lower potency TC. But all thatmeans is, you know, just like
lower potency beer. They used tosell lower alcohol content beer in Ohio called
three two that if you were eighteenor nineteen or twenty before you could buy
real beer, you could buy threepoint two percent beer. Oh you know,
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great, but all you have todo is three point two percent beer
to drink an extra beer or two, and you'd be just as drunk,
you know. And now Delta eightit's the same thing. Delta eight is
THHC. It has works on thesame receptors. It can do the same
thing. It can make you paranoid, stone confused everything. You know,
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if you're cautious with it, it'sless likely to do that as rapidly as
real THHC. But if you're notcautious with it, you're gonna have the
same things happen. And if you'rea young top person who has no tolerance
at all, you're really going toget in trouble. You're going to test
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positive at work, especially because there'ssome regular THHC. So if you're smoking
massive amounts of this Delta A product, you're also smoking significant amounts of you
know, Delta nine in your vapepen, and you're gonna be subject to
getting fired, you know. It'sit's that kind of situation. So the
states one by one are banned it. Yeah, and I'm glad you're bringing
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this up because it is so justto make it clear for everyone out there,
Look, the Delta nine is regularTHC that's in the marijuana plant,
and so is CBD. Quite frankly, it's as part of the marijuana.
There's one hundred cannabinoids in the marijuanaplant. Those are natural cannabinoids in the
plant. There are now synthetic cannabinoidsthat are being made in labs from hemp
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to sort of mimic the effects ofdelta nine, and that's Delta eight and
there's even one called Delta ten.There's even products called thhco products that are
synthetic created forms of cannabis. AndI don't know if you've ever tried one
of these, you know, likea gummy that there's a Delta eight,
But it's just it's a horror.It's it's just a synthetic feeling. And
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I'm glad you use the analogy ofmath, because it's like the math of
cannabis. I hate to say it, but you know, all one good
thing to say about delta A.Okay, it's not as bad as spice
and K two because those came first. Those synthetic cannabinoids that were made with
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chemistry were even more dangerous and potentthan Delta eight. So spice. The
problems with spice and K two piledup so quick that governments reacted a lot
quicker. Of course, that spiceand K two were more popular before there
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there was as much access to medicalmarijuana too. Yeah, you know,
so Delta eight is very potentially dangerous, but the only reason it's not getting
banned quicker is it is not asbad as spice K two. You know,
bath spice and K two are basicallythe bath salts of synthetic cannabis.
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You know, well, I don'twant to burst you sort of bursted the
person I wants to put a shingleout and sell deep Delta eight. But
actually a report was just released todayand it was a quote basically from the
d EA at a conference. AndI'll just read one of the quotes.
This was in Medical Marijuana Moment dotnet if anybody wants to look it up.
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But it's hot off the precess today, and so this is the quote
from the agent that act of takingthat substance, in any synthetic step now
brings it back under the CSA,which is the Controlled Substance to Act,
because Substances Act, he said,adding that a number of states have come
up with regulatory responses. It's somewhatof a patchwork right now, but it
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is happening as we speak. There. You you won't get be able to
get Delta eight. I don't thinkvery soon, Joe. I just can't
add a question. I believe inMichigan where they have recreation on medical,
it's sort of a two tiered systemwhere if you have the medical card,
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you're you can have access to acheaper price and a product that might be
more potent, I think if I'mright with that, I was. I
was just thinking how that can relateto medical marijuana potentially being more effective,
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because what I found is the peoplewho come to me for medical marijuana recommendation
who have tried marijuana and know thatit helps, it's a no brainer that
they need a medical card so theycan get reliable access to a safe product
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to help their to help their condition. You know, people who've never tried
marijuana at all, they are fiftyfifty at best that they're going to get
the result they want for any givencondition. So what I just thought of
is, well, you know alot of these people who come to me
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who tried it, went to Vegasfor a trip and grab some recreational and
said, oh my god. Youknow I was able to not have nightmares
and fall asleep like I never havesince I was abused as a child.
You know, So I guess Ithink Ohio may be considered considering recreational and
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I think if they do, itwould be great to build a system in
where, you know, if youget access to it recreationally, but you
find that it helps some medical condition, if you then take the next step
and get a medical recommendation that perhapsyou have a better price and you know,
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and a bigger quantity that you canbuy, etc. You know.
Yeah, and that's and here's alittle bit of spin on that that I
don't know if any any of thestates have tried this yet or not that
have gone adult use, But whynot just eliminate the taxes on the medical
one or reduce the tax associated witha medical and then still continue to tax
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the recreational And that would you know, make it less expensive already? Well,
that would be ideal because you know, as a medical marijuana provider,
I get everybody's complaints, you know, and they may they may be you
know, they may say it toyour face at the dispensary, but they
sure to help me behind your backwhat their complaints are. And the number
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one complaint regarding medical marijuana is thecost, you know, then and and
the fact that you have to paycash. You can't use a credit card
because the federal federal illegality. Thenumber two complaint is that the supply of
any given product is inconsistent, youknow. So that causes me to tell
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people, well, when you buysomething first time, buy a small amount.
When you find something that you like, buy as much as you can
because the next time you go itmay not be there. Yeah, yeah,
because harvest change and hey, youknow, and you know, the
barriers to entry are expensive in medicalprograms, There's no doubt about it.
It's interesting, you know, ourwhole beginning part of our conversation could be
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moot because you know, if itbecomes adult use, you know, nobody's
going to go to a medical marijuanadispensary anymore. Let's go to the rec
dispensary, and they're not going togo to the doctor anymore either, right,
you know, I mean, youknow, and in Washington State,
the medical marijuana, you know,people were very much opposed to the recreational
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But on the other hand, ifthey if they work it right, there
could be still room for a medicalmarijuana program and medical marijuana dispensaries, you
know, and it could actually bea benefit to the medical marijuana patients and
industry. You know, I think, I think in reality, what you
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see is these elderly people trying togo up to a recreational dispensary that's got
people lined up out the door,and they're just sort of lost in the
shuffle. I mean, they tryto put rules in place at special hours
for these people, but it justit's just not realistic. But we'll see
and the same thing. To behonest, you know, I can't people
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over sixty five who have no experiencewith marijuana, you know, I say,
only about one in five of themat best will try medical marijuana and
stick with it. I mean,we're gonna, you know, you and
I are gonna have to have athird podcast because I totally disagree with you
on this. We have plenty ofpatients that do well with that are elderly.
(35:00):
All of the one of the fivethat I see, they all filtered
to you. You see, youknow, you get you get them all
concentrated and sent to you. Youknow. Um you may I guess one
of the thing I think we talkedabout before the podcast, they may be
adding another psyche indication, which isOCD. You know, um well,
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we have currently PTSD is the onlypure psyche indication in Ohio. And we've
discussed that people are stretching the definitionof PTSD um which is you know,
which is okay to some degree.And it's also a sort of tragic that
people sometimes don't realize how much ofwhat their anxiety is PTSD. You know,
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I've done the same thing. I'vehad people I've diagnosed with generalized anxiety
and then I talked to them evenmore about their past because they're interested in,
you know, a PTSD diagnosed oosisbecause they might get access to medical
marijuana, and you explore their past, and yes, they have trauma.
You know, it's not as badas having done two tours in Afghanistan,
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but it's enough to really justify diagnosisof PTSD. So yeah, we were
talking about maybe misdiagnosis over diagnosis ofPTSD and then the potential for more psyche
conditions for the medical marijuana program inOhio. And I you're you're pleased with
that, right? I think youthink there should be Oh yes, I
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mean, you know, there arepeople who don't respond to the traditional meds
that we have. When the traditionalmeds that we have have side effects that
can be extremely, extremely annoying,like sexual dysfunction and you know SSR eyes
like prosax olof packs, l xapro. They can be great, but I
(36:59):
really hate for my patients also tohave to make a trade off decision between
their mental health and their sexual function. Yeah, yeah, it's part of
mental health. Okay. So toend this thing, I want to ask
you kind of one of my rapidfire questions. Are you ready if you
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could have a billboard up on thehighway and you could put one line on
it in relation to marijuana, whatwould it be? It would be fined
an ethical provider of a medical marijuanarecommendation. Find an ethical provider, someone
who's going to give it to youstraight. Be concerned that not only you
(37:45):
get your recommendation, but that yousucceed with it and don't run into trouble
with it, not just oh hey, you know, talk to me for
fifteen minutes, ten minutes over thephone, there's your recommendation for year.
Bye bye. Yeah, no,I love it. And they do exist,
(38:06):
but they don't tend to exist inthe pure talimed range. They do
exist in the hybrid in person talimed, but pure talimed teams to be a
lot of you know, oh yougot pain, there's your there's your card.
Well, if we can find agood marketer to droll that down into
(38:27):
one little sentence, I mean,you could have a nice billboard on your
hands. Yes, hey, It'sbeen a great talking to you again.
Appreciate a meeting your staff the otherday. You obviously do treat people well
and ethically, so thank you fordoing that. And it's a great talking
to you again. All right,Thanks Joe, all right, take care,
Not every mess cooker had the skilland diligence of Walter White to produce his
excellent product. You know, it'sthe same thing with Delta eight, you
know, but and unlike Walter White, He's Delta eight cartridges gummies are being
(00:23):
sold in gas stations everywhere. Youare listening to the Plant Wise Pharmacist with
Joe Jeffries. We talked to expertsin the cannabis field, from growers and
scientists to doctors recommending this treatment.Our goal is to bridge the gap between
(00:46):
using cannabis as a drug and understandingit as a medication. Today we are
talking to doctor Vincent Poloone for thesecond time. He is a board certified
(01:10):
psychiatrist in Ohio and also holds acertificate to recommend medical marijuana in this state.
I do invite you to go backand hear our first podcast from June
twenty twenty two with doctor Poloane tohear more about his education and practice background.
That episode also gets into his uniqueperspective on recommending cannabis and requiring his
(01:30):
patients who test positive for THHC tohave a medical marijuana registration. I think
it's a really great discussion on theimportance of having the recommendation if you are
testing positive for TC obviously, sothat you're not getting it from the black
market. So please go back andlisten to that. Today we're going to
be discussing Delta eight, the cbedthat's showing up at CBD shops, and
(01:56):
doctor Polone has seen this in hispractice, using cannabis for harm reduction and
opioid addiction, using cannabis for PTSD, and the use of telemedicine for recommending
medical marijuana. In fact, let'sstart there. First off, welcome doctor
Pullo, How are you I good? Even Let's let's kind of set the
(02:17):
table with a little background on telehealth. You know, obviously it became very
popular during COVID. In fact,most people listening to this podcast may have
had a telehealth visit. I knowI have. So those rules go back
to COVID. But in February Februarytwenty twenty three, actually Ohio passed their
(02:43):
Telehealth Guidance to carry Telemedicine forward.It allows healthcare professionals to provide telehealth services
to a patient located in Ohio ifthey can meet the standard of care for
the patient in their medical condition.It explains when a healthcare professional must see
the patient in person or refer thepatient. So if a healthcare professional determines
(03:07):
at any time while providing telehealth servicesto a patient that the standard of care
for in person visit cannot be met, kind of up to the practitioner at
that point. Allows for remote monitoringobviously, blood clue ghost monitors and the
like, and the rules get alittle more fuzzy. Now with controlled substances.
There's a lot of information in thenews about prescribing adderall and other stimulants
(03:31):
and opiates, so they're kind ofcracking down there. But you know,
from my perspective, it's you know, it's potentially more patients that are able
to obtain medical marijuana, and that'sI think we're going to get into that
discussion here a minute. But onegood article that's out there right now on
telemedicine and cannabis specifically is in CRXmagazine, And I'm going to quote the
(03:55):
positive side of things from a positionand then I'll I don't hand it over
to doctor Polone to kind of talkto talk about what he's seen. So
this is quote, telemedicine has thepower to remove so much of the stress
and the burden on patients. Thisdoctor says, I have quite a few
patients who are disabled and coming tophysically see me as a big production.
(04:18):
It requires wheelchairs and coordination with theircaregivers. I even had one patient who
had to schedule an ambulance transport justto be able to see me in person
and fulfill that requirement. Had Ibeen able to see this patient via telehealth,
it could have spared a thousand dollarambulance ride. So, doctor Polone,
(04:39):
why do you think we need moreface to face meetings with doctors in
order to obtain medical marijuana. Well, I was doing telehealth before the pandemic
because in psychiatry there's a shortage acrossthe state, and if I were treating
someone who was from an hour ormore away, or I had a relationship
(05:03):
with someone who then moved farther awayin Ohio, I would do telemed,
And so I was. I wasfamiliar with telemed before the pandemic, and
I was familiar with the rules oftelemed before the pandemic, the rules being
that, especially with controlled substances,the very first appointment had to be in
(05:26):
person, and then there had tobe at least one in person meeting per
year, and the means of thetelemed had to be an approved medical kind
of telemed, something that is encrypted, not just using like FaceTime. Then
(05:49):
we had the pandemic and all therules went out the window for good reason,
because it was so necessary to dotalimed and it was so much safer
to do talimed, even for apsychiatrist. As a psychiatrist, we were
(06:11):
relatively safe, being able to positionour chairs six to nine feet apart in
our office. But still, youknow, talimed is one hundred percent safe.
During the pandemic, they allowed FaceTimeto be used. They allowed to
do Tealimed to be done across statelines. Normally, the patient has to
(06:33):
be physically inside the state where thedoctor is licensed, which is interesting because
the doctor doesn't have to be physicallyin the state during tlement. So I
could be on vacation in Florida anddo talimed with the patient who's physically in
Ohio because I'm licensed in Ohio.However, if the patient is on vacation
(06:56):
in Florida and I'm in Ohio andthey're physically in Florida, I'm not supposed
to do telement or if I havea patient who lives literally fifteen minutes away
but lives across the state line inPennsylvania. Since I'm in northeast Ohio,
they would technically have to come acrossthe border and be physically Ohio in Ohio
(07:16):
during telement. But they removed thatrestriction. They even removed you know restriction
restriction that it had to be faceto face. It could be just you
know, literally all audio. Andthere was a good reason for that,
because many people have limited technological skills. And then during the pandemic, when
(07:42):
so many people all at once wereusing telemet, the system was breaking down.
I think the servers for the telementservices were overwhelmed because you know,
I had used telemed fairly successfully before, and I noticed just how much of
a problem there was, especially inthe first year of the pandemic. Now,
(08:03):
as there are fewer telemet appointments,and I think the telement providers have
up their game, it's gotten alot better again. I always tried even
during the pandemic, I was stillseeing many of my patients for the first
AVAL in person, but I diddo some of the first AVAL videos,
(08:28):
especially during the pandemic, before wewere vaccinated. Now, I still do
telement. I try to go backto the rules prior to the pandemic,
where I really want to see theperson face to face the first time.
You know, definitely not audio only. You know, there's just so much
(08:52):
more you get from video, thefacial expression. What you can't get from
video is you know, sense smells. You know, um, let's face
it, if in face to face, if a patient comes into the office
stone, you're gonna smell it usuallyare are there drunk? Are there specific
(09:16):
conditions that uh, you're you're mostlyconcerned about in terms of psychiatry, that
that may be more affected by thisproblem of not seeing someone in your office.
Well, you know, you can'tassess someone's grooming very well if you
know you can't see them close up, or you know, if they're really
(09:39):
not bathing, you wouldn't be ableto tell just with audio or even video.
UM. You know, as faras you know, if you're doing
a medical WANTA evaluation UM for pain, you know, quite often UM the
(10:01):
person will you know, you'll beable to see their body, see the
scars. I mean you can dothat on video UM, but on a
pure audio call you can't see scars. I mean, you know, for
a lot of the patients that I'vedone who have chronic pain, I mean,
you can you can easily see,you know, the scars on their
(10:22):
wrists, knees, um. Ifthey're wearing a shirt, they could pull
their collar aside and you can seethe scars on the shoulders from their shoulder
surgery. You know, that's that'suh, you know, uh, face
to face, you could have themraise their arms. You can hear their
their joints crackle. You know,you can do somewhat of that kind of
(10:43):
physical exam. Um. But moreeven more than that, I don't think
you form as good a bond witha patient if it's all audio. Um.
And the thing I've gotten concerned withis I've interviewed patients who have gotten
their medical marijuana recommendation from pure audiosources, is that they seem to really
(11:07):
be lacking in having got appropriate informedconsent. When I see a patient,
even by video, patients can accesson my portal the informed consent material and
electronically sign it and then review itanytime they want on the portal and in
(11:31):
person. You know, I givepeople written forms which they sign, we
scan them in and then they cantake the written forms home. And I
think conformed consent is extremely important,not only for medical marijuana, but with
any kind of controlled substance certainly.And what I've seen is that, you
(11:54):
know, I've discovered my patients whowere, for example, getting a franquilizer
prescription or getting a prescription for attentiondeficit, in which I'm required to check
the database for controlled substances. I'vechecked this database and all of a sudden
seen medical marijuana show up, becausein Ohio it is reported to the database.
(12:18):
And I tell them, well,wait a minute, you're you're on
medical marijuana. Now. Um,you know, first of all, you
should have, you know, runthis by me first, you know.
The second of all, you know, whoever did give you the recommendation should
have pointed out to you that ifyou're seeing another provider and that provider would
(12:43):
ever start or continue a controlled substance, they're going to know by seeing your
dispensary purchases that you're on medical marijuana, and it would behoove you to warn
them so you don't get a veryangry action. I'm a slow to anger
individual, but there's a lot ofdoctors, you know, I tell them
(13:05):
a lot of doctors they'll see somethinglike this kick you out of their practice
right away. I could start somethinglike that that interacts with my meds and
not put me in the loop.Yeah, most patients that I talked to,
it's definitely the story ends much betterwhen they've been honest with their their
physician on taking that they're taking medicalmarijuana. Let's let's define informed consent real
(13:33):
quick, so the patients understand orpeople understand, you know, I'm presuming
it's most practices have a list ofrules of of of how I want you
to take this medicine, how I'llbe testing you for these types of medicine
that you're prescribing. Is that amI right? Or yeah? I mean
informed consent especially revolves around getting informedabout common side effects that you're likely to
(14:01):
have, but also rare side effectsthat could be serious. And with medical
marijuana, there's the added aspect ofenlightening them that this is not FDA approved
medical treatment. This exists since moreof an experimental realm and it's you know,
(14:26):
it's to work, And you alsohave to extra warn the patient of
things like the fact that with medicalmarijuana they could lose their job. You
know. That is the other thingthat I noticed that people weren't realizing or
weren't being informed over the phone,or at least weren't picking up that they
have been informed that because marijuana isfederally not legal, there can be no
(14:54):
accommodation that's mandatory in the workplace.So if you are a drug free workplace,
you know, if you're a nurseworking on a medical unit and it's
a drug free workplace, it doesn'tmatter, and your subject to drug tests.
It doesn't matter if you have amedical marijuana card. It's thought an
(15:15):
accommodation that's federally mandated. You wouldbe terminated unpotentially reported to the nursing board.
If you're at a factory and workingwith heavy equipment, there's the same
thing. You know, if you'rein a drug free workplace and you test
positive for marijuana, have it,and doesn't matter that you have a card
(15:39):
and it came from a dispensary,you can be terminated. So that's you
know. I always tell my medicalmarijuana patients who are employed, you know,
and a lot of them have alreadydone this themselves, which is investigate
with their employer what your employer's attitudeis but if they haven't, I say,
you really need to investigate, especiallyif they're in any kind of a
(16:02):
job that involves operating equipment. It'sso much better just let them know ahead
of time and figure out where theystand in. And it's kind of refreshing
to see some employers changing from afive panel to a lower panel that doesn't
even test for THHC. Obviously,like you said, it depends on the
(16:22):
job. But the other thing Isaw coming I saw an article about it,
is they may for marijuana, theymay be moving to a saliva test
because it is not as sensitive asthe urine. So if you're testing positive
and your saliva, it indicates thatyou used much more recent, more recent
(16:47):
use, which is more applicable towhat they do with alcohol. I mean,
alcohol is the ideal example where youcould be legally drunk and if you
stop drinking five hours later, yourblood alcohol level will be zero and you
can verify that by blowing into abreathalyze, you know. So unfortunately it's
(17:10):
much more complicated with marijuana. Buta step in the direction of letting people
have recreational use but not get introuble at the job just to have some
sort of a test that gets anidea of what how recently they've used,
what's going on in their body atthat time. I mean, that's a
big issue with driving, you know, especially with medical marijuana. The other
(17:37):
aspect of informed consent was medical marijuanais the issue that I tell people in
my form and verbally. I alwaystell them, you know, technically,
if you buy plant material, you'renot supposed to burn it. I tell
them that, you know, weyou and I had this discussion that you
(17:57):
know, how many people are actuallybuying a vaporizer and heating it and boiling
off the tac rather than just stickingit in a bomb piper bowl. Um,
but I do tell them, youknow, and the law in Ohio
is that if you have plant material, it is not to be burned.
(18:18):
And then they do with that whatthey will. Yeah, I guess the
dispensaries do the same thing. Youguys, don't make people produce a vaporizer
before to show proof of purchase rightwhen you give them plant material. And
quite frankly, the number one itempurchased as flower is bud for fifty percent
(18:38):
of the purchases in Ohio. Um, you know, and one thing that
some people don't realize is the paraphernaliato use to smoke marijuana, is you
know, potentially hire I hire misdeanmisdemeanor fine as well. So you see
a pipe or papers or that,that could be a bigger fine than actually
the amount of of cannabis you mighthave on your person. Oh yeah,
(19:02):
paraphernalia. Yeah. So actually,if you don't mind a segue into uh,
you know, being tested for cannabisat the workplace and patients that are
going to CBD shops. Another thingthat has kind of proliferated over the last
few months a year maybe is thethe the amount of THHC that's in these
(19:26):
products and CBD shops and uh.And I think some people go into them
assuming that they're they're not going totest positive or TC by by getting something
from a CBD shop, but theycertainly will. They it's this weight weight
problem that the farm bill had.So if you know, if it's a
it might say it can't be morethan point three percent THHC, but that
(19:47):
that could that based on the weightof the product, that could be a
lot of THHC approaching I mean,the whole delta eight issue has exploded,
as things tend to do in theUnited st. States. We're fad based
country, you know, and whensomething catches on, it tends to explode.
(20:08):
And Delta eight has exploded in away bigger than anything else I've seen.
And as you mentioned the Farm Bill, Yeah, in twenty eighteen,
the Farm Bill said that hemp waslegal, and hemp is a cousin of
cannabis, and CBD comes from hemp, so CBD is legal. And then
(20:33):
but what these manufacturers are doing arebasically cooking delta eight out of CBD,
you know. And by cooking,I mean cooking as in breaking bad cooking,
you know. It is It's likecooking meths from suda fat. It
is applying heat and organic chemistry andcreating a new compound from something else.
(21:00):
Now, since the delta eighth theycreate is derived of the CBD, which
is derived of how it's technically legal. It's subject to control, but technically
legal. Now the problem arises inthat you might assume that someone is looking
(21:22):
over the shoulder of these manufacturers tomake sure they're doing it right, and
that would be a false assumption.You know, the article I read said
this lab took twenty seven samples ofcommercially available gas station CBD products and analyze
(21:47):
them to see, well, okay, I mean not CBD Delta eight products,
and analyze them to see, okay, is the amount of percentage content
of Delta eight what's they're according tothe package? And not only that,
is there Delta nine in there?You know? And other things. And
what they found was that the advertisedpotency could be much much different, much
(22:17):
more Delta eight than was advertised.That there could be significant amounts of Delta
nine THC. There could be otheryou know, byproducts of cooking CBD that
are also also related to THHC andpsychoactive and able to cause side effects and
(22:40):
intoxication. And they found fun thingslike heavy metals like lead and mercury.
Yeah, you know, so youknow, And as we know with Mess,
not not every mess cooker had theskill and diligence of Alta White to
(23:00):
produce his excellent product. You know. It's the same thing with Delta eight,
you know. But and unlike MaltWhite, he's Delta eight cartridges gummies
are being sold in gas stations everywhere, yes, you know, health food
stores, babe shops and you canyou can imagine how frustrating it is for
(23:25):
somebody in my position. You know, there are so many hurdles to get
somebody in our doors at a medicalmarijuana dispensary, the black market, the
CBD shops. Uh, you know, it's just not it's still not.
It's it's certainly not promoted in Ohiomuch by the Pharmacy Board. And then
(23:47):
you know the regulations that we haveto abide by and the testing that has
to be done before that product everenters our building. Heavy metals like you
said, Uh, you know,the funguses. Uh, you know,
anything that could be harmful to thelungs is tested, and that you can
make the price more expensive than theblack market, but at least you know
it's safe. But man, they'renot doing anything. It doesn't seem like
(24:11):
they're doing anything. And you know, well, you know that's ironic because
with real marijuana, it's federally illegal, and state by state, more states
are making it legal for medical andeven recreational. For Delta A, it's
(24:37):
going the opposite direction, whereas federallyit's it's legal. So the DA and
the fans aren't doing anything. Butas the problems from it pile up state
by state, they're starting to banit, you know, So if anybody
in Ohio is thinking of opening aDelta A shop, they have to watch
(25:00):
that investment because it could become illegalanytime, you know. And the bad
events that are piling up are thatkids are getting ahold of this and getting
intoxicated and sick bringing it to school. You know, people who are of
age are getting intoxicated and sick.Because Delta eight is THHC. It's just
(25:26):
lower potency TC. But all thatmeans is, you know, just like
lower potency beer. They used tosell lower alcohol content beer in Ohio called
three two that if you were eighteenor nineteen or twenty before you could buy
real beer, you could buy threepoint two percent beer. Oh you know,
(25:49):
great, but all you have todo is three point two percent beer
to drink an extra beer or two, and you'd be just as drunk,
you know. And now Delta eightit's the same thing. Delta eight is
THHC. It has works on thesame receptors. It can do the same
thing. It can make you paranoid, stone confused everything. You know,
(26:15):
if you're cautious with it, it'sless likely to do that as rapidly as
real THHC. But if you're notcautious with it, you're gonna have the
same things happen. And if you'rea young top person who has no tolerance
at all, you're really going toget in trouble. You're going to test
(26:36):
positive at work, especially because there'ssome regular THHC. So if you're smoking
massive amounts of this Delta A product, you're also smoking significant amounts of you
know, Delta nine in your vapepen, and you're gonna be subject to
getting fired, you know. It'sit's that kind of situation. So the
states one by one are banned it. Yeah, and I'm glad you're bringing
(27:03):
this up because it is so justto make it clear for everyone out there,
Look, the Delta nine is regularTHC that's in the marijuana plant,
and so is CBD. Quite frankly, it's as part of the marijuana.
There's one hundred cannabinoids in the marijuanaplant. Those are natural cannabinoids in the
plant. There are now synthetic cannabinoidsthat are being made in labs from hemp
(27:29):
to sort of mimic the effects ofdelta nine, and that's Delta eight and
there's even one called Delta ten.There's even products called thhco products that are
synthetic created forms of cannabis. AndI don't know if you've ever tried one
of these, you know, likea gummy that there's a Delta eight,
But it's just it's a horror.It's it's just a synthetic feeling. And
(27:52):
I'm glad you use the analogy ofmath, because it's like the math of
cannabis. I hate to say it, but you know, all one good
thing to say about delta A.Okay, it's not as bad as spice
and K two because those came first. Those synthetic cannabinoids that were made with
(28:12):
chemistry were even more dangerous and potentthan Delta eight. So spice. The
problems with spice and K two piledup so quick that governments reacted a lot
quicker. Of course, that spiceand K two were more popular before there
(28:33):
there was as much access to medicalmarijuana too. Yeah, you know,
so Delta eight is very potentially dangerous, but the only reason it's not getting
banned quicker is it is not asbad as spice K two. You know,
bath spice and K two are basicallythe bath salts of synthetic cannabis.
(28:55):
You know, well, I don'twant to burst you sort of bursted the
person I wants to put a shingleout and sell deep Delta eight. But
actually a report was just released todayand it was a quote basically from the
d EA at a conference. AndI'll just read one of the quotes.
This was in Medical Marijuana Moment dotnet if anybody wants to look it up.
(29:18):
But it's hot off the precess today, and so this is the quote
from the agent that act of takingthat substance, in any synthetic step now
brings it back under the CSA,which is the Controlled Substance to Act,
because Substances Act, he said,adding that a number of states have come
up with regulatory responses. It's somewhatof a patchwork right now, but it
(29:41):
is happening as we speak. There. You you won't get be able to
get Delta eight. I don't thinkvery soon, Joe. I just can't
add a question. I believe inMichigan where they have recreation on medical,
it's sort of a two tiered systemwhere if you have the medical card,
(30:07):
you're you can have access to acheaper price and a product that might be
more potent, I think if I'mright with that, I was. I
was just thinking how that can relateto medical marijuana potentially being more effective,
(30:30):
because what I found is the peoplewho come to me for medical marijuana recommendation
who have tried marijuana and know thatit helps, it's a no brainer that
they need a medical card so theycan get reliable access to a safe product
(30:52):
to help their to help their condition. You know, people who've never tried
marijuana at all, they are fiftyfifty at best that they're going to get
the result they want for any givencondition. So what I just thought of
is, well, you know alot of these people who come to me
(31:15):
who tried it, went to Vegasfor a trip and grab some recreational and
said, oh my god. Youknow I was able to not have nightmares
and fall asleep like I never havesince I was abused as a child.
You know, So I guess Ithink Ohio may be considered considering recreational and
(31:37):
I think if they do, itwould be great to build a system in
where, you know, if youget access to it recreationally, but you
find that it helps some medical condition, if you then take the next step
and get a medical recommendation that perhapsyou have a better price and you know,
(31:57):
and a bigger quantity that you canbuy, etc. You know.
Yeah, and that's and here's alittle bit of spin on that that I
don't know if any any of thestates have tried this yet or not that
have gone adult use, But whynot just eliminate the taxes on the medical
one or reduce the tax associated witha medical and then still continue to tax
(32:22):
the recreational And that would you know, make it less expensive already? Well,
that would be ideal because you know, as a medical marijuana provider,
I get everybody's complaints, you know, and they may they may be you
know, they may say it toyour face at the dispensary, but they
sure to help me behind your backwhat their complaints are. And the number
(32:44):
one complaint regarding medical marijuana is thecost, you know, then and and
the fact that you have to paycash. You can't use a credit card
because the federal federal illegality. Thenumber two complaint is that the supply of
any given product is inconsistent, youknow. So that causes me to tell
(33:07):
people, well, when you buysomething first time, buy a small amount.
When you find something that you like, buy as much as you can
because the next time you go itmay not be there. Yeah, yeah,
because harvest change and hey, youknow, and you know, the
barriers to entry are expensive in medicalprograms, There's no doubt about it.
It's interesting, you know, ourwhole beginning part of our conversation could be
(33:29):
moot because you know, if itbecomes adult use, you know, nobody's
going to go to a medical marijuanadispensary anymore. Let's go to the rec
dispensary, and they're not going togo to the doctor anymore either, right,
you know, I mean, youknow, and in Washington State,
the medical marijuana, you know,people were very much opposed to the recreational
(33:52):
But on the other hand, ifthey if they work it right, there
could be still room for a medicalmarijuana program and medical marijuana dispensaries, you
know, and it could actually bea benefit to the medical marijuana patients and
industry. You know, I think, I think in reality, what you
(34:13):
see is these elderly people trying togo up to a recreational dispensary that's got
people lined up out the door,and they're just sort of lost in the
shuffle. I mean, they tryto put rules in place at special hours
for these people, but it justit's just not realistic. But we'll see
and the same thing. To behonest, you know, I can't people
(34:37):
over sixty five who have no experiencewith marijuana, you know, I say,
only about one in five of themat best will try medical marijuana and
stick with it. I mean,we're gonna, you know, you and
I are gonna have to have athird podcast because I totally disagree with you
on this. We have plenty ofpatients that do well with that are elderly.
(35:00):
All of the one of the fivethat I see, they all filtered
to you. You see, youknow, you get you get them all
concentrated and sent to you. Youknow. Um you may I guess one
of the thing I think we talkedabout before the podcast, they may be
adding another psyche indication, which isOCD. You know, um well,
(35:22):
we have currently PTSD is the onlypure psyche indication in Ohio. And we've
discussed that people are stretching the definitionof PTSD um which is you know,
which is okay to some degree.And it's also a sort of tragic that
people sometimes don't realize how much ofwhat their anxiety is PTSD. You know,
(35:47):
I've done the same thing. I'vehad people I've diagnosed with generalized anxiety
and then I talked to them evenmore about their past because they're interested in,
you know, a PTSD diagnosed oosisbecause they might get access to medical
marijuana, and you explore their past, and yes, they have trauma.
You know, it's not as badas having done two tours in Afghanistan,
(36:12):
but it's enough to really justify diagnosisof PTSD. So yeah, we were
talking about maybe misdiagnosis over diagnosis ofPTSD and then the potential for more psyche
conditions for the medical marijuana program inOhio. And I you're you're pleased with
that, right? I think youthink there should be Oh yes, I
(36:34):
mean, you know, there arepeople who don't respond to the traditional meds
that we have. When the traditionalmeds that we have have side effects that
can be extremely, extremely annoying,like sexual dysfunction and you know SSR eyes
like prosax olof packs, l xapro. They can be great, but I
(36:59):
really hate for my patients also tohave to make a trade off decision between
their mental health and their sexual function. Yeah, yeah, it's part of
mental health. Okay. So toend this thing, I want to ask
you kind of one of my rapidfire questions. Are you ready if you
(37:22):
could have a billboard up on thehighway and you could put one line on
it in relation to marijuana, whatwould it be? It would be fined
an ethical provider of a medical marijuanarecommendation. Find an ethical provider, someone
who's going to give it to youstraight. Be concerned that not only you
(37:45):
get your recommendation, but that yousucceed with it and don't run into trouble
with it, not just oh hey, you know, talk to me for
fifteen minutes, ten minutes over thephone, there's your recommendation for year.
Bye bye. Yeah, no,I love it. And they do exist,
(38:06):
but they don't tend to exist inthe pure talimed range. They do
exist in the hybrid in person talimed, but pure talimed teams to be a
lot of you know, oh yougot pain, there's your there's your card.
Well, if we can find agood marketer to droll that down into
(38:27):
one little sentence, I mean,you could have a nice billboard on your
hands. Yes, hey, It'sbeen a great talking to you again.
Appreciate a meeting your staff the otherday. You obviously do treat people well
and ethically, so thank you fordoing that. And it's a great talking
to you again. All right,Thanks Joe, all right, take care,
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