CNM October 2015 by Cannabis Nurses Magazine

LIFESTYLES LIFESTYL

Nurse Profile Real Nurses share stories to inspire and educate.

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OPPORTUNITY

Job Opportunities CNM features job postings in every nursing specialty.

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Living Well Cannabis Nutrition: The Mediterranean Diet

EDUCATION

What a Nurse Needs to Know Cannabis and Harm Reduction

Editor’s Letter Welcome to our first issue of Cannabis Nurses Magazine. This national monthly magazine is based out of Las Vegas, Nevada where I have resided since 1995 and I have seen tremendous change not only in this state but nationally when it comes to the Cannabis Industry. In fact, the term Cannabis IIndustry is new in its development. I remember moving here driving into town on Highway 15 with posted signs warning visitors to be on their best behavior and not be tempted into consuming marijuana because if one remembers, the state laws of Nevada, one of the stiffest in the nation, made it a felony to even possess marijuana, let alone smoke it, and the jail time unbelievable for such a simple plant. Today, medical cannabis is now legal in Nevada and within 24 states across the nation, with more following the lead, and it can now be “recommended” by your physician as a treatment option in numerous disease states and symptoms in multiple facets. The more I began to learn about cannabis, the more I became amazed and it all started with a friend of mine who stated in January 2010, “Juhlzie, did you know cannabis cures cancer?” I know this to be a bold statement and difficult to wrap your head around. It was for me too, however, that question alone, opened Pandora’s Box and I was never able to go back. In my profession as a Registered Nurse, I questioned while triaging many in the ERs over the years, why so many people were plagued with illness and they all usually had over a dozen pharmaceuticals prescribed to them and they were still sick. Well, my question was answered when I started doing the research. Unfortunately, due to prohibition, we have been put on a seventy year plus delay and forced by laws to abide by the laws of the land and we have been prohibited from its use. Western medicine educated the masses that it is a Schedule 1 drug, with no beneficial value, and taboo to even consider its consumption and as a Nurse I stayed far away from it. Upon my research, I came across the American Cannabis Nurses Association (ACNA) and attended their conference, which I received CEUs for the first time ever, and it was hosted with Patients Out of Time in Portland, Oregon in May of 2014. This conference changed my life forever. Since that event, I have been motivated to find a platform to promote the National Cannabis Nurses and all that we are doing across the nation since then. Many of our dedicated cannabis nursing leaders across the nation have been doing amazing things with activism, creating changes with state and national legislation, lecturing nationally and internationally, being integrated into dispensaries across the nation, consulting professionals, entrepreneurs, patients, caregivers, and providing local communities with information and education, assisting in every facet of their lives, keeping them safe, and acting as a voice for the patients when they are denied access. We as national nurses are creating change and leading the way and we strongly believe: Every Patient Deserves a Nurse. With our expertise in the newly developing field of Cannabis Nursing, we are the change that the Cannabis Industry needs to assure that patients are kept safe and are informed with evidence-based education. We are so excited with all the movement here in Las Vegas and at a National level within the Cannabis Industry. We have been gearing up for some exciting events this October and working hard to make it become a reality. And now, without further a due, we welcome you to enjoy this first edition ever of Cannabis Nurses Magazine. Enjoy! Nurse Juhlzie “Ask Nurse Juhlzie”

Contributors October 2015

Publisher

Robert Herman

Managing Editor

Julie Monteiro RN, BSK

Creative Director

Tiffany Watson

Contributors Heather Manus, RN Leslie Reyes, RN Marcie Cooper, RN, MSN, AHN-BC Lisa Buchanan, RN ,OCN Mary Lynn Mathre, RN, MSN, CARN Susan Trossman, RN Dr. LAWRENCE MAY, MD Lisa Ricciotti, RN

Cannabis Nurses Magazine is a national monthly magazine committed to providing insights about the health care profession, current events, what’s working and what’s not in the health care industry, as well as practical advice for physicians and practices. We are currently accepting articles to be considered for publication. For more information on writing for Cannabis Nurses Magazine, check out our writer’s guidelines at: cannabisnursesmagazine.com/writers-guidelines

Heather Manus, RN Heather Manus is a native New Mexican and Registered Nurse specializing in all aspects of medical cannabis care. She is currently a board member of the American Cannabis Nurses Association, serving as Chairwoman for the ACNA conference committee. She also holds a certificate of completion for The Core Curriculum for Cannabis Nursing.

Leslie Reyes, RN Leslie Reyes, RN is a Board Member and the Secretary for the American Cannabis Nurses Association (ACNA). Leslie has worked as a Registered Nurse in Urgent Care, Psychiatric and Behavioral Health, and has been involved in cannabis patient advocacy for over nine years. She is a co-creator and co-author of the Core Curriculum in Cannabis Nursing owned by the ACNA, and is also on the committees for Communications and Media, Conference Planning, Certification, Events, Membership, Nominations, and the Executive Committee.

Marcie Cooper, RN, MSN, AHN-BC

Marcie Cooper is Board Certified as an Advanced Holistic Nurse and licensed as a Registered Nurse in Colorado. Originally from Memphis, Tennessee, she started her nursing career on a general med-surg hospital floor in 2004 and began a focus specializing in Oncology.

Lisa Buchanan, RN, OCN

Lisa Buchanan is an Oncology Certified Nurse (OCN) who has worked with the seriously ill and dying for more than 20 years. She a member of the Oncology Nurses Society (ONS), American Cannabis Nurses Association (ACNA), and the Washington State Nurses Association 1100 S 10th St. #420 Las Vegas, NV 89104 Editor@cannabisnursesmagazine.com Online 24/7 at cannabisnursesmagazine.com

(WSNA). She has earned certificates in the Core Curriculum for Cannabis Nursing and the Advanced Curriculum for Cannabis Nursing.

Mary Lynn Mathre, RN, MSN, CARN Mary Lynn (ML) Mathre, RN, MSN, CARN is the President and Co-founder of Patients Out of Time, a national non-profit organization dedicated to educating health care professionals and the public about the therapeutic use of cannabis, and the founding member of American Cannabis Nurses Association (ACNA).

Contributors Carey S. Clark, PhD, RN, AHN-BC, RYT Dr. Carey S Clark, PhD, RN, AHN-BC, RYT has been a nurse for over 20 years and her research interests are focused on caring and integral approaches in nursing and nursing education. She completed a qualitative research internship at the Institute of Noetic Sciences and she has been actively involved with the grassroots research of the Nurse Manifest Project, which focuses on the emancipation of the nursing profession. She has written about the nursing shortage and transformations needed in nursing academia and the profession.

Dr. LAWRENCE MAY, MD Lawrence May M.D. is a Board Cetified Internist with broad experience in clinical medicine, academics, media and business. From Harvard Medical ('74) he started residency and joined the faculty of the UCLA medical school where he directed the health services research center at the Wadsorth, VA Hospital and served as a founder and co-director of the Center for Health Enhancement Education and Research (CHEER) at UCLA. Dr. May has written many books and articles including a widely used textbook entitled Primary Care Medicine. Dr. May became an important formulator of nutritional products and served as Executive Vice President for medical and scientific affairs for Herbalife International. He has appeared in the media, lectured internationally, and consulted to industry and medical institution, as well as serving on their boards. He was a founder of Physician's Therapeutics and helped develop its parent company, Targeted Medical Pharma.

Dr. David Bearman, MD Dr. David Bearman, MD has spent 40 years working in substance and drug abue treatment and prevention program. He was a pioneet in the free and community clinic movement. Dr. Bearman's career includes public health, administrative medicine, provision of of primary care, pain management and cannabinology. He is also an author, and Vice President of the American Academy of Cannabinoid Medicine.

Contact Information Publisher ND1Media Editorial Robert Herman

Art&Graphic Design To submit artwork/ad creation Email: ads@cannabisnursesmagazine.com

Advertising & Marketing For advertising opportunities Email: ads@cannabisnursesmagazine.com Sales/Product Director Email: sales@cannabisnursesmagazine.com

Writers To submit articles for publication Email: editor@cannabisnursesmagazine.com

Reach Us By Post Cannbis Nurses Magazine 1100 S. 10th Ste 420 Las Vegas, NV 89117 info@cannabisnursesmagazine.com www.cannabisnursesmagazine.com

Table of

Contents

October

2015

COVER ARTICLES

FEATURES

P.06

Exploring the Science of Medical Marijuana

P.36

A PHYSICIAN'S PERSPECTIVE ON PAIN & "THE PLANT"

P.26

Cannabis and Harm Reduction

P.26

P.10

Nurse Profile: Heather Manus RN Every Patient Deserves a Nurse!

P.22

CANNABIS AND HARM REDUCTION A NURSING PERSPECTIVE 2015 Clog Trends!

P.2

P.06

EDITORIAL Updating the Image of Nursing One Project at a Time...

Exploring the Science of Medical Marijuana

P.12

The Endocannabinoid System: What Nurses Need to Know

P.16

Weeding Out Pain: The Cannabis Dictum

P.22

FASHION WATCH 2015 Clog Trends!

P.26

P.34

CANNABIS AND HARM REDUCTION: A Nursing Perspective LIVING WELL THE MEDITERRANEAN DIET

P.18

P.32

THE MIND: MEDICINAL MARIJUANA LAUGH OUT LOUD Nursing Humor

P.33

RESOURCES: Recommended Books

P.42

Nurse Job Opportunities: Perm & Travel

P.43

Helpful Apps for Health Care Professionals

The Science of Medical Marijuana

Exploring the science of Medical Marijuana By Susan Trossman, RN

spirin is often touted as a wonder drug, while critics challenge the medicinal effects of a natural

plant used for centuries marijuana. As a way to counter those challenges, medical marijuana advocates helped plan a clinical conference in Rhode Island this April in which health care professionals could hear the latest science on cannabis and state initiatives allowing its use.

Nearly 250 nurses, physicians, and patients attended the Sixth National Clinical Conference on Cannabis Therapeutics, entitled “Cannabis: The Medicine Plant.” The conference was sponsored by the advocacy organization, Patients Out of Time, and the University of California, San Francisco School of Medicine, with support from the Rhode Island State Nurses Association (RISNA) and several other organizations. One of the key presentations focused on the latest research on the Endocannabinoid System, which initially was discovered in the late 1980s. At that time, scientists believed that cannabinoid receptors were located solely in the brain.

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“Although the science is still in its infancy, research shows that the Endocannabinoid System has receptors throughout the body,” said Mary Lynn Mathre, MSN, RN, CARN, a Virginia Nurses Association member and president and co-founder of Patients Out of Time. Mathre says, "this is why medical cannabis can prevent or alleviate such a wide range of symptoms". “This system affects how we eat, sleep, relax, protect, and forget,” she said. “So we felt it was important to share more information about it with conference participants.” (Presentations will be available online for both physicians and nurses; 11.5 CEU contact hours were granted for the conference.) Medical marijuana has long been recognized — and its use legalized in 24 states — for its efficacy with cancer pain, glaucoma, spasticity associated with multiple sclerosis, and other conditions. New and ongoing research, including studies presented at the recent conference, shows it can also help in pain associated with endometriosis and other women's

health issues, as well as post-traumatic stress disorder (PTSD), according to Mathre. “For nurses not familiar with the science behind medical marijuana, this conference probably was a real eyeopener, especially information about the Endocannabinoid System,” said Ken Wolski, MPA, RN, Executive Director of the Coalition for Medical Marijuana— New Jersey and a

The Science of Medical Marijuana New Jersey State Nurses Association (NJSNA) member. “We keep learning about more uses of medical marijuana, including its ability to help with eye movement disorders and healing bone fractures.” Wolski attended the conference to learn the newest science, earn continuing education contact hours, network with other health care professionals and patients, and provide information on New Jersey’s new law legalizing medicinal marijuana use. Wolski’s organization was instrumental in passage of the state law. Also supported by NJSNA, it allows for the creation of six non-profit, medical marijuana distribution centers throughout the state, which will be tightly regulated by the New Jersey Department of Health. Currently, only patients with certain qualifying conditions, such as MS, seizure disorder, and glaucoma, can get a certificate for medical marijuana use from their health care provider.

Glick noted that another speaker, Steve DeAngelo, presented information on a California lab that not only tests and certifies cannabis for patients to ensure it’s free of pathogens and contaminants, but also has been successful in determining different ratios of specific cannabinoids and flavonoids. New Mexico Nurses Association member Bryan Krumm, RN, CNP, also thought DeAngelo’s presentation was important because, for many patients, finding the correct strain of marijuana to ease their symptoms often is done by trial and error. Krumm, who wrote draft legislation for medical marijuana use in New Mexico and whose advocacy helped it become law in 2007, presented information on his state’s program. That law allows for medical cannabis use for one psychiatric disorder, PTSD. And Krumm, a Psychiatric Nurse Practitioner, said that several patients under his care already have benefited from its use. “Patients report decreased anxiety and racing and perseverating thoughts,” he said. “It also has stopped their nightmares, and has helped in decreasing irritability and anger that can accompany PTSD because [Cannabis] reduces hyperactivity of the amygdala.”

“We would like to see the law cover other conditions, such as PTSD,” he said. “We also would like to see home cultivation allowed, because it really empowers patients to take charge of their health care. And because it can be produced for pennies, it prevents patients from being dependent on pharmaceutical and insurance companies.”

Home-grown medicine

Medical marijuana cultivation also was a topic at the conference, with one presentation given by advocate and nurse Ed Glick. Glick specifically spoke about the importance of safe cultivation for optimal growth. “Cultivating cannabis is a very complicated process, and safe handling is important, because plants and dried and cured flowers must be kept free of pathogens, mildew, and mold,” he said. Nurses need to know about these safety issues, as well as gain a better understanding of medical marijuana’s effects and uses, according to Glick. In Oregon, currently about 36,000 residents are enrolled in the medical marijuana program and thousands more are enrolled nationwide. And therapeutic cannabis use likely will become more common. “Clinicians often have a difficult time wrapping their mind around a plant that can be used for some 150 clinical conditions,” Glick acknowledged. “But there are 100s of different strains of marijuana, which can have different ratios of certain cannabinoids. That’s why patient-guided research has shown that one strain may be better for MS than for some other condition.

Krumm added that many state laws allowing medical marijuana use will not truly be effective until cannabis is no longer classified as a Schedule I drug. “Even with laws in place, people are worried about losing their jobs or their children, and health care providers often are afraid of losing their license or being prosecuted by the DEA (U.S. Drug Enforcement Administration),” said Krumm, who petitioned and sued the federal agencies to remove the Schedule I classification. “Marijuana doesn’t meet the legal definition of a Schedule I drug, because it has accepted medical use in the United States. So, the DEA is technically violating the Controlled Substances Act.”

Legalization gaining ground from coast to coast To date, 23 states and the District of Columbia have passed laws allowing the legal use of medical marijuana.

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The Science of Medical Marijuana

Organizations Get Involved Charles Alexandre, MS, RN, chief, Rhode Island Office of Health Professionals Regulation and a RISNA member, presented information on the roughly fouryear-old law in his state regarding medical marijuana use. Although currently 1,500 patients are enrolled in the Rhode Island program, Alexandre said that the law initially had no plan for these patients to safely access medical marijuana. “Patients were really out on their own,” Alexandre said. “They could have relatives go out and get it [on the street], help them grow it, or grow it for them.” This lack of safe access was an issue for RISNA, which actively lobbied and testified on behalf of a state law, according to RISNA Executive Director Donna Policastro, RNP, who also provided welcoming remarks at the recent medical cannabis conference. Last year, however, the Rhode Island Department of Health created regulations allowing for the creation of up to three “compassion centers” statewide to ensure safe access. Further, based on RISNA’ s legislative success giving nurse practitioners’ global signature authority, NPs now have the right, like physicians and physician assistants, to sign the certification that’s needed for patients to enroll in the medical marijuana program as MS, cancer, and HIV/AIDS. Patients must re-apply for certification annually and pay a fee of $10 for those receiving government benefits and $75 for others, Alexandre explained. Mathre’s presentation focused primarily on nurse advocates’ plan to create a specialty nursing association called the American Cannabis Nurses Association (ACNA). Physicians, both researchers and clinicians, already formed a specialty group in 2009, called the American Academy of Cannabinoid Medicine. ACNA’s goals include educating nurses, other health care professionals, policymakers, and the public about the science and uses of medical cannabis. Further, the association would lobby for medical marijuana’s therapeutic use throughout the nation, as well as protect those, including nurse-patients, from retaliation when they advocate for its use, according to Glick and Mathre.

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ACNA also eventually wants to become an organizational affiliate of ANA, which has policy around the issue. In 2003, ANA’s broad policy-setting body, the House of Delegates, passed a resolution supporting nurses’ “ethical obligation to be advocates for access to health care for all,” including patients in need of marijuana/cannabis for therapeutic use. ANA’s Congress on Nursing Practice and Economics developed a position statement, called “In Support of Patients’ Safe Access to Therapeutic Marijuana,” which was approved by ANA’s Board of Directors in December 2008. Clearly, advocates say there is work that needs to be done in both research and education. There are health care professionals who still believe that medical marijuana isn’t really needed, because there is an approved oral pill, Marinol, that patients can use, Mathre said. But marinol is a synthetic THC – the substance that causes the “high.” “Medical marijuana is a synergistic shotgun containing cannabinoids, flavonoids, and terpinoids that have more therapeutic effects, and fewer side effects when taken together [than marinol or other pharmaceuticals],” Mathre said. “I know people are skeptical, but for centuries, various cultures have found it to be beneficial and so have patients.” For more information on ANA’s position statement, go to: www.nursingworld. org/ positionstatements_ethics.aspx. For more information on Patients Out of Time and links to online cannabis education, go to: www.medicalcannabis.com. This article orginally appeared in the May/ June 2010 issue of The American Nurse Repinted with permission.

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Heather Manus,RN Every Patient Deserves a Nurse Nurse Heather is a native New Mexican and Registered Nurse specializing in all aspects of medical cannabis care. She currently holds a position on the Board of Directors for the American Cannabis Nurses Association, serves as the Chairwoman of the ACNA Educational Outreach Committee, and holds certificates of completion in The Core Curriculum for Cannabis Nursing and Advanced Curriculum: Beyond the Basics. She is also an ACNA Faculty Presenter, and recently participated as an educator for both curriculums during the pre-conference workshops associated with The Ninth National Clinical Conference on Cannabis Therapeutics. Nurse Heather was honored this year to be nominated and awarded for “Best Charitable/Community Outreach Program” during the 2015 CannAwards. Heather is a Medical Advisor for Sacred

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In addition to advising, consulting, teaching, and speaking, Heather also founded the Arizona Cannabis Nurses Association,

syndrome, and Diabetes.

Heather began her career as a Registered Nurse by providing home health care services to patients in the Four Corners area of New Mexico, and acquired additional training and experience as a psychiatric nurse. Her current position as Medical Advisor for Sacred Garden requires Nurse Heather to stay up to date with all aspects of cannabinoid medicine; including standards, laws, research, trends, patient care and services. In both, New Mexico and Arizona, she opened the first medical cannabis infusion kitchens, which she established to create and provide medical cannabis patients with smokeless alternatives for cannabis use. Heather has extensive background in natural healing modalities and herbal remedies, some of which she obtained from her close association with Hispanic and Native American healers in New Mexico. As a practicing nurse, she has worked personally with hundreds, and has helped to create & provide quality medicine for thousands of medical cannabis patients in New Mexico and Arizona. Nurse Heather believes that Cannabis is a Gateway to Health and promotes the National Campaign: Every Patient Deserves a Nurse!

Contact: Heather Manus, RN cannabisnurseheather@gmail.com

https://facebook.com/heather.manus

http://instragram.com/cannabisnurseheather

https://www.pinterest.com/heathermanus

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What Nurses Need to Know

The Endocannabinoid System An introduction

edical cannabis is now legal in 24 states and Washington DC, along with recreational cannabis also being legal in several states. Many patients and families are now relocating to Colorado and Washington State as “marijuana refugees”, knowing they can freely and safely access cannabis as medicine in these recreational cannabis states. Nurses may still wonder, how is cannabis “medicine”?

As nurses we have a lot to learn about cannabis, including how it works in the mind-body-spirit system, and how we can best advocate for and support patients who could or do benefit from this medicine. Last spring, I witnessed a brief presentation being given to nurses around medical cannabis use, and it was obvious from the questions asked by many of the nurses that the social stigma around “marijuana” was alive and well.

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By Carey S. Clark, PhD, RN, AHN-BC, RYT Would these nurses be so reluctant to accept and support medical cannabis use if they truly understood the Endocannabinoid System (ECS)? The ECS was discovered some time ago, with Dr. Ralph Mechoulam (Faukner, 2015) being a pioneer in this area in the mid-1990’s. There are 20,000+ scientific articles written about the Endocannabinoid System (ECS). Though it has been many years since the discovery of this body regulatory system, most nurses likely know very little, if anything, about the ECS. A functioning ECS is essential to our health and well being. Endocannabinoids and their receptors are found throughout the body; in the brain, organs (pancreas and liver), connective tissue, bones, adipose tissues, nervous system, and immune system. We share this system in common with all other vertebrate animals, and some invertebrate animals (Sulak, 2015). Cannabinoids support homeostasis within the body’s system;

the ECS is a central regulatory system, cannabinoid receptors are found throughout the body, and they are believed to be the largest receptor system in our bodies. Cell membrane cannabinoid receptors send information backwards, from the post-synaptic to the pre- synaptic nerve. CB1 (found primarily in the brain) and CB2 (mostly in the immune system and in the bones) are the main ECS receptors (Former, 2015), though several more are currently being studied. The exogenous phytocannabinoid THC, or the psychoactive compound in cannabis, works primarily on CB1 receptors (hence the “high feeling” in the brain), while the cannabinoid CBD works primarily with the immune system and creating homeostasis around the inflammatory response through CB2 receptors and does not have psychoactive effects. Cannabinoids and their actions are still being studied, such as the nonpsychoactive cannabinoids CBN and CBG, also found in cannabis. Our bodies react to both our own

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While this process keeps normal cells alive, allowing them to maintain a balance between the synthesis, degradation, and subsequent recycling of cellular products, it has a deadly effect on malignant tumor cells, causing them to consume themselves in a programmed cellular suicide. The death of cancer cells, of course, promotes homeostasis and survival at the level of the entire organismâ&#x20AC;? (Sulak, 2015, paragraph #7). Cannabinoids support apoptosis and suppress cancer tumor angiogenesis (McPartland, 2008). Heart Disease: Additionally, it has been stated that the ECS plays an important function in protecting the heart from myocardial infarction and cannabinoids can have anti-hypertensive effects (Lamontagne et al, 2006). Inflammation: When inflammation occurs, the ECS helps to stop the process, similar to applying the brakes on a car. This is why cannabis is proving to be good medicine for inflammatory related illness. â&#x20AC;&#x153;Activation of CB2 suppresses proinflammatory cytokines such as IL-1Î˛ and TNF-Îą while increasing anti-inflammatory cytokines such as IL-4 and IL-10. Although THC has well-known anti-inflammatory properties, cannabidiol also provides clinical improvement in arthritis via a cannabinoid receptorâ&#x20AC;&#x201C;independent mechanismâ&#x20AC;? (McPartland, 2008). PTSD: â&#x20AC;&#x153;This review shows that recent studies provided supporting evidence that PTSD patients may be able to cope with their symptoms by using cannabis products. Cannabis may dampen the strength or emotional impact of traumatic memories through synergistic mechanisms that might make it easier for people with PTSD to rest or sleep and to feel less anxious and less involved with flashback memories. The presence of endocannabinoid signalling systems within stress-sensitive nuclei of the hypothalamus, as well as upstream limbic structures (amygdala), point to the significance of this system for the regulation of neuroendocrine and behavioural responses to stress. Evidence is increasingly accumulating that cannabinoids might play a role in fear extinction and antidepressive effects. It is concluded that further studies are warranted in order to evaluate the therapeutic potential of cannabinoids in PTSD.â&#x20AC;? (Passie et al, 2012). Seizures: Most hopeful, cannabis has been used to support pediatric treatment-resistant epilepsy, and while more research needs to be done in this area, many parents are becoming medical marijuana refugees by moving to states where they can procure cannabis for their children who suffer from seizures. Co-agonists: Cannabis increases the pain relieving effects of morphine, as discovered by researchers at UCSF. The two medications are synergistic, and this provides great hope for patients suffering intractable pain at end of life, chronic pain suffers, and opiate addicts. (http://www.maps.org/research-archive/mmj/ Abrams_2011_Cannabinoid_Opioid.pdf)

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For Nurses: So as nurses, what do we need to know to support patients who use cannabis? Legal Issues: If you live or work in a state that has legalized medical or recreational use of cannabis, familiarize yourself with the laws in that state, as well as your own workplace policies around supporting patient’s use of medical cannabis. Patients may have questions and as a patient advocate, your responsibility is to support patients with their knowledge and use of this medicine within the confines of your practice setting and state laws. You should also be aware of constraints around your role as a nurse in supporting patient use of medical cannabis. For instance, Kaiser patients in some states are likely to be removed from chronic pain patient programs if they test positive for cannabis. Nurses with knowledge around the benefits of medical cannabis can also advocate to support shifts in such policies will no longer align with the emerging ECS science.

American Cannabis Nurses Association: There are many nurses actively involved in supporting the use of medical cannabis and the defining the nurse’s role in this process. The ACNA has a mission to advance excellence in cannabis nursing practice through advocacy, collaboration, education, research, and policy development. http://americancannabisnursesassociation.org/ In Israel, nurses actively support patients in cannabis consumption from the process to the dosage. http://www.tabletmag.com/jewish-news-and- politics/137423/ medical-marijuana-kibbutz Nurses’ supporting patients healing process through cannabis medications may someday be common place in the USA as well.

The Endocannabinoid System (ECS) CBD, CBN, and THC fit like a lock and key into existing receptors. These receptors are part of the endocannabinoid system which impact physiological process affecting pain modulation, and appetite plus anti-inflammatory effects and other immune system responses. The endocannabinoid system comprises two types of receptors, CB1 and CB2 which serve distinct functions in animal health andwell-being.

Safety: This goes along with the legal aspects; medical cannabis patients should be supported in how to manage and store their medications with safety. While cannabis is known to be extremely safe (far safer than opiates and alcohol), cannabis consumers still need to store medication out of reach of children and pets. They should be supported in knowing the safety of driving or operating machinery if they consumer THC- based cannabis medicines. They also may need information on cannabis testing for both THC: CBD ratios, pesticides and/or other hazardous materials. Many patients need assistance with the basics around medical cannabis use, such as dosage, ratios of THC: CBD, strain information, and ingestion methods. Overcoming Stigma: Unfortunately, a stigma was created around around cannabis during the process of prohibition in the 1930’s, which was largely financially and racially driven. Contradictory state and federal laws, and the stigma around smoking cannabis (though many cannabis patients can now get relief from vaporizing, tinctures, topicals, patches, and edibles), along with a clear ignorance around the body’s ECS, serve to further with medical cannabis. associated with medical cannabis. Educate yourself on the roots of the phohibition of the medicine: http://origins.osu.edu/article/ llegalization-marijuana-brief-history And other issues around stigma and cannabis myths: http://alibi.com/feature/48426/Erasing-Stigma.html http://sandiegofreepress.org/2014/05/12-of-thebiggest-myths-about-marijuana-debunked/http:// www.huffingtonpost.com/mary-hall/weed-thepeople-movie-loo_b_5501864.html

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Reprint with premission Carey Clark, PhD, RN, AHN-BC, RYT. Also, references for this article can be found at: http://nursemanifest.com/2015/07/14/the-endocannabinoid-system-whatnurses-need-to-know-an-introduction?fb_action_ids=10153504495480970&fb_action_types= news.publishes

Weeding Out Pain:

The Cannabis

Dictum U

ntil recently, marijuana was known to a limited medical use because different amounts of various compounds are contained in different strains of the plant. The most commonly isolated substances from the plant are cannabinoids,

which can be administered in specific doses either alone or in combination with other drugs. THC or chemical delta-9-tetrahydrocannabinol is the most potent cannabinoid. While other marijuana extracts are still under test, the US Food and Drug Administration, FDA, has approved some cannabinoid drugs to control vomiting/nausea, boost appetite in cancer and AIDS patients.

Cannabis sativa, also called weed, marijuana, pot, cannabis, grass, hemp, marijuana (marijuana), hash, ganja, and smoke, etc. is an annual flowering plant that grows wild in tropical and warm climates and is often cultivated commercially, though illegally in many countries. There are two other species of cannabis apart from Cannabis sativa:

15th century BC Chinese Pharmacopeia, the RhYa.â&#x20AC;? The U.S. law, since 1970, has classified marijuana in Schedule I controlled substances. In other words, there was no generally accepted medical use for the substance, particularly when smoked.

Today, THC and marijuana are promoted as pain relievers, in Why Cannabis? addition to the uses already identified above. Experts also Cannabis has a long history of medical use. The US Federal focal report that THC lowers intraocular pressure, the reason it is believed point for research on drug abuse and addiction, National Institute on to be useful in managing glaucoma. Marijuana, as also Drug Abuse (NIDA), states that â&#x20AC;&#x153;The use of cannabis for purposes argued by some promoters, has anti-bacterial properties, is an of healing predates recorded inhibitor of tumor growth and a history. The earliest written dilator of the airways â&#x20AC;&#x201C; believed reference is found in the

Cannabis indica and Cannabis ruderalis.

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By Olusegun Iselaiye to be useful reducing the severity of asthma crises. It has also been argued that marijuana is effective in controlling seizures and mus-cular spasms in individuals with epilepsy and injured spinal cords. Bloggers and medical writers, as of 2012, also reported that cannabis oil can cure a wide range of diseases including cancer, diabetes, ulcers, migraines, arthritis, infections, and insomnia, etc. Cannabis Misuse Around The World

According to the World Drug Report (WDR) 2013, cannabis is the most widely consumed illicit substance in the world; about 180.6 million people, aged 15-64, joined the population of illegal users of cannabis in the world between 2009 and 2010 alone. Cannabis cultivation seems to have gone up in the United States in general.

Cannabis herb seizures in South America rose by 46% in 2011. Many African countries reported high level of cannabis herb seizures, with Nigeria having the highest figures in the region. WDR 2013 could not provide accurate numbers for European countries because its cultivation varies widely across the continent.

outrightly exempted medical cannabis, and many others have come up with both proposals to decriminalize and pass medical laws. Colorado and Washington states have both legalized the cannabis for recreational use via state referenda approvals in 2012 elections, while Oregonâ&#x20AC;&#x2122;s attempt to do same failed.

The regions with the highest prevalence rate of cannabis use are Central and West Africa (12.4%); Australia and New Zealand (10.9%); North America (10.7%); and Central and Western Europe (7.6%). About 10 million people in the UK admit to having tried cannabis. Over a 33 percent of people aged 16-24 have taken cannabis at least once in their lives. In the UK, more than 2 million people smoke the substance. Legalizing Cannabis

Cannabis use, sale, and/or possession is illegal in the United States. However, the Federal Government has declared that states reserve the right to pass laws to legalize cannabis for recreational use. The Federal Government advised further that states should have cannabis laws in place to guide the use of the substance. But how well have the individual state laws proposals complied with the Federal standard on cannabis use? It has been a mixed result. While a number of states have successfully permitted the psychoactive substance to some varying degrees, others have

Basically, cannabis legality for recreational or general use varies from country to country, though many countries are beginning to decriminalize its possession in small quantities and accepting its consumption for medical purposes. Does Cannabis Weed Out Pain?

In terms of pain treatment with cannabis, both pill and puff forms work well according to a carefully controlled, small-scale, new research study. The pill has a longer pain relief effect than puff, but may not cause high-feeling effect like puff form. A non-profit group ProCon. org reports that cannabis, called medical marijuana, has now been made legal in 24 American states

as well as the District of Columbia. Surveys have shown that pain is one of the major reasons medical marijuana is prescribed by doctors. But researchers testing the pain relieving properties of cannabis have reported dichotomous results. Some maintain that it works much like mild opioid/narcotic pain relievers such as codeine, while others have revealed that there are possibilities of the drug worsening the pain instead of reducing it. Despite the mixed results, pain relief remains one of most established benefits of medical marijuana. Actually, the American Academy of Family Physicians (AAFP), the American Public Health Association (APHA), and the American Nurses Association (ANA) have all endorsed medical marijuanaâ&#x20AC;&#x2122;s use in treating severe chronic pain. In fact, the New England Journal of Medicine also supports its use for severe chronic pain. Cannabis has also been reported as an effective treatment for nerve injury (chronic neuropathic pain). Medical marijuana was tagged the most promising neuropathic pain treatment by a group of pain research experts who convened at a MedPanel summit in 2006. For more information, scan the QR code below to view pain management video.

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Cannabis and Harm Reduction: A Nursing Perspective By: Mary Lynn Mathre RN, MSN, CARN

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Summary.The goal of nursing care is

to promote health and reduce harm caused by injury, disease, or poor selfcare. Harm reduction is a public health model, which is gaining popularity as an effective modality to help persons reduce the negative consequences associated with their drug use. The harm reduction model blends well with the core principles of nursing. When viewed from a nursing perspective, cannabis could be an effective harm reduction agent based on its high benefit low risk ratio when compared to other standard medications/drugs. As a medicine, cannabis has demonstrated a high therapeutic potential with relatively few side effects or adverse reactions. As a social/recreational drug, cannabis has a wide margin of safety with relatively few risks. The greatest risks from cannabis use are the legal consequences, which are the result of

safe environment to nurture them back to a more independent self-caring state? Nursing is much more than simply caring and providing comfort; it involves the art of knowing how to give the right kind of care and comfort to facilitate the healing process, and this knowledge is based in science. The goal of nursing care is to promote health and reduce the harm caused by injury, disease, or poor self-care. Nurses are the largest group of health care professionals, and are keenly aware of the potential risks related to medications. While pharmacists dispense medications and physicians prescribe medications,nurses administer them to countless numbers of patients and monitor the effects of the medications.

or using a helmet when riding a motorcycle. Today, harm reduction is gaining popularity as a more effective and realistic modality for helping persons who use drugs to reduce negative consequences associated with their drug use. Such harm reduction strategies include needle exchange programs for intravenous drug users to prevent blood-borne infections, use of a designated driver for persons consuming alcohol away from home, overdose prevention education, and offering a variety of drug treatment options (www.harmreduction.org). Harm reduction is based on the premise that people are responsible for their behavior, that they make personal choices that affect their health and well-being, and that they can make safer and better decisions if

Cannabis and Harm Reduction the cannabis prohibition rather than the drug itself. The therapeutic relationship between individuals and their health care providers is severely compromised by the cannabis prohibition.

INTRODUCTION

Nursing is the art and science of caring. Since 1999 when nurses were included in the Gallup “Honesty and Ethics” poll, nurses have been rated as one of the most trusted professional groups by the American public (http://www. gallup.com/ poll/releases/pro011205.asp). What is it about nurses that the public is willing to trust? Could it be that nurses often see people in their most vulnerable states and during that time treat them with respect and provide a

Nurses are in a key position to see not only the beneficial effects of a particular medication, but also the side effects or adverse reactions that can accompany medications even when used as recommended. Safe administration of medication is a critical skill all nurses must master because any error could cost a patient added suffering, organ damage, or could result in death. Harm reduction is a public health approach to human behaviors, which involves helping persons learn to make better personal choices to minimize the potential risks associated with their behavior. Examples of harm reduction practices include using condoms properly during intercourse to avoid STDs, wearing a seatbelt when traveling in a motor vehicle,

given useful and honest information. The harm reduction approach accepts the fact that individuals will use drugs for various reasons and offers to help them “where they’re at.” In contrast, the War on Drugs is based on the premise that certain drugs are “bad” and that the government has the paternal right and duty to prohibit the use of these drugs. This “zero tolerance” or “just say no” approach condemns the use of certain drugs and punishes those who use them. Acceptance comes after transgressors admit their wrongful ways and adhere to the abstinence option. O C T O B E R 20 1 5

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“Health care is a 24/7 business; fatigue is everywhere, and we know that a disproportionate number of injuries occur during night shifts.”

The underlying flaw in the war on drugs is the belief that some drugs are inherently bad and therefore deserve to be prohibited for the greater good of society. A drug is not simply good or bad, right or wrong, but rather the manner of use of a drug by an individual may be helpful or harmful. The harm reduction approach is based on science and the respect of others, while the war on drugs is based on moralistic ideology and the control of others. Drug use will always have the potential of causing sequelae. Harm reduction strives to minimize the harmful effects from drug use, while the drug prohibition creates more harmful effects from drug use.

Commission on Marihuana and Drug Abuse to determine whether or not that placement was appropriate. President Nixon appointed most of the commissioners including the former Republican Governor of Pennsylvania, Raymond Shafer, as the chairman. The “Shafer Commission” completed their study in 1972, and it remains the most comprehensive review of marijuana Cannabis was a Medicine in the U.S. ever conducted by the federal government. In the end, the Shafer Prior to the prohibition of marijuana, Commission concluded that cannabis cannabis products were widely used by did not belong in Schedule I and stated physicians. By the 1930s there were 23 (National Commission on Marihuana pharmaceutical companies producing and Drug Abuse 1972, p. 130), cannabis preparations. In 1937, the “Marihuana’s relative potential for passage of the Marihuana Tax Act harm to the vast majority of individual marked the beginning of the cannabis users and its actual impact on society prohibition. The head of the Federal Cannabis is an herbal agent that has does not justify a social policy designed Bureau of Narcotics (now the Drug been used as a medicine, a recreational to seek out and firmly punish those Enforcement Administration or DEA), drug, as well as a source of food and who use it.” The recommendations Harry Anslinger, led this legislative fiber. It is environmentally friendly, were ignored and cannabis remained in effort using exaggerations and lies essentially non-toxic, yet currently Schedule I, a forbidden drug. (Bonnie and Whitebread 1974). During forbidden by our federal government. the congressional hearings the American US citizens are prohibited from Now, fourty years later, the Medical Association (AMA) opposed growing this plant or possessing any of infamous Nixon tapes of Oval Office the Act and supported cannabis as a its leaves, seeds, stems or flowers. conversations from 1971 to 1972 have therapeutic agent. The law makers won Physicians are forbidden to prescribe it been declassified and made available to and the AMA has since given up the for medical use. When the cannabis the public (transcripts available at fight. plant is examined in a scientific and www.csdp.org). It is clear that Nixon logical manner, its therapeutic value used his political power to influence The Controlled Substances Act of 1970 becomes apparent. From a nursing the outcome of the Shafer furthered the cannabis prohibition when it perspective cannabis could be a useful Commission, and when that didn’t called for a system to classify harm reduction tool, yet the laws work he simply dismissed their psychoactive drugs according to their risk prohibiting its use present contrived recommendations and launched the potential. Five Schedules were created, risks that can cause more harm than war on drugs. Curiously, at the same with Schedule I being the most restrictive the drug itself. time, the Bain Commission in The category. Under the Act, cannabis was Netherlands (with a similar mission) initially placed in Schedule I, but ConThis article will examine cannabis as a gress called for a National harm reduction agent from a nursing perspective. Cannabis as medicine is

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not a magic bullet that will work for everyone, and is not without potential risks. Cannabis as a recreational drug is not enjoyable for everyone and is not harmless, but when put in the broader perspective and compared to standard medicines or common recreational drugs, cannabis offers greater benefit with fewer relative risks.

issued its report with similar findings. The government of The Netherlands acted on the recommendations of the Bain Commission, and today the Dutch have half of the per capita cannabis use as the U.S., with far fewer drug-related problems at much lower drug enforcement costs (Zeese 2002).

Cannabis as a Harm Reduction Medicine.

Compared to standard medications, cannabis has a remarkably wide margin of safety. In 1988, after a lengthy legal battle to reschedule cannabis, the DEA Administrative Law Judge, Francis Young, ruled that marijuana should be assigned to Schedule II and thus available for physicians to prescribe. In his summary he noted that (p. 57), “Marijuana in its natural form is one of the safest therapeutically active substances known to man.” Throughout the centuries of its use, there has never been a death from cannabis (Abel 1980). In contrast, there are more than 32,000 deaths per year associated with prescription medications in hospitalized patients (Lazarou, Pomeranz and Corey 1998). All opioids carry the risk of overdose. Even over-the-counter (OTC) medications can be lethal. There are approximately 120 annual deaths from aspirin. Cannabis has been studied extensively in regard to determining its health risks. General McCaffrey called upon the Institute of Medicine (IOM) to study the therapeutic value of marijuana in 1997.

In March of 1999 the IOM released its 18-month study, which concluded that cannabis does have therapeutic value and is safe for medical use (Joy, Watson and Benson 1999). Concern was noted about the potential risks related to smoking medicine, but the study concluded that for patients suffering from cancer or AIDS, the potential pulmonary risks were minimal when compared to the benefits. The study also noted that while more research is warranted, cannabis is safe enough for physicians to conduct studies on their patients who they believe could benefit from cannabis if other medications are not effective.

The IOM report put health risks associated with cannabis in perspective noting (p. ), “. . . except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications.” A recent study of the chronic effects of cannabis on four of the seven federally provided medical marijuana patients showed minor bronchitis in two of the patients (Russo et al. 2002). These patients smoked from mg to 10mg low-grade (2 to 4% THC content) cannabis cigarettes on a daily basis for 10 to 20 years. No other attributable long-term problems were noted, but rather a reduction in their use of other medications and a feeling of well-being was experienced by the patients.

While smoking cannabis may cause lung damage after chronic use, there are various actions that can be taken to reduce the harm from smoking. Patients can smoke less if using a high potency product (THC content greater than 10%) and can easily adjust the dosage by decreasing the number of inhalations. Also, when smoking cannabis, patients should limit their breath holding to less than ten seconds to avoid lung damage (Tashkin 2001). Vaporizers are being developed that heat the plant material to the point of vaporization without combustion, thus avoiding smoke inhalation (Gieringer 2001, Whittle, Guy and Robson 2001). Finally patients may use cannabis in alternative delivery forms such as pills, sublingual spray, eye drops, suppository, dermal patch, or salve, thereby eliminating pulmonary risks. The federal government claims that cannabis is harmful to the immune system. When reviewing the published animal studies that reported harm to the immune system the reader should note that most of the researchers used delta-9-tetrahydrocannabinol (THC) rather than natural cannabis and that extremely high doses were used. A review of the active ingredients in cannabis suggests that some of these constituents act synergistically to enhance the beneficial effects of THC,

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while others may mitigate the harmful side effects of THC including possible immunosuppression (McPartland and Russo 2001). Given the thousands of immunocompromised patients who have used cannabis there have been no reports of direct damage to the immune system from cannabis except when the patient has used a contaminated supply. Many AIDS patients who, by virtue of their disease have a severely compromised immune system, do not show any decline in their health status related to cannabis. In fact, a recent study of cannabis use by AIDS patients showed that cannabis did not interfere with protease inhibitors and helped increase weight gain for a significant number of patients (Abrams et al. 2000).

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Another cannabis risk has been an allegation that it causes brain damage. Although the federal government continues to use this scare tactic, modern research has not confirmed such findings. A Johns Hopkins study examined cannabis’ effects on cognition on 1318 subjects over a 15-year period (Lyketsos et al. 1999). The researchers found no significant differences in cognitive decline between heavy users, light users, and nonusers of cannabis. They concluded that the re-sults provided strong evidence of the absence of long-term residual effects of cannabis use on cognition. Perhaps the most illogical argument the federal government uses to prohibit the therapeutic use of cannabis is that to allow its medical use would “send the wrong message to our youth.” General Barry McCaffrey openly fought the growing popular opinion and scientific findings that cannabis has medical value. In response to the passage of state initiatives allowing the medical use of marijuana, McCaffrey dismissed

its therapeutic value and declared that state laws allowing medical use of cannabis would increase the rate of drug use among teenagers. He stated, “While we are trying to educate American adolescents that psychoactive drugs are bad, now we have this apparent message that says ‘No they’re medicine. They’re good for you’” (Substance Abuse Report 1996). That is nonsense. Teenagers don’t think, “Insulin is medicine. It must be good for me.” A persistent message that parents and health care professionals should demonstrate and reinforce with children and teenagers is that medicine is for sick people and that all medicine should be used with caution based upon an awareness of the risks and benefits. Since nurses are advocates and health educators for patients, families, and communities, they have a key role in helping others learn to use medications safely. With more than 400,000 medication preparations available in the U.S. it is unlikely that any person can know everything about these medications. However, the user can reduce harm from medications by following some general guidelines designed to ensure that the risks are minimized. Mothers Against Misuse and Abuse (MAMA) has developed medication guidelines that persons may follow when using any OTC, prescribed medication, or recreational drug. The premise for these guidelines is that no medication is completely risk-free, but harm can be minimized

"Nurses have been rated by the public as the most trusted professional group by the Gallup Honesty and Ethics poll for the past 10 years." if the user has appropriate information to make an informed decision. MAMA seeks opportunities to teach these guidelines to parents to help them set a good example for their children when it comes to the use of medications or recreational drugs (www. mamas.org). This includes essential information that nurses include in their patient education, such as the name of the medication, desired effect, possible side effects or adverse reactions, proper dosage and route of administration, risk of tolerance, dependence or drug interactions.

Pain is the most frequent symptom for patients seeking medical care. Cannabis analgesia provides a good example of its potential as a harm reduction medication. Innumerable chronic pain patients have found it difficult to find a balance between managing their pain and being able to function in daily life. Opiates are frequently used for management of severe pain, however they sometimes leave the patient feeling “drugged” and come with the risk of overdose and side effects such as constipation, nausea and vomiting. Increasingly, patients are acting on the advice of others and are trying cannabis as an analgesic. Per numerous reports (Mathre 1985, Corral, Black and Dalotto 2002, Russo et al. 2002, Rosenblum and Wenner, 2002), the introduction of cannabis into pain management regimens has been very helpful. Most patients report a significant reduction in the use of opioids or need them on occasion for acute exacerbations; this reduction in the use of opioids lessens the risk for physical dependence. Cannabis is an effective antiemetic, and is not constipating.

Resources In summary, many chronic pain patients who use cannabis report that they feel better, experience fewer untoward side effects, are able to reduce their use of opioids and other medications, and are thereby able to eliminate additional side effects that may accompany those medications as well as the added risks from drug interactions.

Margo McCaffery (1968) has taught us that pain “is whatever the experiencing person says it is, existing whenever he says it does.” Pain is a subjective experience and patient feedback is essential to effective pain management. Current national guidelines for pain management endorse McCaffery’s standard (Jacox et al. 1994). Given patients’ reports of pain control with cannabis and its relative safety, nurses recognize that cannabis should be an option for patients. To date 15 state nurses associations, including but not limited to, AK, CA, CO, HI, MS, NJ, NM, NY, NC, VA, and WI have passed formal eresolutions supporting patient access to this medicine (www.medicalcannabis.com). In addition, the American Nurses Association’s Congress on Nursing Practice issued a statement in 1996 calling for the education of all RNs on evidence-based therapeutic indications for cannabis.

Abel, E.L. 1980. Marihuana: The first twelve thousand years. New York: Plenum Press. Abrams, D.I., S.B. Leiser, S.B. Shade, J. Hilton, and T. Elbeik. 2000. Short-term effects of cannabinoids on HIV-1 viral load. Poster presentation at the 13th International AIDS Conference, Durban, South Africa. 13 July 2000. Bates, M.N. and T.A. Blakely. 1999. Role of cannabis in motor vehicle crashes.Epidemiol Rev 21(2): 222-232. Bonnie, R.J. and C.H. Whitebread. 1974. The marihuana conviction: A history of the marihuana prohibition in the United States. Charlottesville, VA: University Press of Virginia Compton, D.R., W.O. Dewey, and B.R. Martin. 1990. Cannabis dependence and tolerance production. Adv Alcohol Subst Abuse 9(1-2):129-147. Corral, V.L., H. Black, and T. Dalotto. 2002. Medical cannabis providers. Panel presentation at The Second National Conference on Cannabis Therapeutics, Analgesia and Other Indications, Portland, OR, 4 May 2002. Federal Bureau of Investigation. 2001. Uniform Crime Reports for the United States2000. U.S. Government Printing Office: Washington, DC. Frood, A. 2002. Alcohol impairs driving more than marijuana. New Scientist (UK). March 20 Gieringer, D.H. 2001. Cannabis “vaporization”: A promising strategy for smoke harm reduction. J Cannabis Therap 1(3/4):153-170. For more resources please refer to the original article released at: http://www.cannabis-med.org/data/ pdf/2002-03-04-6.pdf O C T O B E R 20 1 5

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Nursing Humor

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Resources

Recommended Books

Drugs & the Human BodyBy Ken Liska

This is a reliable reference addressing the effects of high-use, high-abuse drugs in America in a timely and straightforward fashion. It reflects up-todate research throughout, including coverage of street, over-the-counter, and prescriptive drugs. Ideal for professionals in health and drug education, criminal justice, sociology, biology, and chemistry.

Marihuana: The Forbidden Medicine Grinspoon and Bakalar have compiled testimonials on the medicinal uses of marihuana for a variety of medical problems, including glaucoma, multiple sclerosis, epilepsy, and the nausea and vomiting associated with cancer chemotherapy. These accounts dramatically illustrate marihuana’s potential to alleviate suffering when traditionally prescribed medications have proved ineffective, but they also illustrate the great stress placed on these individuals and their families by using an illegal substance. Many people don’t know how to obtain marihuana, can’t afford it, and are fearful andresentful of being considered criminal for using it. The authors discuss social attitudes towards marihuana and the reasons why the drug was outlawed. They argue that making marihuana available on a prescription basis is unworkable and that its legalization is necessary to make it available to those who need it. Recommended for public and academic libraries.- Kathleen McQuiston, Philadelphia Coll. of Pharmacy and Science

Marijuana Myths Marijuana Facts:

Marijuana Myths, Marijuana Facts provides reliable information about marijuana’s effects on people. This book is for everyone interested in the drug itself, and for everyone concerned about people who use it. It is for parents and adolescents, for school counselors and police officers, for drug treatment specialists and drug policy reformers. It is for people who love marijuana and people who hate it.

A Comprehensive Guide to Conditions Treated by Cannabis. The Medical Marijuana Desk Reference. The most comprehensive and up-todate guide on the scientific research of Cannabis species for medical treatment. The MMDR compiles primary scientific studies on the efficacy of marijuana for both state-authorized and other, not yet authorized conditions in an easy-touse format.

Demons, Discrimination and Dollars:

A Brief History of the Origins of American Drug Policy

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The Mediterranean Diet: A Healthy Option to Reduce Your Risk of Heart Disease In the 1950s, researchers found that the adult life expectancy for people living in the Mediterranean regions (Crete, part of Greece, Southern Italy, and other countries bordering the Mediterranean Sea) were among the highest in the world. They also found that rates of coronary heart disease, certain cancers, and some other diet-related chronic diseases in this region were among the lowest in the world.

Research suggests that the dietary patterns of those living in the region can be a healthful alternative to the traditional American diet. Will the diet alone significantly reduce your risk of heart disease and increase your longevity? Researchers point out that the low incidence of heart disease and low death rate in the Mediterranean countries may be due, in part, to other lifestyle factors, such as more physical activity and extended social support systems.

What Is the Mediterranean Diet? There is no one typical Mediterranean diet. Many countries border the Mediterranean Sea and variations in the Mediterranean diet exist between these countries. However, according to the American Heart Association, traditional Mediterranean diets have the following characteristics in common: n An abundance of plant foods:

• Fruits • Vegetables • Whole grain breads and cereals • Beans, nuts, and seeds

n Olive oil used as a common

monounsaturated fat source

n Low-to-moderate amounts of fish

n Small amounts of red meat n Low-to-moderate amounts of dairy

products (mostly cheese and yogurt)

n Low-to-moderate amounts of eggs

(zero to four times per week)

n Low-to-moderate amounts of wine

(one glass of red wine per day)

and poultry

Comparison

with the American Diet The American diet is characterized by: • Animal products daily, as main source of protein • White starches, predominantly • Moderate to low in fruits and vegetables • High in saturated and trans fats Unlike the typical American diet, the traditional Mediterranean diet is high in fiber and low in saturated fat. However, the Mediterranean diet is not necessarily low in total fat. But, the types of fats emphasized in the Mediterranean diet are “healthy” monounsaturated fats, like those found in olive oil and canola oil, which do not raise cholesterol levels.

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Tips for

Mediterranean

Eating

How can you eat more authentically Mediterranean? • Include an abundance of food from plant sources such as fruits, vegetables, whole grains, seeds and nuts. • Choose a variety of minimally processed foods, preferably those that are seasonally and locally grown. • Use olive oil or canola oil as the principal fat in your diet, replacing other fats and oils.

health benefits There has been a lot of research on the potential health benefits of following the Mediterranean diet. According to studies, this diet may offer these benefits: • Reduce the rate of death in people who have had a heart attack • Reduce the rate of heart attack in people who have heart disease • Reduce the rate of stroke • Aid in weight loss • Lower the risk of developing cancer

• Eat low-to-moderate daily amounts of cheese and yogurt (preferably low-fat and non-fat versions). • Eat fish and poultry at least twice per week. • Have fresh fruit as your typical daily dessert. • Eat red meat only a few times per month. When eating red meat, choose lean cuts and smaller portions. Avoid sausage, bacon, and other meats that are high in fat.

Talk to your doctor about the Mediterranean diet to see if it’s right for you. Find out more by visiting the Health Library on www.SAHealth.com and searching “Mediterranean Diet.”

• Lower HbA1c levels (a measurement of how well the body uses blood sugar) in people with diabetes • Reduce pain in rheumatoid arthritis • Lower the risk of developing type 2 diabetes • Reduce the risk of metabolic syndrome. The term “metabolic syndrome” refers to a group of risk factors for cardiovascular disease. These risk factors include obesity, low amounts of “good” (HDL) cholesterol, high triglycerides, high blood pressure, and pre-diabetes. It is important to remember, though, that other factors can affect these benefits. For example, people who follow the Mediterranean diet may have a lower risk of cancer because of other lifestyle factors or their environment. O C T O B E R 20 1 5

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Mistakes can happen, but new patient safety standards teach students to move beyond individual blame to a shared culture of prevention. Body parts are everywhere, enough to keep Dexter happily occupied through to Season 12. Torsos, disembodied heads and limbless hands are efficiently stacked on shelves, legs lean against the walls and a neat row of arms line a tabletop. “We’re getting arms pumped up with ‘blood’ for the IV lab,” explains Colette Foisy-Doll, Professional Resource Faculty in the Clinical Simulation Centre at MacEwan University. Behind her, full-sized (and fully intact) bodies of men, women and children lie prone on stretcher beds, and infants of all skin colours stare unblinkingly, perched in sitting poses. “Welcome to the Sim Lab, where everything is pretend but as real as possible,” Foisy-Doll continues. The vivacious nurse educator has helped design and develop more than 13 simulation centres in educational facilities across Canada (and most recently one in Doha, Qatar), but this one, spread over two floors in MacEwan University’s Centre for Professional Nursing Education, is her baby. She set it up more than a decade ago as an early pioneer in the use of simulation learning for the training of health-care professionals in Canada. As she opens a black suitcase to reveal an almost-too-realistic below-the-belt segment of the male anatomy, she explains it’s used to teach students correct catheter insertion techniques under conditions as true to life as possible, without harming a real patient. “Sure, there are some giggles at first, but students quickly get over that,” Foisy-Doll says.

"They often forget that the mannequins aren’t real. I’ve seen students cry when their ‘patient’ dies.” 40

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“They often forget that the mannequins aren’t real. I’ve seen students cry when their ‘patient’ dies.” Students learn and refine their skills on “task trainers,” the various body parts needed to perfect skills such as giving injections or inserting feeding tubes through nasal passageways. Then their abilities are put to the test using high-fidelity simulators such as “Stan” – who obligingly talks, coughs, yells, turns blue, develops an erratic pulse or appropriately responds to medications as needed. Or “Noelle” may give birth, often with complications, to an equally realistic baby. The series of medical events unfold during scenarios that are designed to show how things can go wrong once students have left the classroom behind. “Gaps in learning show up during a crisis,” Foisy-Doll explains. “We simulate common crisis situations in the lab so students can discover what they don’t know or need to learn better. But it all happens in a psychologically safe environment where it’s okay to make mistakes. This is where we want errors to happen, not in clinical settings.” To err is human; it’s part of how we grow. Business gurus urge entrepreneurs to embrace their errors, learn from failure and move on to greater heights. After all, even Steve Jobs was fired from Apple before his ultimate success. But what if your business is health care? Because doctors and nurses are fallible, their mistakes can prove fatal for patients. Statistics on avoidable medical errors weren’t measured until the late 1990s, when Australia, the UK and the US were the first to release ground-breaking reports. In 2002, the World Health Organization (WHO) summarized worldwide data, estimating that one in 10 patients is harmed while receiving care in an advanced hospital setting. The Canadian Adverse Events Study later showed similar results, reporting a 7.5– per cent medical error rate in hospitals nationally in 2004. Another study, published that same year in the Canadian Medical Association Journal, estimated the human toll was 9,000 to 24,000 deaths in Canada annually.

Ironically, as the art and science of healing advances, so does the potential for medical error. Yet the international search for answers over the past 15 years has shown that the real problem isn’t negligence or incompetent care; instead, it’s the increased complexity of the system itself. The solution isn’t the traditional kneejerk (but very human) reaction of assigning blame and punishment. The root cause within the system must be addressed, and to do that health-care professionals must be encouraged to report their errors or “near-misses” rather than hide them. “We have to move beyond the old habits of blame and shame and silence to create a new culture of patient safety where the entire system protects the patient,” says Foisy-Doll. She points out that this radically different philosophy and systemic approach is evident in the new patient safety standards created worldwide over the past decade.

“We’ve adopted these as our guiding principles to make patient safety an overarching theme in all areas of MacEwan University’s nursing curriculum, including simulation learning. Globally, we look to the WHO; nationally, we incorporate standards developed by the Canadian Patient Safety Institute and the Canadian Interprofessional Health Collaborative; provincially, we draw on the framework developed by the Heath Quality Council of Alberta.” As well, MacEwan University instructors are staying on top of new developments in the patient safety field through continuous learning of their own. Along with 10 other MacEwan University staff, Foisy-Doll recently completed specialized training to receive certification as a Canadian Patient Safety Trainer. “I now have a 14-pound binder of extensive teaching resources that we can insert into our curriculum,” Foisy-Doll says with her typical enthusiasm.

Her passion for instilling a new culture of patient safety is shared throughout the Centre for Professional Nursing Education. “Research has given us a heightened awareness that we need a systems approach,” says Director Shirley Galenza. “Safety isn’t about blaming individuals; it’s about finding the root cause. The major causes of incidents are lack of communication and lack of interprofessional collaboration within a complex system. Our goal is to give students the new skills needed to manage this complexity, as well as an understanding that when systems break down it’s a nurse’s ethical responsibility to be part of finding the solution.”

How Alberta is building a stronger patient safety culture Like other patient safety organizations formed during the past decade, the Health Quality Council of Alberta (HQCA) has been busy defining what the implications of this emerging discipline of health care are for the provincial health system. HQCA was created as an arm’s-length not-for-profit in 2006 by the Alberta government, charged with the province-wide promotion and improvement of patient safety and quality health services. Taking a collaborative approach, it works with numerous provincial stakeholders to fulfil its mandate, including the College and Association of Registered Nurses of Alberta. In 2010 an HQCA working group defined five guiding principles for Alberta’s health system in Patient Safety Framework for Albertans, a 20-page publication available at no charge. This framework recognizes that education will play a key role as Alberta develops a new systemic culture of patient safety. In fact, one of the framework’s six strategies focuses directly on the development of a provincial curriculum rooted in patient safety: “Strategy 5: Build Knowledge Capacity to Support Patient Safety.” In 2009, HQCA began another multi-year collaborative project to develop a framework for patient safety education in Alberta. Known as the

Blueprint Project, its steering committee includes representatives from Alberta’s educational facilities. Together they’ve identified key messages relevant to patient safety that should be incorporated into educational programs at all levels, for all health care workers. These are summarized in the Blueprint Project’s Patient Safety Principles, released in 2010, which defines the patient safety learning topics for curricula. As well, HQCA recently created a methodology for the reporting and analysis of adverse events, Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews (2012). The guide reflects the new transparent, systembased approach to medical errors and focuses on finding systemic root causes rather than assigning individual blame. The principles identified in these HQCA documents were used as touchstones by the Centre for Professional Nursing Education (CPNE) to ensure its curriculum addresses the importance of patient safety in healthcare education. Patient safety is emphasized in every aspect of training, particularly in specialty programs, and the CPNE will continue to work with the Blueprint Project to incorporate any future recommendations. To review the documents mentioned here or to order a copies, consult the Health Quality Council of Alberta website at www.hqca.ca.

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Apps for Health-Care Professionals Smartphone apps and web-based tools are increasingly important resources for health-care practitioners. Check out these great tools and put a wealth of health-care information in your pocket.

01 NURSING CENTRAL

06 EPONYMS

Nursing Central is the complete mobile solution for nursing produced by Unbound Medicine. The app includes disease, drug and test information for nurses. http://goo.gl/XWglb

A browse-able and searchable app that provides short descriptions of more than 1,700 obscure medical eponyms. http://goo.gl/BKP0H

02 LIPPINCOTT NURSING

07 NETTERâ&#x20AC;&#x2122;S ANATOMY FLASH CARDS

DRUG HANDBOOKS

Keep over 300 outstanding anatomical flash cards on your device. This app enables you to carry the popular Atlas of Human Anatomy (4th edition) and its detailed anatomical illustrations on your phone or tablet. http://goo.gl/jr9Th

This app provides up-to-date drug information on your device, including contraindications, nursing considerations, patient teaching and integration of the nursing process. http://goo.gl/em9E1

03 MANAGEMENT GUIDELINES FOR NUSING PRACTITIONERS WORKING WITH ADULTS The app is a best-practice guide for health-care professionals who work with adult patients. Other apps in the series provide guidelines for working specifically with women, with children, with older adults or in family practices. http://goo.gl/o2hC6

04 JOURNAL WATCH This tool from the Massachusetts Medical Society notifies you about new papers published on topics of your choice. http://goo.gl/dxbrd

05 3M PREP This app provides a detailed rationale for selecting surgical prep solutions. You can view how to correctly apply solutions while listening to a detailed set of instructions. http://goo.gl/QGwsY

08 CNOR EXAM PREP The Competency and Credentialing Institute, the governing body of the Certified Nurse Operating Room (CNOR) credentialing program, has created the CNOR exam prep app to help perioperative nurses prepare for the CNOR exam. The app helps individuals assess their exam readiness and develop critical thinking skills; it also provides tips for success, reviews knowledge related to the CNOR exam and can enhance test-taking confidence. http://goo.gl/n1DMo

09 EPOCRATES Rx The app includes a drug guide, formulary information and a drug interaction checker. This product also includes continual, free updates and medical news. Additionally, the app works on your device when you are offline, so you can look up information without a wireless connection. http://goo.gl/fqchG

10 MACEWAN LIB The MacEwan University Library app simplifies searches for books and articles. It allows you to place a hold on library catalogue items, renew items, download full-text resources and perform many other tasks. http://goo.gl/YAUQe

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