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Full Circle
By: Wendy Buck-Benge, RN
AM I A Cannabis Nurse?
By: Barbara Blazer, RN-Retired
How Should Cannabis be Regulated?
Page 12
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For decades, Nurses have been on the front lines of the battle to legalize Medical Cannabis and we have made great strides in social, medical and political arenas. According to recent polls, 83% of Americans now support legalizing Medical Cannabis and there is a paradigm shift in the majority of thinking. We know that cannabis education is vitally important for Nurses, Healthcare Providers and individuals than ever before and Cannabis Nurses Magazine is bridging that gap for the second year in a row. But what are Nurses really doing in this newly developing field? In this issue we revisit The Cannabis Nurse: An Update where we further define Cannabis Nursing through nursing articles that focus on how or what defined them as a Cannabis Nurse and focusing on the advancement of this developing specialty in the nursing profession. We first explore our featured Cover Nurse, Wendy Buck-Binge, RN who defines her childhood experiences, here nursing professional years, her experiences as owning a dispensary and how her story parallels to our clinical lives in nursing. “Cannabis Nursing is more than teaching how to use the plant for its healing properties and educating about the Endocannabinoid System (eCS). It is the shift in the healthcare paradigm that attracts nurses. It is not about applying Band-Aids any longer but about teaching how to institute real and lasting change in people’s lives with brutal honesty. Cannabis Nurses not only know that is possible, we make it possible.” We then discuss the question from a 71 year old retired nurse, “Am I a Cannabis Nurse?” as, Barbara Blazer, RN-Retired, discusses how her daughter asked her to start assisting the patients in her dispensary. Although her nursing hat was retired, she dusted it off, put it back on, and realized that she was and is making a difference in this pioneering healthcare industry. We then visit, Kebra Smith-Bolden, RN who defines how “My Heroes Lead me to Cannabis” and the impact its making within her nursing profession on the east coast while on the west coast, we visit Michael Rochlin, RN, MN, COHN-S, CSP as he is moving “Onwards and Upwards: Forging the New Oregon Trail” within Cannabis Nursing through legislation in Oregon. These Cannabis Nurses are on the move and bridging the gap. There is much discussion within the Cannabis Nursing Professionals as to “How Should Cannabis be Regulated?” Should we Re-schedule, De-schedule, or Legalize? and What Does that Mean?" Four of our high-skilled nursing educators broke it down for us to ponder in their article. They state, “This is not the time for Nurses and other healthcare professionals to stay mute on the issue. It is our ethical responsibility to advocate for our patients best interests. Rescheduling will increase cost, decrease access, and waste a lot of precious time in more rulemaking. Rescheduling will benefit a few, not the majority. De-scheduling will open the door for all to enjoy this highly beneficial and versatile plant. Which do you choose?” As difficult as this may be to decide as a Cannabis Nurse, we are given the tools to read, understand, and have these ideals outlined in the following to further our potential: Patients Out of Time Position Statement in support of De-Scheduling of Cannabis, Bryan Krumm, CNP, MSN, RN, BC An Update: Rescheduling Petition for Cannabis 2009 (continued from CNM July/Aug 2016 Issue: Oaths, Duties and the Pursuit of Harmony), and the ACNA Scope and Standards of Practice for Cannabis Nurses which is precluded by Carey S. Clark, PhD, RN, AHN-BC, RYT article, “The Future of Cannabis Nursing”. Unanimously, we agree that the main goal is to support Cannabis Nursing as an officially recognized specialty within nursing. There are many steps outlined to reach this goal and with it come the challenges ahead as we strive to professionalize this role. Cannabis Nurses are creating a national momentum and are bringing their patients the most up-to-date information on this newly developing field. Cannabis Nurses are bridging the gap with knowledge. Cannabis Nursing is creating national momentum toward supporting Cannabis Nurses in maximizing their roles and keeping their patients safe. We are Cannabis Nurses: Natural Born Leaders
We must Grow. Julie Monteiro, RN, BSK “$VN 1XUVH -XKO]LH” Editor@CannabisNursesMagazine
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Elizabeth Dost, RN Dawn-Marie Merrill-Steenstra, LPN Wendy Buck-Binge, RN 3KRWRJUDSK\ 1HOVRQ Ramirez 0RUQLQJ &RIIHH 3URGXFWLRQV &DQQDELV 1XUVHV 0DJD]LQH publishes the most recent and compelling health care information on cannabis health, studies, research, and professional nursing issues with medical cannabis. As a bimonthly, evidence-based magazine, it provides professionals involved in providing optimum nursing care with the most up-to-date information on health care trends and everyday issues in a concise, practical, and easy-to-read format. Readers can view the magazine digitally online at: CannabisNursesMagazine.com or subscribe to a printed copy to be delivered to your door or office.
We are currently accepting articles to be considered for publication. For more information on writing for &DQQDELV 1XUVHV 0DJD]LQH, check out our writerâ&#x20AC;&#x2122;s guidelines at: cannabisnursesmagazine.com/writers-guidelines or submit your article to: editor@cannabisnursesmagazine.com : $QQ 5G 6XLWH 1 /DV 9HJDV 19 (GLWRU#FDQQDELVQXUVHVPDJD]LQH FRP 2QOLQH DW FDQQDELVQXUVHVPDJD]LQH FRP
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Mary Lynn Mathre, RN, MSN, CARN has over 40 years of experience as a Registered Nurse. Her nursing career began in the US Navy Nurse Corps for 4 years, followed by acute care medical-surg nursing and specializing in addictions nursing in 1987. She received her Masters degree from Case Western Reserve University in 1985 and her masters thesis was on marijuana disclosure to health care professionals. She is the President and Co-founder of Patients Out of Time and the Founder of American Cannabis Nurses Association (ACNA).
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Contributors Michael Rochlin, RN, MN, CSP, COHN-S MichaelRochlin is known for his proven health and science leadership in the highly-regulated Legal Cannabis space. He is board-certified in occupational health and safety, with more than 30 years public health: Fortune 100 companies, government and academic organizations. Competencies include: Project Proposal, Risk and Contract Management. He is a member of ACNA, active with the
education and research committee. His Oregon company MJ Enterprises, LLC has successfully educated Oregon Legislature to update cannabis regulations.
Maria Pettinato, PhD, RN, CCN Maria Pettinato Maria Pettinato, RN, PhD, is an Associate Professor in the College of Nursing at Seattle University, Seattle, Washington. She is an experienced faculty member teaching Patho-physiology, Neurobiology, and Med/Surg nursing in both undergraduate and graduate programs on the east and west coast of the United States for the past 25 years. Her research interests focus on sexual minority health issues and medicinal cannabis. Her scholarly work focuses on substance use, mental health issues, and sexual minority health issues.
Wendy Buck-Benge, RN Wendy Buck-Benge, RN started her 26 year career in medicine at the age of 17 from CNA to Flight Nurse working her way through college in the back of an ambulance as an EMT. She was seasoned at 21 when she received her RN. Triage/Charge Nursing became her favorite specialty with side specialties in Level 2 NICU, L&D and Peds ER. Wendy enjoyed her role on the Pain Control Committee educating colleagues with peer reviewed research and clinical demonstration of opiate and alternate pain control methods at Flagstaff Medical Center and St Joseph's Barrows Neurological Institute. She enjoyed seeing the US from the road as a travel Nurse with RN Network practicing in Pennsylvania, New York and Florida and the air with Naive American Air Ambulance. She now resides with her husband Nicholas in Port Angeles, Washington where they run a medical and recreational cannabis dispensary called Sparket and has been guiding patients and educating local healthcare colleagues about the Endocannabinoid System for over 3 years.
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Kebra Smith Bolden, RN Kebra Smith-Bolden is a Registered Nurse in Connecticut and the proud mother of four, including 16 year old triplets. Kebra studied at the Northeastern Institute of Cannabis. She is the CEO of CannaHealth a Holistic Cannabis Health and Wellness Center, and the Market Leader for a networking organization that empowers women to become entrepreneurs in the Cannabis Industry. Her memberships include The Connecticut Coalition to Regulate Marijuana, Connecticut NORML and The Minority Cannabis Business Association. Kebra also volunteers on the Steering Committee for Huerfano County, Coloradoâ&#x20AC;&#x2122;s Faris Green Campus project to Fight Opiate Addiction with Cannabis.
2016 Educational Achievement Award Heather Manus, RN Cannabis Nurses Magazine
September/October
2017
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Inside: 06: Full Circle By: Wendy Buck-Benge, RN 10: Am I A Cannabis Nurse? By: Barbara Blazer, RN-Retired 12: How Should Cannabis be Regulated? Re-schedule, De-schedule, or Legalize â&#x20AC;&#x201C; What Does that Mean? Written by: Mary Lynn Mathre, RN, MSN, CARN Nancy Quigley, MSN, NP-C, M.Ed, AHN-BC, HWNC-BC Elizabeth Dost, RN Dawn-Marie Merrill-Steenstra, LPN 15: IN SUPPORT OF THE DE-SCHEDULING OF CANNABIS : Patients Out Of Time Position Statement 17: An Update: Rescheduling Petition for Cannabis 2009 By: Bryan Krumm, CNP, MSN, RN, BC 18: Medicinal Cannabis: A Primer for Nurses By: Pettinato, Maria PhD, RN, CCN 26: DB Labs, a Cannabis-Testing Laboratory, has become the first and only ISO/IEC in Nevada 28: My Heroes Lead Me to Cannabis By: Kebra Smith-Bolden, RN 30: Onwards and Upwards: Forging the New Oregon Trail By: Michael D. Rochlin, RN, MN, COHN-S, CSP
32: END OF SUMMER HEALTHY RECIPES By: CHEF HERB 36: The Future of Cannabis Nursing By: Carey S. Clark, PhD, RN, AHN-BC, RYT 39: CARTOON: Cannabis Nursing HealTHCare vs Healthcare 40: Scope and Standards of Practice for Cannabis Nurses: American Cannabis Nurses Association By: Carey S. Clark, PhD, RN, AHN-BC, RYT 46: Resources 47: Nursing Conferences
By: Wendy Buck-Benge, RN People tell me things. They always have even when I was a kid. Maybe it was because my face on the playground had no history with the other kids. Maybe it was my sister Betsy. She had a seatbelt installed on the bus especially for her. This was before short buses and calling kids with Down’s Syndrome, retarded was rude. There were no programs for my sister 40 years ago in many of the places that my military engineer family was assigned. We got on the bus together that first day of Betsy’s education and belted into what would become a lifetime of redefining labels until they became blessedly passe’. My Mother knew there was something wrong during the pregnancy she told me later but she certainly knew something was wrong upon her birth. Betsy did not develop on target and she never cried. When she did, it didn’t sound right. Mom went to the Doctor and at the tender age of 20 she was told she was failing to care for her infant properly. We two girls in matching clothes she had sewn. The misdiagnosis was failure to thrive. I am too young to remember this moment. I was only 18 months old but I can imagine the change in my Mother’s posture, the set to her jaw shifting into a veiled look of sadness, confusion and defiance. The expression of a Searcher I believe was born in that moment and the death of the girl for there would be many more white coats to come and I would see this posture and expression of my Mother’s perfected over time. Betsy was 2 years old when she received her proper diagnosis of Down’s Syndrome Epilepsy and Autism. It took her first grand mal seizure to finally tip the scales. Betsy has consumed a lifetime of anti-convulsants, endured blood draws and side effects but still managed to win medals at Special Olympics and develop a small vocabulary of words in sign and speech.
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Among her favorites are No and Mine which she says quite clearly. Her favorite sign is hamburger which can double for coloring book, but can sometimes be slurred into All Gone, much like a magician’s slight of hand. She laughs when people fall down and she never loses a staring contest.
Advocacy is my birthright. My Mom showed me you can never accept the opinions of others no matter how learned especially when it grates on every truth you own. My Sister trained me that there is more to communication than words. Being a Cannabis Nurse is a dedication to their tenacity. The class bully in my new 4th grade school was diabetic. She had a seizure on the playground and peed herself. My sister had already seized herself to death twice by then and I’d seen both my parents perform CPR on her but her seizure was different. The playground was utter pandemonium. It is a terrifying thing to witness mortality in our peers at such a young age. The shunning began. That bully and I ended up being best friends for the very thing that put us at odds is what drew us together. At every school I attended I had to teach everyone you couldn’t catch Down’s Syndrome. Usually it is the class bully who requires this dissertation first. My new Bully Buddy and I had to teach everyone you can’t catch Diabetes and by the way, we’ll have no more talk of peeing either. An inaccurate perception turned this bully, the most popular girl in school, into a non-person. A virulent non-person worthy of militant fear and mistrust all organized inside a single incident. Almost like birds wheeling in flight.
Why all this back story? I see a parallel to our clinical lives. It has been my great accidental pleasure to own a dispensary in Washington state. After hanging up my stethoscope from ER nursing, I fully believed I would never call myself a nurse again. Our business partner had the good grace to have a seizure in front of us where his wife stepped forward and used cannabis oil as a rescue. Despite the fact that I myself was a medical patient for insomnia after failing on Ambien, sleep driving broke us up forever, I still believed that Cannabis as medicine was a hippy pipe dream. Until I saw that. It shook me to the core. My eyes opened for the first time as I realized that all my IV skills and 1st line seizure protocol meds were looking pretty cheap. Like all my king’s horses and men had really been plastic all along and now here at last was the real thing. My business partner came out of this seizure with a minimal transient post-ictal state that cleared itself further as his wife walked him through cross body exercises that use both hemispheres of his brain. Lights are back on, shall we continue? Would you like to be Nurse Wendy again he asks…
A brain cancer patient continues to inspire me. The ER triage nurse saw her as an overweight, anxious woman with a migraine. The RN did not dig further into her chart to see the documentation of a brain tumor or the seizure activity, expressive aphasia and debilitating migraines that is a side effect of her surgery. Instead, this nurse chose to judge the package based on the patient admitting her use of cannabis for seizure and pain control, documented her as a drug seeker and allowed her to languish in the waiting room. This drug seeker is 15 credits away from her Phd. in Special Education with a focus on Autism. My patient bravely told her physician later after asking her what she was doing differently to reduce her tumor size that she was using cannabis. He replied, I don’t believe in it. She replied, it is not a religion asking us to suspend belief but a science asking for study. She is thee quintessential Cannabis patient who went through a great deal of spiritual and moral gymnastics to walk through our front door much less take on learning a new skill like titration of Cannabis but she did. Then she discovered she is a good person and she is dependable and she is healthier and she became her own advocate. She had to stand up to the ignorant and to bullies using the only light we have. Reality. We have an Endocannabinoid system she says proudly. You should look it up!
As patients come in for counseling on how to begin this relationship with Cannabis I am relieved that I have the experience I do. The acuity and panorama of the challenges people face with their health are on par with what I saw in the Emergency Department. Every age and every issue, from the mundane to the grave. Ultimately in the dispensary we listen. Before all else, we listen. Our patients are here to heal. They are here to change and they have already done an enormous amount of change to walk through the front door. Perhaps like me they took time to shed their 'Just Say No' upbringing, get over the fear of disappointing conservative parents or relatives and loved ones, stop being fearful of losing their livelihood and reframe their entire understanding of the human body and their souls interaction with it. After all are you a good person if you use Pot? Are you still the same reliable person you have always been if you use Pot? Will my body be healthy if I use pot? Will someone judge me if I use pot? Yes people, the answer is yes.
Are you a bully? Have you allowed yourself to believe that medications are healthcare? Have you allowed your opinions of your patients and what kind of time and investment they get from you to become colored by the substances that they use? Is this compassion fatigue? Have you wheeled in flight with the rest of your colleagues eager to escape peer pressure? Is the responsibility of solving another patients impossible battle with pain by simply labeling their methods of dealing with it as verboten, disgusting and unacceptable thusly removing them from our to do list going to be a framework that can ethically hold in the healing arts? An alarming culture of dismissing our patient’s pain while painting them as failures is developing as I see reflected in the tears of many frustrated patients including this Brain Cancer patient as she tearfully recounted one of the most humiliating days of her life at the hands of a nurse. Did this bread winner, Master level degree educator, student, mother and professional ever think anyone would honestly look her in the face and have the stones to call her a drug abuser? Here is the humbling part. I have been that ER nurse.
Unfortunately it is likely that judgment will come via a medical professional. In the ER we use words like seeker or drug seeker or he’s just seeking when people come in claiming to be in pain. Things that make an ER nurse or Docs radar go up is coming in asking for specific medication at specific dosages for specific problems. Namely headache, back pain and dental pain. It is estimated that 20% of all ER visits are drug seeking behavior. Pain is the number one reason people visit our ER’s nation wide everyday. Through Cannabis use into the history and things can interesting. (Grover et al. 2012) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556950/
This isn’t responsible healthcare. The opiate crisis was created by healthcare and labeling people in chronic pain who have a Failure to Heal as seekers is refusing to take responsibility for it. This is negligent. This is damaging. This is a bully’s mind set allowing supposition to take the day and us with it. While I agree with the CDC that opiates should be used for acute pain crisis I do not agree with the knee jerk reaction of pulling people off their meds without proper titration or education. The culture of abuser and seeker I feel act as unhealthy justifications for withholding proper treatment and is a sure road to increased morbidity and mortality from plan ole negligence dressed as diagnosis or shall I say misdiagnosis. I beg you not to fall for it. https://www.cdc.gov/drugoverdose/ prescribing/guideline.html Consider we have all been educated this way. The pharmaceutical industry spends more money on media marketing than research and development. We are educated as consumers to ask for specific drugs for specific problems and as healthcare providers we are educated to judge you for asking for what you know you need. September/October 2017 CANNABISNURSESMAGAZINE.COM
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Consider Cannabis as a correct drug. It can work in tandem with opiate receptors to potentiate the effects of opiate pain medications making them feel stronger and last longer hence using less opiates. (Abrams et al 2011) It’s incredibly low LD-50 rating make it impossible to overdose on and the CDC reports say that yet again, there are no overdose deaths from Cannabis in 2016. It has been my experience that Cannabis has been an Off Ramp medication for our patients resulting in a gateway to healing. It’s ability to mitigate anxiety and nausea make it a useful harm reduction medication for tapering off a myriad of narcotics and psycho-tropics. (Melameade 2005 https://harmreductionjournal.biomedcentral.com/articles 10.1186/1477-7517-2-17 ) This scenario is backed up the CDC’s finding that Opiate overdose is down by as high 25% in states where cannabis is a legal option. (Bachhuber etal 2014) http://jamanetwork.com/journals/jamainternalmedicine/ fullarticle/1898878 Quite a different scenario then the one we’ve been brought up to believe. Being a Cannabis Nurse is a tall order. The first order is Believe Thy Patient. They tell me it works. I see that it works. Administer, Observe, Titrate, Appreciate. If this were any other med I was pulling out of the Pxyis I’d be in love it with it because it works. This is the real question facing us now, in our current social epidemic of medicating America. Does how a person elects to treat their pain negate the fact that they are in pain? Cannabis Nursing is more than teaching how to use the plant for its healing properties and educating about the Endocannabinoid System (eCS). It is the shift in the healthcare paradigm that attracts me. It is not about applying Band-Aids any longer but about teaching how to institute real and lasting change in people’s lives with brutal honesty. Watching patients elect to take this path is the most rewarding of all especially when we as Cannabis Nurses are no longer needed and they have been able to set aside all substances for the new self-care tools they have cultivated. To me this is the ultimate in achievement. I am naive enough to believe that there are enough sick people to go around for all of us to make a comfortable living. No need to create clients. We have plenty. Empowering our patients to graduate from the healthcare system in entirety should be every nurse’s end game. Cannabis Nurses not only know that is possible, we make it possible. We are redefining the future of healthcare one “seeker” at a time until the use of certain words become blessedly passé.
Resources: 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3556950/ 2. https://www.cdc.gov/drugoverdose/prescribing/guideline.html 3. Melameade 2005 https://harmreductionjournal
.biomedcentral.com/articles 10.1186/1477-7517-2-17
4. Bachhuber et al 2014 http://jamanetwork.com/journals/jamain ternalmedicine/fullarticle/1898878
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September/October 2017 CANNABISNURSESMAGAZINE.COM
KeyNote Speakers Cannabis Nurses Network Conference www.CNNC2017.com Empowering Nurses through Education, Opportunity, Recognition, and Advocacy OCTOBER 5-7th, 2017 | UNLV LAS VEGAS, NV
3-Day Schedule
Ken Sobel, Esq.
Heather Manus, RN
Julie Monteiro, RN, BSK
Jennie Stormes, RN, BSN
Marcie Cooper, MSN, RN, AHN-BC
Lisa Buchanan, RN, OCN
Oct 5th Cannabis Education for Nurses (*5.33 CEUs) With states across the nation recently implementing cannabis recreational laws and many states having medical cannabis the need for cannabis education is more important for Nurses, Health Care Providers and individuals than ever before. This course goes in depth covering the history of cannabis from 5,000 BC to present, legalities nationally as well as state specifics with a focus on Nevada, patient and nursing rights and responsibilities, basic understanding of the Endocannabinoid System (eCS) and plant components, cannabinoid therapeutics including but not limited to: routes of administration, dosing, testing, metabolism, side effects and where cannabis is headed in the future. Nurses will receive: *5.33 CEUs including 2.0 Advanced Practice Nursing (APRN) Pharmacokinetics all others will receive Certificate of Completion. Open to All. * Bonus: Cannabis Education for Nurses Workbook included with purchase of course
Oct 6th eCS Connections Workshop & Interactive Sports Panel eCS Connections Workshop is a hands-on experience where attendees will feed and learn of the eCS function and purpose; explore Foundations of Eastern Medicine in directed Acupuncture, and a Tune your Senses with Terpenes making personal terpene profiles.
The Interactive Sports Book Panel includes: Marvin Washington (Prior NFL- Giants/
Broncos), Boo Williams (Prior NFL Saints), Steve Cantwell (Prior MMA Fighter now NV Grower), and Frank Hawkins (Prior NFL- Raiders now NV Dispensary Owner) will provide you the opportunity to interact directly with Canna-Sport Heroes as they tell their stories, share their knowledge, and how they strive hard to have cannabis therapies accepted in professional and youth sports. Interactive Sports Book Autographs segment a first of its kind and a collector’s item. Swag included and are exclusive to this event!
Oct 7th CNM 2-Year Anniversary & Leaders of Nursing Awards To round out the weekend, come join us as we celebrate the 2-Year Anniversary of Cannabis Nurses Magazine Party and ‘Leaders of Nursing’ Awards Ceremony, to thank and honor, all the Nurses and Professionals who have contributed to the success of the publication, by being the first line of Canna-Warriors who are creating change around the world! This is a free event and open to all. Registration required.
For more information visit:
www.CNNC2017.com
Affiliate Sponsors:
For Educational Purposes Only. A Non-Consumption Event.
www.CNNC2017.com
www.CannabisNursesMagazine.com
www.NatureNurseHealth.com
Am I A Cannabis Nurse? By: Barbara Blazer, RN-Retired Nurses once again, ranked number 1 for ethics and honesty since 2001, and remain there after the latest survey conducted in December 20161. I have been thinking about this in relationship to being a nurse at Magnolia Wellness in Oakland, California. Magnolia is a medical marijuana dispensary who service patients in the East Bay. The article2 made me wonder, am I a Cannabis Nurse? When Debby Goldsberry, my daughter, asked me to work in the dispensary, I thought, "I will take the Oaksterdam classes, read everything I can, shadow the budtenders, listen to patients and memorize the products and poof- - be a Cannabis Nurse! It is a now over a year later. An amazing year later. I attended the Oaksterdam classes that I highly recommend, I have attended cannabis conferences, I read everything I can. I shadow our outstanding budtenders. I did all I planned and yet I am light years behind where I thought I would be in knowledge! Two things, ok three, stick out to me. First, at 71, there is not the space in my brain to store and retrieve information. My hard drive is full and I can't increase the storage capacity. Second, I walk a fine line between my license and medical marijuana. I cannot prescribe or dispense therefore, I am careful with getting even close to recommending. I do discuss the potential value of different modes of delivery. I do share information I have read or heard from other patients, I know some about interaction with pharmaceuticals based on personal experience. I work closely with the budtenders who have extensive product knowledge. I try to be there for vendor demos.
Third- what was third?!! Give me a minute, I am running through my brain, opening file drawers to find what was the third thing!!
Oh! The ethics and honesty piece. Most important. This, for me, has been the cornerstone of my 50 year nursing career. At Magnolia I am there basically to help improve the health and wellness of our patients. To listen to their concerns. I can sit, hold a hand, give a hug if needed. Talk about the difference between sativa and indica, we can focus on their goals. I try and keep track of who just lost a child, who had stopped eating but has now gained 5 needed pounds. I have regular office hours and I facilitate medical groups. I coordinate a food pantry and a compassion Med program that provides free meds to patients living with HIV/AIDS, Crohn's Disease and cancer. Does this make me a Cannabis Nurse? Hell yes! Nurses rock. We can make a real difference. I am. Sources: 1. https://www.nurse.com/
blog/2016/12/21/nursesrank-1-once-again-in-galluppoll-for-ethics-and-honesty/ 2. https://.eastbayexpress.com/ oakland/barbara-blaser-didnttry-cannabis-until-herseventies-now-shes-aregistered-nurse-at-anoakland-dispensary/Content? oid=6304727
Barbara Blazer, RN- Retired working at Magnoilia Wellness Dispensary Cirque 2017
Photo Credit: Eastbayexpress.com
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How Should Cannabis be Regulated?
Re-schedule, De-schedule, or Legalize – What Does that Mean? Written by: Mary Lynn Mathre, RN, MSN, CARN / Nancy Quigley, MSN, NP-C, M.Ed, AHN-BC, HWNC-BC Elizabeth Dost, RN / Dawn-Marie Merrill-Steenstra, LPN Currently, marijuana (cannabis) is prohibited under federal law. Cannabis was arbitrarily placed in Schedule I of the regulatory system that was created under the Controlled Substances Act (CSA) of 1970 and has remained there for more than 4 decades despite the science that proves it never belonged there in the first place. There are 5 levels of control under the CSA, ranging from Schedule V, the lowest level of control to Schedule I, the forbidden drugs. As of September 2017, there are 29 states and Washington, DC that recognize cannabis as medicine, 8 states that have “legalized” adult use of cannabis, and a dozen additional states that allow restricted use of cannabis high in cannabidiol (CBD), a non-intoxicating cannabinoid. The U.S. is left with a patchwork of varying state laws conflicting with federal law and activists pushing for some sort of reform including measures such as re-scheduling, de-scheduling and legalizing. What do these terms mean and what would the cannabis laws and regulations look like under the various scenarios?
Pre-Prohibition Cannabis: Cannabis sativa or Cannabis indica has been growing wild for millennia and used by humans as a source of food, medicine and fiber. In early American history, some states such as Kentucky and Virginia, required farmers to grow hemp (the cannabis plant low in THC) because of its valuable fiber in making ropes or fabrics, among other uses. The cannabis plant was also a source of medicine, and as it became more established in the U.S., several pharmaceutical companies sourced their medicine as Cannabis Americana (see picture of Ely Lilly bottle label- Cirque 1906). Up through the 1930s one could find cannabis medicines in the form of tinctures, tablets, salves and even cigarettes. However, with the end of the alcohol prohibition, the Bureau of Narcotics and Dangerous Drugs, headed by Harry Anslinger, had lost its purpose. Anslinger needed another target for his department and found it among the Mexicans who were smoking marijuana and the “negroes” smoking reefer. This was cannabis by other names. Anslinger created a “Reefer Madness” hysteria about a new drug menace called marijuana, despite the fact that that same plant was known as a valuable medicine. The misinformation campaign ultimately led to the passage of the Marihuana Tax Act of 1937, which marked the beginning of the cannabis prohibition (Bonnie & Whitebread, 1974). The subsequent tax on cannabis along with other factors led to the removal of cannabis from the U.S. Pharmacopoeia by 1942.
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By the 1960s marijuana use was associated with the anti-Vietnam war protesters and via the passage of the Controlled Substances Act in 1970, President Nixon used this as a means to control African Americans and hippies. Marijuana was initially placed in the forbidden category, with the plan to create a national commission to study the issue and make a final recommendation (National Commission on Marihuana and Drug Abuse,1972). When the commission found that cannabis did not fit the criteria, Nixon simply ignored their findings and left it in Schedule I (Downs, 2016).
The Comprehensive Drug Abuse Prevention and Control Act (CSA) of 1970:
The impetus for the CSA was for the U.S. to create legislation in response to the global Single Convention on Narcotic Drugs, signed in New York in 1961. The purpose of the federal CSA was to regulate the manufacture, importation, use and distribution of potential drugs of abuse according to their “abuse potential” in alliance with the international treaty entitled the Convention on Psychotropic Substances, signed in Vienna in 1971. (See Table 1). Interestingly, alcohol and tobacco were not included in the list of controlled substances. While the Department of Health and Human Services helps determine the abuse potential of drugs, the Drug Enforcement Administration (DEA) has the authority to add to, remove from or change the level of control of a drug within the CSA listing. Congress, through legislation, has the authority to remove cannabis from the CSA completely.
To be placed in Schedule I, a drug must meet 3 criteria: 1) has a high potential for abuse, 2) is not safe for medical use, and 3) has no currently accepted medical use in treatment in the U.S. Schedule II drugs are highly addictive, but have accepted medical use and are considered safe under medical guidance. Schedule III drugs are less addictive than Schedule II, and Schedule IV drugs are less addictive than Schedule III drugs, and Schedule V drugs are less addictive than those in Schedule IV. The regulations for these drugs are restricted according to the placement, with the most restricted in Schedule I to the least restricted in Schedule V. Schedule I drugs cannot be prescribed to patients. Schedule I drugs may be studied, but that requires a special license from the DEA to do so and the supply of cannabis must come from the only federal government approved source that is grown at the University of Mississippi under the control of the National Institute of Drug Abuse (NIDA). Schedule II drugs include the strong opioids that are locked in the “narcotics cabinet” on the hospital units or in clinics. Prescriptions for Schedule II drugs are limited to 30 days and cannot be called in to a pharmacy – that means that a patient needs to see their practitioner at least monthly in order to continue taking a Schedule II medication. However in 2007, the regulations were amended to allow a care provider to write three 30-day dated prescriptions, providing a 90-day supply of their medication. Prescriptions for Schedule III and IV drugs require prescriptions that can be oral, written, or faxed and may not be filled or refilled more than 6 months after the initial date or refilled more than 5 times after the date of the prescription unless renewed by the practitioner. Schedule V drugs can only be distributed or dispensed for medical purposes.
Is Cannabis in the Wrong Schedule? Cannabis is an herbal plant not a drug. The cannabis plant does not meet any of the 3 criteria for placement in Schedule I and there is clear evidence that it does not belong in the controlled substances listing. Cannabis is no more addictive than caffeine. The cannabis plant is “one of the safest therapeutically active substances known to man,” as determined in 1988 by the DEA’s own Administrative Law Judge, in his findings in the petition to the DEA by the National Organization for the Reform of Marijuana Laws (NORML) that was initially submitted in 1972 (Young, 1988). And finally, per the passage of multiple states passing laws that allow for the medical use of cannabis, there is “currently accepted medical use of marijuana in treatment in the U.S.” So, should cannabis be re-scheduled to a less restrictive, legal level of control? If not in Schedule I, which schedule would be appropriate? When dronabinol (Marinol®) was first approved by the FDA in 1985, it was placed in Schedule II. Dronabinol is synthetic THC in sesame oil – it is the specific constituent in the cannabis plant that causes the intoxication or high. After years of minimal to no diversion, the DEA down-regulated dronabinol to Schedule III – the only drug in the Scheduling system that has ever been downregulated. One would have to question why the whole plant is in a more restrictive schedule than the pure intoxicating constituent. A more accurate way to look at this is to acknowledge the difference between the whole plant and medicinal products made from the plant. When products are made from the cannabis plant to be sold to patients (whole plant formulations or isolated cannabinoids), there must be regulations in place to ensure safety and quality control related to the processing, packaging, and labeling of the product. Within the realm of medical cannabis is a wide range of products, from flowers, to tinctures and oil concentrates, to transdermal patches, to topicals, etc. and a wide range in dosage of these products. The question here is: Do any medical cannabis products even belong in the CSA listing?
Legalize or De-Schedule? The terms legalize and de-schedule are terms used in the discussion of cannabis law, but they are not synonymous terms. Placing the plant cannabis in Schedule I ultimately means that our federal government has prohibited the planting of cannabis seeds, cultivating the plant, and using the plant. To “legalize” cannabis actually accepts the notion that our government does indeed have the right to prohibit this plant and that the government can then ultimately “allow” the legal use of it. If one accepts the idea that the government can outlaw a plant, then it follows that the government may choose to legalize the sale and use of cannabis,
but not allow anyone to grow their own. Or the government may choose to restrict the legal use of cannabis to adults as with tobacco cigarettes and restrict the development of medicinal products to pharmaceutical companies. The argument against “legalization” of cannabis is similar to the argument for the initial placement of cannabis in Schedule I – how does one justify the power of government to “allow” or “not allow” a person to grow a natural plant? How can the government put our military at risk to defend our country and its freedoms and then threaten the wounded warriors if they choose to use this plant to ease their suffering? De-scheduling would end the federal prohibition. De-scheduling cannabis would mean that it does not belong in the CSA regulations and hopefully sends a message that our government should not have the power to prohibit a highly valuable natural plant. Cannabis should be recognized as a healing herb, a green leafy vegetable, and/or a beautiful plant. This live plant is non-toxic and poses no public health risk and to the contrary, it actually helps clean the air and the environment from toxins. If de-scheduled, anyone could grow their own cannabis plants and do with them as they choose, or purchase the plant at a farmer’s market and make their own food or medicinal products. Compare this to growing your own grapes or purchasing them and being able to make your own wine if you choose. Fresh grapes are a food source, but they can be fermented to create an intoxicant. Most folks are not interested in growing their own food or making their own medicine, but if cannabis were de-scheduled farmers could grow the herb under the guidelines established by the American Herbal Pharmacopoeia and a person could buy various nutraceuticals or herbal remedies from an herbalist, or in a dispensary or health food store. Just recently Whole Foods has begun to offer packaged “Baby Hemp Leaves and Kale” in their produce department. At the same time, pharmaceutical companies could isolate various cannabinoids and/or develop synthetic cannabinoids to create cannabinoid medicines and go through the FDA approval process to get them to market.
Regulations for Public Safety: The authors of this article are Nurses and as such we are patient advocates and hold great concern for the health and safety of our patients and the public in general. It is crystal clear that the current federal prohibition of cannabis causes great harm to individuals, families and communities. Despite the fact that many states have laws that allow patients access to medical cannabis, as long as the federal prohibition continues, numerous problems remain:
non-violent people will get arrested and incarcerated for growing or possessing this plant, persons may be forced to relocate simply to access this medicine, patients cannot travel out of state or country with their medicine, loss of employment due to a urine test positive for cannabis metabolites, health care providers are not educated about the medical use of cannabis, health care providers cannot write prescriptions and are hesitant to write cannabis recommendations, hospitals won’t allow patients to use it in their facilities, patients won’t openly discuss their use of it with their health care provider, and subsequently patients don’t get medical guidance with their use of cannabis by a health care provider. While rescheduling cannabis to a less restrictive schedule would open the door to pharmaceutical research and the creation of pharmaceutical grade medicines, greed would be the driving force. Patents will become prevalent as they insure exclusivity to the developer/investor in an effort to aid in recouping the multi-millions of dollars required to receive FDA approval. Money, lots of money, will be the driving force in these arenas. Cost and accessibility will become a major obstacle for those most in need. Even if states continue to allow cannabis dispensaries to provide the medicine during the interim, most states don’t allow patients to grow their own medical cannabis, so the patient would be stuck with the local dispensary and the local state “patient registration” rules that generally don’t provide confidentiality. The problem with simply rescheduling cannabis is that the government would continue to consider the plant a drug that must be controlled. De-scheduling cannabis could end the prohibition of this plant and that would allow anyone to grow it. De-scheduling will allow for a more open marketplace including big pharma, smaller pharmaceutical companies striving towards whole plant medicine in a modern medicinal form, herbalists creating medicine from long standing traditions, and backyard growers making their own concoctions. De-scheduling will not exclude pharmaceutical companies from producing products that they believe will be superior, but putting the cannabis plant in ANY schedule will concede it to pharmaceutical control and eliminate all the other possibilities. De-scheduling allows all uses of the plant. As a food source one can grow it as a green leafy vegetable (baby leaves or juiced leaves and flowers) or purchase it in the produce department of a grocery store or at a farmer’s market. As a whole plant, herbal medicine, it can be purchased over the counter with assurance that it met quality control standards. Herbal medicines don’t need FDA approval.
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Where Do You Stand? Cannabis is not a new drug, it is an ancient plant that has been valued and used by humans throughout the centuries. The “drug” marijuana has been demonized for the last eight decades in the U.S. despite the fact that its prohibition has been based on lies and exaggerations. There is a growing acceptance by the public for access to medical cannabis and as a result, more states will be allowing patient access to cannabis either by a citizen-driven initiative or state legislation. Federal legislators are presenting bills to effect changes in the Schedule I placement of cannabis.
References: 1. Bonnie, RJ & Whitebread, II, CH (1974). The Marihuana Conviction: A History of the Marihuana Prohibition in the United States. Charlottesville: University Press of Virginia. 2. Downs, D (April 19, 2016). The science behind the DEA’s long war on marijuana. Scientific American. https://www.scientificamerican.com/article/the-science-behind-the-dea-s-long-war-onmarijuana/ 3. National Commission on Marihuana and Drug Abuse; (1972). Marihuana: A Signal of Misunderstanding. Washington, DC: Government Printing Office. 4. Young, F. (Sept. 6, 1988). In the Matter of Marijuana Rescheduling Petition, Docket #86-22, Opinion and Recommended Ruling, Findings of Fact, Conclusions of Law and Decision of Administrative Law Judge. Washington DC:U.S. Dept. of Justice, Drug Enforcement Administration.
Table 1
Photo Credit: Patients Out of Time. Cirque 1906
Today we have an opioid overdose epidemic resulting in 92 deaths/day and Veterans are committing suicide at the low estimate of at least 22/day. Science and countless anecdotal reports indicate that cannabis can be an effective tool to help reduce these tragic deaths, let alone ease chronic pain for so many others. This is not the time for Nurses and other healthcare professionals to stay mute on the issue. It is our ethical responsibility to advocate for our patients best interests. Rescheduling will increase cost, decrease access, and waste a lot of precious time in more rule-making. Rescheduling will benefit a few, not the majority. De-scheduling will open the door for all to enjoy this highly beneficial and versatile plant. Which do you choose?
Controlled Substances Scheduling: Sample Listing
Schedule I: Heroin, LSD, mescaline, Ecstasy, marijuana, psilocybin, methaqualone Schedule II: Cocaine, amphetamine, morpine, fentanyl, hydrocodone, methadone, oxycodone, phencyclidine, pentobarbital, opium Schedule III: Anabolic steroids, buprenorphine (Suboxone), dronabinol (Marinol), dihydrocodeine, ketamine Schedule IV: Benzodiazepines, chloral hydrate, phenobarbital, tramadol Schedule V: cough suppressants with small amounts of codeine, antidiarrheals with small amounts of opium, some anticonvulsants, lomotil (mixed with atropine to make it unpleasant to grind up, cook and inject). More About Nutraceuticals, Dietary Supplements, or Herbal Medicines: “FDA regulates the dietary supplements under the Dietary Supplement Health and Education Act of 1994. These do not require premarket approval and it's the responsibility of the marketer to ensure the safety and labeling compliance of their products with the regulations. The claims need to comply with the regulatory guidelines issued by the FDA. The manufacturing of dietary supplements should be done as per the current GMP for dietary supplements.” https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC4678984/ “Good Manufacturing Practice (GMP) specifies many requirements for quality control of starting materials, including correct identification of species of medicinal plants, special storage and special sanitation and cleaning methods for various materials. In the quality control of finished herbal medicinal products, particularly mixed herbal products, it is more difficult to determine whether all the plants or starting materials have been included.” http://apps.who.int/medicinedocs/en/d/Js7916e/2.html
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“The Federal Food, Drug, and Cosmetic Act defines a dietary ingrediet as a vitamin; mineral; herb or other botanical; amino acid; dietary substance for use by man to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of the preceding substances. Unlike drugs, supplements are not intended to treat, diagnose, prevent, or cure diseases. That means supplements should not make claims, such as “reduces pain” or “treats heart disease.” Claims like these can only legitimately be made for drugs, not dietary supplements. Dietary Supplements include such ingredients as vitamins, minerals, herbs, amino acids, and enzymes. Dietary supplements are marketed in forms such as tablets, capsules, softgels, gelcaps, powders, and liquids. Under existing law, including the Dietary Supplement Health and Education Act passed by Congress in 1994, the FDA can take action to remove products from the market, but the agency must first establish that such products are adulterated (e.g., that the product is unsafe) or misbranded (e.g., that the labeling is false or misleading).” https:// www.fda.gov/Food/DietarySupplements/ProductsIngredients/default.htm What is a Nutraceutical? “It is a dietary supplement that, in a credible clinical study, is shown to have a beneficial effect.” http:// thedecrapitationsociety.com/2015/12/02/whats-the-difference-between-anutraceutical-and-a-dietary-supplement/
IN SUPPORT OF THE DE-SCHEDULING OF CANNABIS Approved: December 4, 2016 Cannabis is a natural non-toxic plant that is biologically synergistic with human health and wellness:
Whereas, the prohibition of this plant has diverted our law enforcement and their resources away from violent criminals and true criminal activities; and,
Whereas, Cannabis has been used as a food source and an herbal medicine for thousands of years throughout the world; and,
Whereas, due to the cannabis prohibition numerous non-violent individuals have been imprisoned, resulting not only in destroying their lives, but adding pain and suffering to their loved ones in their absence; and,
Whereas, Cannabis in its natural form has a remarkably wide margin of safety and there have been no recorded overdose deaths by cannabis throughout centuries of human use; and, Whereas, Cannabis in its fresh and natural form is not psychoactive, but rather a nutritious food source; and, Whereas, Cannabis has a low risk of addiction with minor withdrawal symptomology and, in fact, can be utilized in opioid harm reduction; and, Whereas, Cannabis was inappropriately omitted from the U.S. Pharmacopoeia in 1941 based on the reefer madness campaign that led to the passage of the Marihuana Tax Act of 1937 (Bonnie and Whitebread, 1974) that demonized the plant as a dangerous new drug; and, Whereas, the United States Government had incorrectly and arbitrarily placed cannabis into Schedule 1 (forbidden category) of the controlled substances under the Controlled Substances Act of 1970 based on old myths and political ideology; and,
Whereas, the cannabis plant is highly beneficial to our environment when allowed to grow naturally (Clark & Pate, 1997); and Whereas, cannabis may be an essential nutrient for those suffering from health problems caused by an endocannabinoid deficiency (Russo, 2016); and, Whereas, this resolution is not addressing pharmaceutical alterations of concentrates, or extractions of specific cannabinoids, or the synthesis of any of the active constituents of cannabis; Therefore be it resolved that PATIENTS OUT OF TIME will: 1. 2. 3. 4.
Whereas, in 1972 the “Shafer Commission” (The National Commission on Marihuana and Drug Abuse) found that marihuana (cannabis) did not meet the criteria for Schedule I placement; and,
5.
Whereas, in a petition to Drug Enforcement Administration (DEA) to remove cannabis from Schedule I, the DEA’s own Administrative Law Judge, Francis Young ruled that cannabis did not belong in Schedule I, but the Director of the DEA rejected Judge Young’s ruling (Washington, DC U.S. Department of Justice, 1988); and,
7.
Whereas, the primary psychoactive substance in Cannabis is THC and the pharmaceutical product, dronabinol (synthetic THC in Sesame oil) was down-regulated from Schedule II to Schedule III of the controlled substances due to its safety and lack of diversion, and per the DEA’s own rules, a plant should not be more restricted than its primary psychoactive constituent; and, Whereas, the American Herbal Pharmacopoeia published a monograph, Cannabis Inflorescence, which provides quality and safety standards for this herbal plant (AHP, 2013); and Whereas, the public has been allowed to grow and use herbal plants without a prescription; and,
Whereas, 8 states (AK, CA, CO, MA, ME, NV, OR, and WA) and Washington, DC allow use of cannabis by adults, causing much confusion between state and federal laws; and, Whereas, the prohibition of cannabis has resulted in cruel punishment to countless individuals for simply growing the plant or possessing its harvested flowers; and,
6.
Promote the nutritional and healing value of this herbal plan Educate its members and the public about the safe cultivation, storag and use of herbal cannabis. Support the end of the cannabis prohibitio Encourage its members to use this resolution to petition their sta legislators and the federal government to end the cannabis prohibition. Urge the DEA to de-schedule Cannabis and end the prohibition on th highly beneficial plant. Support pesticide- and herbicide-free cultivation of this plant commercial growers and individuals. Support the immediate release of those convicted of marijua growing, possessing, or consuming charges.
References: 1. American Herbal Pharmacopoeia. (2013). Cannabis Inflorsence. ScottsValley, CA: American Herbal Pharmacopoeia. 2. Bonnie RJ & Whitebread, II, CH (1974). The Marihuana Conviction: A History of the Marihuana Prohibition in the United States. Charlottesville: University Press of Virginia. 3. Clarke RC & Pate DW. (1997). Economic and environmental potential of cannabis (pp. 192-211), in Cannabis in Medical Practice; A Legal, Historical and Pharmacological Overview of the Therapeutic Use of Marijuana, edited by ML Mathre. Jefferson, NC: McFarland & Company, Inc. 4. National Commission on Marihuana and Drug Abuse. (1972). Marihuana: A Signal of Misunderstanding. Washington, DC: National Academy Press. 5. Russo EB. (2016). Clinical endocannabinoid deficiency Reconsidered: Current research supports the theory in migraine, fibromyalgia, irritable bowel, and other treatment-resistant syndromes. Cannabis and Cannabinoid Research. 1(1):154-165. DOI:10.1089/can.2016.0009. 6. Washington, DC, U.S. Department of Justice, Drug Enforcement Administration. (September 6, 1988). In the matter of marijuana rescheduling petition, Dkt. No. 86-22, opinion, recommended ruling, findings of fact, conclusion of law, and decision of administrative law judge.
Young ruled that, "Marijuana, in its natural form, is one of the safesttherapeutically active substances known to man. By any measure of rational
1 analysis marijuana can be safely used within a supervised routine of medical care." Young continued with: "It would be unreasonable, arbitrary and
capricious for DEA to continue to stand between those sufferers and the benefits of this substance in light of the evidence in this record."
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An Update: Rescheduling Petition for Cannabis 2009 Continued from CNM July/Aug 2016 Issue: Oaths, Duties and the Pursuit of Harmony (pgs.14-15)
By: Bryan Krumm, CNP, MSN, RN, BC In 2009, I filed a Rescheduling Petition for Cannabis with the DEA, demanding that Cannabis be removed from Schedule 1 of the Controlled Substances Act now that it has “accepted medical use in the United States”. In August 2016, after two lawsuits, the DEA denied the petition. However, they were forced to lift the restrictions against Cannabis research that has prevented the advancement of science for decades. Researchers can also grow their own Cannabis for research now, instead of relying on moldy Cannabis from NIDA. The DEA was also forced to admit that Cannabis does not cause psychosis, does not cause lung cancer, does not cause permanent cognitive deficits and is not a “gateway drug”. The illegal action by the DEA, by continuing the total prohibition of Cannabis, places millions of Americans at risk by denying them access to appropriate medical treatment. In May, I filed a new rescheduling petition demanding that Cannabis be removed from federal control and that the States be allowed to develop rules for the Medical, recreational and religious use of Cannabis. The new petition can be found here: http://www.letfreedomgrow.com/cmu/new%20petition%205_22.pdf The DEA’s complete disregard for the safety and welfare of American citizens demands that Cannabis be taken out of their control. Law enforcement simply has no place in developing health policy and deciding who lives and who dies. Although the DEA has been blocking the large scale studies they claim need to be done before they will allow medical use of Cannabis, the Center for Medical Cannabis Research at UCSD has conducted several smaller studies of Medical Cannabis that have proven its safety and efficacy. In my clinical practice, Cannabis has proven to be the only medication effective for treating every symptom cluster of PTSD and has also proven to be the only medication effective at rapidly reducing suicidality in most patients. Medical Cannabis laws have been correlated with reductions in suicide rates, opioid overdoses, traffic fatalities and the use of far more dangerous pharmaceuticals. Yet the DEA continues to ignore science, the laws of 29 States, thousands of medical providers and millions of patients.
The DEA’s complete disregard for human life has led to hundreds of thousands of needless deaths. The DEA is responsible for the death of more Americans than Al Qaeda, the Taliban and ISIS combined. While they line their pockets with billions of dollars stolen through forfeiture laws, seriously ill Americans are forced to suffer needlessly, and die from lack of needed medical treatment. The DEA has become little more than a well funded domestic terrorist organization with no accountability for the damage they cause. This reign of terror must end! Nursing has been the most trusted profession for 15 years straight, and nurses have long been leaders in developing healthcare policy. Nurses are recognized for honesty and high ethical standards. We educate healthcare providers, patients, lawmakers and the public. We advocate for our patients in Washington DC, state legislatures and in healthcare institutions. We listen to our patients and act as their voice when they are unable to speak for themselves. For decades, Nurses have been on the front lines of the battle to legalize Medical Cannabis and we have made great strides in social, medical and political arenas. According to recent polls, 83% of Americans now support legalizing Medical Cannabis. Unfortunately, those with the power to change the law have held stubbornly to outdated propaganda that only serves to obfuscate the need for change. Nurses must continue to keep pressure on lawmakers at both the federal and State levels, to end the prohibition of this lifesaving medication. We must also keep pressure on the Attorney General, Jeff Sessions, who has supported the death penalty for people who sell Cannabis. We must keep pressure on DEA Administrator, Chuck Rosenberg, who continues to claim that Cannabis has no Medical Use. Together, we can bring this war against the sick suffering to end.
To Read the Full Petition http://www.letfreedomgrow.com/cmu/new% 20petition%205_22.pdf September/October 2017 CANNABISNURSESMAGAZINE.COM
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Medicinal Cannabis: A Primer for Nurses
By: Pettinato, Maria PhD, RN, CCN PATIENTS TRUST and depend on nurses, who need to have informed and valid answers to patients' questions about the use of medicinal cannabis for various health disorders. Conditions for which cannabis has been approved for medicinal use vary from state to state. To date, 30 states and the District of Columbia have legalized its use for many conditions, although not all have legalized every form. Several additional states have legalized the use of nonpsychoactive forms of cannabinoids for seizures or epilepsy only.1 Even in states where using medicinal cannabis isn't yet legal, patients may have questions in anticipation of it becoming legally available there. Healthcare providers provide documentation that authorizes patients to use medicinal cannabis in jurisdictions where it's legal. If a healthcare provider determines that a patient has a disorder that qualifies him or her to use medicinal cannabis, the provider issues an authorization for use (recommendation) rather than a prescription. An authorization for use doesn't provide information such as cannabis strain, dose, or frequency of consumption. Depending on the state system, the patient takes the authorization form to a medicinal cannabis dispensary or a recreational cannabis store with medicinal products. Recreational stores that provide medicinal products employ personnel who've been trained in the dispensing of medicinal cannabis to patients. Medicinal cannabis isn't available in traditional pharmacies where no trained personnel are available for providing guidance and recommendations to patients.1,2 In the best scenarios, healthcare providers are knowledgeable about the therapeutic effects of medicinal cannabis and provide education about various strains, including which one has been shown to be effective for the patient's diagnosis. They need to have as much knowledge about the various products as possible. In general, clinicians including nurses need to know how to optimize the use of medicinal cannabis and how to answer their patients' questions.(See American Nurses Association position on use of medicinal cannabis.)
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This article provides a synopsis of the different strains of medicinal cannabis and their contents, as well as some basic information about dosing. Additional resources are provided for those interested in deepening their understanding of medicinal cannabis. Although many jurisdictions have legalized medicinal cannabis under state law, the sale and use of all types of marijuana continue to be illegal under Federal law. Nurses should check with their board of nursing for guidance on legal issues affecting nursing practice in their state.
With over 29 State in the U.S. now with a Medicinal Cannabis Program, We as Nurses need to fight to make this a specialty
Advantages of Medicinal Cannabis
As more research comes to light about the therapeutic effects of medicinal cannabis, its use for various medical disorders is becoming more widely accepted (See Conditions approved for medicinal cannabis in one state). Many healthcare providers may be considering initiating use with their patients. The legalization of cannabis could help stem the opiate/heroin epidemic in the United States. Medicinal cannabis can be used to treat chronic pain instead of opioids, which are much more dangerous.3 The CDC reports that in 2015, over 15,000 deaths could be attributed to prescription opioid overdose, accounting for over 60% of all pharmaceutical overdose deaths in the United States.4 When patients with chronic pain find opioids are no longer prescribed for them, many turn to heroin.5 When heroin and other opioid overdose deaths are added to the previous figure, that number rises to over 33,000 deaths in 2015 alone.4 A recent study found that in U.S. states where medicinal cannabis is legal, deaths due to opioid overdose were reduced by approximately 25%.6 Reducing dosages and overall prescribing of opioids for chronic pain is a current goal within the United States. As one example, the state of Washington has provided education for healthcare providers about the use of medicinal cannabis to treat chronic pain. The education modules produced by a research team at the University of Washington can be viewed for free at http://adai.uw.edu/mcacp/.
State of Cannabis Research
A plethora of information about medicinal cannabis is currently available, and more breakthroughs are on the horizon. A PubMed search of scientific papers specifically dedicated to the cannabis plant and its compounds produced more than 40,000 manuscripts. Search terms were medical marijuana, cannabis, cannabinoids, THC, and CBD. (THC is delta-9 tetrahydrocannabinol and CBD is cannabibidiol.) New information from studies performed within and outside of the United States demonstrates that medicinal cannabis isn't useful only for palliative care, but also possibly for the prevention and treatment of disease.7
The number of states legalizing the medicinal use of cannabis is expected to continue to grow as results from the benefits shown by research are shared. U.S. healthcare providers are currently providing case study evidence at various conferences held annually that supports interventions utilizing the benefits of medicinal cannabis. The Eleventh Annual Clinical Conference on Cannabis Therapeutics was held last spring in Berkeley, Calif. This annual conference is held in various U.S. cities for healthcare professionals and patients. Nurses can obtain education and certification as a cannabis specialist at this conference.10,11,14 Because the United States hasn't removed cannabis from Schedule I designation, U.S. researchers couldn't receive National Institutes of Health (NIH) funding to conduct clinical trials about the benefits of cannabis until recently.7 Schedule I drugs are those that have no currently accepted medical use in the United States such as the synthetic hallucinogen lysergic acid diethylamide (LSD) and heroin. Until very recently, the NIH provided grant money only to those researchers who conducted research that hypothesized harm from cannabis consumption.7 This has begun to change: The NIH has recently approved a study of the effectiveness of cannabis when used in patients with posttraumatic stress disorder.8 Other countries such as Great Britain, Spain, and Israel are far ahead of the United States on research about cannabis because of its U.S. Schedule I designation.9 Keep your eyes open for more interesting findings regarding not only the inhibition of angiogenic growth factor (AGF) as it pertains to cancer, but also the ability of cannabis to inhibit aggregation of amyloid plaque, the substance that contributes to the development of Alzheimer disease.10
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At the 2016 Clinical Conference on Cannabis Therapeutics held in Baltimore, Md., researchers from Great Britain shared data they were compiling from their research about cancer cells with cannabinoid receptors. They found that when those receptors are stimulated by exogenous cannabinoids, cancer cell apoptosis (programmed cell death) is induced.11,12 Besides Great Britain and Spain, Israel is also a leader in cannabis research. Cannabis research with cancer patients has been conducted since the 1970s.13 Currently, research conducted in Israel is providing evidence for osteoporosis prevention.14 Some other examples of current research on medicinal cannabis include studies that examine its use or potential use for treatment of alcohol abuse;15 Alzheimer disease;16 and anxiety, depression, and psychosis.17 The proapoptotic effect of cannabis along with its ability to inhibit AGF makes it particularly interesting to researchers and clinicians who treat patients with cancer.18-20 Its anti-inflammatory effect has drawn the attention of those involved in researching and treating autoimmune diseases as well.21-25
A Lesson in Cannabinoids
Nurses' practice can be enhanced by learning more about cannabinoids. * Endogenous cannabinoids. One reason why cannabis is a relatively safe substance for therapeutic use is that the human body makes its own (endogenous) cannabinoids. Sometimes called endogenous ligands, these molecules serve as both upregulators and downregulators of certain biologic activities.7 Unlike other neuromodulators, endogenous cannabinoids aren't stored in vesicles, waiting for a signal to release them into a synapse. Endogenous cannabinoids are created on demand via enzymatic action that isn't yet well understood. As with most substances found to be therapeutic in humans, the discovery of receptor sites within (and throughout) the human anatomy came before the discovery of the substances that turn on the receptor. When the receptor sites for cannabinoids were discovered, researchers realized that it was only a matter of time before endogenous cannabinoids would be found.26 So far, two endogenous cannabinoids that are created naturally in the body have been discovered. One is named anandamide (the Sanskrit word for bliss) and the other is 2AG (2-Arachidonoylglycerol). Most likely, more will be discovered.27 Because the body makes its own cannabinoids, the cannabinoid receptors throughout the human body (and in animals' bodies as well) also respond to and are activated by exogenous cannabinoids within the cannabis plant.28 * The Cannabis Plant. Patients who don't want to experience the euphoric effect of THC can use strains of cannabis containing very low THC content and high percentages of other beneficial components of the plant such as terpenoids, flavonoids, and CBDs.29,30
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* Strains and Contents. Currently, hundreds if not thousands of different cannabis hybrid plants are used for various therapeutic actions. All varieties of the cannabis plant are one of three main strains: Cannabis sativa, C. indica, and C. ruderalis. Two of these strains, sativa and indica, are the predominant strains that produce the hybrids that are now used in the United States. Each hybrid contains varying percentages of these two strains.31 In general, the sativa plant has a higher THC-to-CBD ratio and provides a more energetic and elevated mood.32 The ratio is significant because the more THC the product contains, the more psychotropic the medication will be. Many patients don't want a psychotropic effect, so it's important for them to know the ratio of THC-to-CBD when purchasing a medication. It's quite effective in helping patients with pain, nausea, and anorexia.33 Some other benefits reported by patients include alleviation of depression and headaches, including migraines.34 Indica strains generally provide a higher THC content. They provide a predominantly physical effect, helping patients with pain, muscle spasms, and inflammation. Again, as with the sativa strain, patients have reported serendipitous benefits of indica-dominant strains, such as relief of anxiety and promotion of sleep.35
Dosing Considerations
Because cannabinoid components vary greatly, establishing precise dosing guidelines is extremely difficult. Each patient's metabolism, preferred route of administration, and level of prior experience with cannabis affect the dosage needed. Nevertheless, some general guidelines have been developed.34 Patients using cannabis for the first time should begin at a very low dose of the THC component and stop therapy if adverse reactions occur. The key point is that dosing must be determined by the patient using a selftitrating model.36 As with any drug therapy, the golden rule of â&#x20AC;&#x153;start low and go slowâ&#x20AC;? applies to medicinal cannabis. Starting low is especially important with products that contain THC. When a cannabis-naive patient begins using
medicinal cannabis with a high level of THC, the euphoric effect can evolve from a generalized relaxed feeling (similar to the effect of drinking a glass of wine) to an anxiety-provoking paranoia.36 Other possible adverse reactions are dry mouth, coughing related to smoking the combustible form, and sleepiness.36 Just as each patient's endogenous cannabinoid system is unique, each patient's tolerance of specific levels of exogenous THC is also unique.37 However, no one consuming medication that contains THC should drive.
Although medicinal cannabis can cause some troubling adverse reactions such as paranoia and anxiety associated with high doses of THC, most adverse reactions such as dry mouth are relatively mild.33 Compared with those of opioids, adverse reactions to medicinal cannabis are much less likely to be serious. Most notably, cannabis doesn't suppress the respiratory system as opioids do. Fatal overdoses with medicinal cannabis products used alone have never been reported. For additional sources of information, see Learn more.
Starting low isn't an issue with products that provide very low THC content. Starting with any dosage of CBD is okay because CBD has no negative effects, but it's of the utmost importance when considering using a product that contains enough THC to produce a psychotropic effect.38
American Nurses Association Position on Use of Medicinal Cannabis
Why do patients choose a product with high levels of THC? One reason is that many consumers appreciate the mild euphoria that comes with consumption. They report they've titrated to their perfect dose, which helps them to relax and not focus on the health problem being treated. They also report enjoying a relatively calm sense of well-being.33
Modes of Administration
After considering the ways cannabis can be consumed, the healthcare provider needs to discuss the most appropriate method with individual patients. The differences between the routes, absorption, and the onset of action are discussed with patients, but patients ultimately determine their preferred method of consumption. Generally, when using inhalation via smoking or vaporization, the patient should wait 2 minutes between puffs to determine if more is needed. If the method is oral consumption, either in a food product or a tincture, the patient should wait 60 to 120 minutes to gauge the strength of the effect.36,40 Encourage the patient to journal the level of symptom discomfort, dose ingested or smoked, and level of relief provided. This will help both the patient and the healthcare provider customize a plan that works best for the patient. More information on methods of administration and patient teaching can be found in an article by Grant and colleagues.41 Patients determine the effectiveness of the dosage over time and increase it accordingly. Patients ultimately are in control of their own dose and the ratio desired.
Potential Adverse Reactions
Most information in the literature about adverse events relates directly to products high in THC that were consumed recreationally or prescribed as THC-only medications.42 The most extensive research on medicinal THC plus CBD cannabis products was provided by clinical trials of nabiximols, a THC/CBD medicinal cannabis product used in Canada. According to this research, the most common adverse reactions during the first 4 weeks of treatment were fatigue and dizziness. These effects lessened over time. Sudden discontinuation of treatment produced no significant withdrawal-like signs or symptoms, although some participants reported temporary changes in their sleeping patterns, mood, or appetite following discontinuation.36
One of the first concerns that many nurse clinicians may have is, “What support do I have in my practice with regard to the use of medicinal cannabis?” Nurses whose patients are using medicinal cannabis may find it comforting to know that the American Nurses Association provides a supportive position statement highlighted in this excerpt below: “Professional nursing organizations need to advocate for all nurses and to advance change to improve health and healthcare.” The ANA strongly supports: * Scientific review of marijuana's status as a federal Schedule I controlled substance and relisting marijuana as a federal Schedule II controlled substance for purposes of facilitating research. * Development of prescribing standards that include indications for use, specific dose, route, expected effect, and possible adverse reactions, as well as indications for stopping a medication. * Establishing evidence-based standards for the use of marijuana and related cannabinoids. * Protection from criminal or civil penalties for patients using therapeutic marijuana and related cannabinoids as permitted under state laws. * Exemption from criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for healthcare practitioners who discuss treatment alternatives about marijuana or who prescribe, dispense, or administer marijuana in accordance with professional standards and state laws. Source: American Nurses Association. http://nursingworld.org/ MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ ANAPositionStatements/Position-Statements-Alphabetically/ Therapeutic-Use-of-Marijuana-and-Related-Cannabinoids.pdf. With permission.
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Learn More
This article provides basic information to help interested clinicians begin the search for more knowledge about the medicinal use of cannabis. For more information, nurses can visit the website of the American Cannabis Nurses Association: http://americancannabisnursesassociation.org. A website not specifically for nurses is https://themedicalcannabisinstitute.org. A Patients Out of Time conference is held in major cities around the United States every year. Its primary goal is to educate healthcare professionals, their specialty and professional organizations, and the public at large about medicinal cannabis. Visit www.PatientsOutofTime.org for more information about this conference. The Society of Cannabis Clinicians and the American Academy of Cannabis Clinicians has developed an online CME course in cannabinoid clinical medicine for all healthcare providers. This course is based in California and may have some state-specific information within the course that differs from other state laws. To register for the California-based course, go to: www.AACMsite.org or e-mail info.aacm@gmail.com.
Sources: 1. Part 2, State-By-State MMJ Qualifying Conditions. https://http://www.leafly.com/ news/health/qualifying-conditions-for-medical-marijuana-by-state. 2. Marcoux RM, Larrat EP, Vogenberg FR. Medical marijuana and related legal aspects. P T. 2013;38(10):612–619. 3. Boehnke KF, Litinas E, Clauw DJ. Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. J Pain. 2016;17(6):739–744. 4. Centers for Disease Control and Prevention. Prescription opioid overdose data. 2016. https://http://www.cdc.gov/drugoverdose/data/overdose.html. 5. National Institute on Drug Abuse. How is heroin linked to prescription drug abuse? 2014. https://http://www.drugabuse.gov/publications/research-reports/heroin/howheroin-linked-to-prescription-drug-abuse. 6. Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668–1673. 7. Werner C. Marijuana, Gateway to Health: How Cannabis Protects Us from Cancer and Alzheimer's Disease. San Francisco, CA: Dachstar Press; 2012. 8. Greer GR, Grob CS, Halberstadt AL. PTSD symptom reports of patients evaluated for the New Mexico Medical Cannabis Program. J Psychoactive Drugs. 2014;46(1):73–77. 9. Bravo-Ferrer I, Cuartero MI, Zarruk JG, et al Cannabinoid type-2 receptor drives neurogenesis and improves functional outcome after stroke. Stroke. 2017;48(1):204–212. 10. Romero J. Cannabinoids and Alzheimer's disease. Presented at the Eighth National Clinical Conference on Cannabis Therapeutics; 2014; Portland, OR. 11. Guzman M. Cannabinoids as possible antitumoral drugs. Presented at the Tenth National Clinical Conference on Cannabis Therapeutics; 2016; Baltimore, MD. 12. Salazar M, Lorente M, García-Taboada E, et al Loss of Tribbles pseudokinase-3 promotes AKT-driven tumorigenesis via FOXO inactivation. Cell Death Differ. 2015;22(1):131–144. 13. Munson AE, Harris LS, Friedman MA, Dewey WL, Carchman RA. Anticancer activity of cannabinoids. J Natl Cancer Inst. 1975;55(3):597–602. 14. Smourm-Jaouni R. Recent advances in cannabinoid research in Jerusalem. Presented at the Tenth National Clinical Conference on Cannabis Therapeutics; 2016; Baltimore, MD. 15. Ceccarini J, Hompes T, Verhaeghen A, et al Changes in cerebral CB1 receptor availability after acute and chronic alcohol abuse and monitored abstinence. J Neurosci. 2014;34(8):2822–2831. 16. Martín-Moreno AM, Reigada D, Ramírez B, et al Cannabidiol and other cannabinoids reduce microglial activation in vitro and in vivo: relevance to Alzheimer's disease. Mol Pharmacol. 2011;79(6):964–973. 17. Breuer A, Haj C, Fogaca M, et al Fluorinated cannabidiol derivatives: enhancement of activity in mice models predictive of anxiolytic, antidepressant and antipsychotic effects. PLoS One. 2016;11. https:/http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4945002/. 18. Fisher T, Golan H, Schiby G, et al In vitro and in vivo efficacy of non-psychoactive cannabidiol in neuroblastoma. Curr Oncol. 2016;23(2):S15–S22. 19. Orellana-Serradell O, Poblete CE, Sanchez C, et al Proapoptotic effect of endocannabinoids in prostate cancer cells. Oncol Rep. 2015;33(4):1599–1608.
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Sources: 20. Nikan M, Nabavi SM, Manayi A. Ligands for cannabinoid receptors, promising anticancer agents. Life Sci. 2016;146:124–130. 21. Gui H, Liu X, Wang ZW, He DY, Su DF, Dai SM. Expression of cannabinoid receptor 2 and its inhibitory effects on synovial fibroblasts in rheumatoid arthritis. Rheumatology (Oxford). 2014;53(5):802–809. 22. Haj CG, Sumariwalla PF, Hanuš L, et al HU-444, a novel, potent antiinflammatory, nonpsychotropic cannabinoid. J Phamacol Exp Ther. 2015;355(1):66– 75. 23. Horváth B, Magid L, Mukhopadhyay P, et al A new cannabinoid CB2 receptor agonist HU-910 attenuates oxidative stress, inflammation and cell death associated with hepatic ischaemia/reperfusion injury. Br J Pharmacol. 2012;165(8):2462–2478. 24. Horváth B, Mukhopadhyay P, Haskó G, Pacher P. The endocannabinoid system and plant-derived cannabinoids in diabetes and diabetic complications. Am J Pathol. 2012;180(2):432–442. 25. Silveira JW, Issy AC, Castania VA, et al Protective effects of cannabidiol on lesion-induced intervertebral disc degeneration. PLoS One. 2014;9(12):e113161. 26. Storozhuk MV, Zholos AV. TRP channels as novel targets for endogenous ligands: focus on endocannabinoids and nociceptive signalling. Curr Neuropharmacol. [e-pub April 24, 2017] 27. Morales P, Jagerovic N. Advances towards the discovery of GPR55 ligands. Curr Med Chem. 2016;23(20):2087–2100. 28. Oltrabella F, Melgoza A, Nguyen B, Guo S. Role of the endocannabinoid system in vertebrates: emphasis on the zebrafish model. Dev Growth Differ. [e-pub May 17, 2017] 29. Hillard C. Endocanabinoids in the circulation. Presented at the Eighth National Clinical Conference on Cannabis Therapeutics; 2014; Portland, OR. 30. Portenoy RK, Ahmed E, Keilson YY. Cancer pain management: adjuvant analgesics (coanalgesics). http://www.uptodate.com. 2017. 31. Gloss D. An overview of products and bias in research. Neurotherapeutics. 2015;12(4):731–734. 32. Holland J. The Pot Book: A Complete Guide to Cannabis. Rochester, VT: Park Street Press; 2010. 33. Whiting PF, Wolff RF, Deshpande S, et al Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456–2473. 34. Backes M. Cannabis Pharmacy: The Practical Guide to Medical Marijuana. New York, NY: Black Dog & Leventhal Publishers; 2014. 35. Betthauser K, Pilz J, Vollmer LE. Use and effects of cannabinoids in military veterans with posttraumatic stress disorder. Am J Health Syst Pharm. 2015;72(15):1279–1284. 36. Abramovici H. Information for health care professionals: cannabis (marihuana, marijuana) and the cannabinoids. Ottawa, ON: Health Canada; 2013. https://http:// www.canada.ca/en/health-canada/services/drugs-health-products/medical-usemarijuana/information-medical-practitioners/information-health-care-professionalscannabis-marihuana-marijuana-cannabinoids.html. 37. Sulak D. Medicinal cannabis for health care providers. Presented at the First Virtual Cannabis Health Summit; January 23-24, 2016. 38. Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H. Low-dose vaporized cannabis significantly improves neuropathic pain. J Pain. 2013;14(2):136– 148. 39. Bearman D. Drugs Are Not the Devil's Tools. Santa Barbara, CA: Blue Point Books; 2015. 40. Carter GT, Weydt P, Kyashna-Tocha M, Abrams DI. Medicinal cannabis: rational guidelines for dosing. IDrugs. 2004;7(5):464–470. 41. Grant I, Atkinson JH, Gouaux B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurol J. 2012;6:18–25. 42. Tait RJ, Caldicott D, Mountain D, Hill SL, Lenton S. A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment. Clin Toxicol (Phila). 2016;54(1):1–13.
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DB Labs, a cannabis-testing laboratory, has become the first and only ISO/IEC 17025:2005 accredited marijuanaanalysis lab in Las Vegas. Consumers might be asking themselves, so what does that mean for me? ISO/IEC 17025:2005 accreditation is a standard used by testing and calibration labs, accreditation is required by most countries. Outside of the United States, calibration and test results will not be accepted from unaccredited labs. Within the United States, having the accreditation raises the bar for testing standards and assures customers that their products have been rigorously tested to ensure the safety and health of users. Unaccredited labs would be wise to follow suit, because receive ISO/IEC 17025:2005 accreditation could become compulsory in the near future. Currently, only one other lab in Nevada -374 Labs- has received an accreditation. Susan Bunce, President at DB Labs, says, “As the first cannabis-testing laboratory in Nevada, DB Labs has always taken patient safety very seriously and has always tried to raise the bar. Now, being the first lab in Las Vegas to receive ISO/IEC 17025:2005 accreditation, we are setting the gold standard and want to set a good example for other labs that can provide this elevated level of testing for users.”
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Bunce continued, “The world of cannabis testing is often compared to the Wild West: each lab uses state regulations to set their own standards, but this leaves a lot of room for subjective interpretations and leniency. This accreditation removes the ambiguity and guarantees a consistent level of testing to users. We are proud to be a part of that.” In Nevada, cannabis labs are required to test for certain contaminates like pesticides, heavy metals, mycotoxins, residual solvent, and microbials. However, these requirements do not list the same rigorous standards the accreditation requires. Bunce stated, “Eventually Nevada’s new, recreational users will realize that their cannabis contains more than the advertised THC number, and that it could contain harmful molds or other contaminates. There is so much more to cannabis that users need to be aware of, including the potential benefits of different strains.” "We at DB Labs are proud to become the first cannabis testing facility in Southern Nevada to obtain ISO/IEC 17025:2005 accreditation. It's awesome to see that all the long hours, late nights and months of hard-work are paying off and being recognized.” Stated Glen Marquez laboratory manager for DB Labs.
DB Labs recommends that patients ask their local budtender at a dispensary which strain will offer the best benefits for their needs, such as appetite suppressant or enhancement, antimicrobials, anti-inflammatories, or other alternatives. Those who are new to cannabis use are encouraged to pick up a DB Labs brochure from their local dispensary titled “Consumer Guide to Cannabis”. DB Labs prepared this brochure to educate users on potential benefits and drawbacks of different strains, as well as potential deleterious ingredients in untested cannabis. Dr. Ben Chew, the new regional lab manager for DB Labs, joined the team in anticipation of the increased demand for recreational marijuana. “I wanted to ensure quality cannabis for users of DB Labs products, because untested or badly tested cannabis can have serious negative effects for users. Although medical patients are more fragile and require more rigorously tested marijuana, DB Labs provides that same level of testing to recreational users, too. DB Labs sought the receive ISO/IEC 17025:2005 accreditation as a guarantee to our users that our products are the gold standard in cannabis.”
For more information about receive ISO/IEC 17025:2005 accreditation, please contact (702) 728-5180. For more information about DB Labs, email at: Test@DBLabsLV.com.
DB Labs and Grow for Vets USA Announce Partnership
Standardization in testing, means that users can expect the same level of high from the same amount of product consistently. For those who have felt the overwhelming sensation of consuming too much of an edible, this assurance will be a huge relief. Additionally, for consumers who have ingested cannabis and felt rippedoff by the underwhelming effects of a product that claims to have a high THC number, this standardization will provide comfort that their investment is fair. Kelly Zaugg, laboratory manager stated, “Now that cannabis cultivators and production facilities, as well as medical marijuana patients have an ISO/IEC 17025:2005 accredited laboratory to partner with, they can guarantee results from DB Labs are the most accurate and reliable. We are happy to show our continued commitment in providing high quality service that the community can depend on." Dr. Chew stated, “I’m proud to work for a lab that doesn’t sell test results. Our clients know that they will receive rigorous testing and results that are accurate. In other states labs have been accused of THC inflation, passing cannabis that is below standard, and other issues: at DB Labs, our ISO accreditation puts users’ minds at ease, because they know their cannabis is safe.”
Ben Chew, a Cornell PhD with 20 year of Experience September/October 2017 CANNABISNURSESMAGAZINE.COM
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My Heroes Lead Me to Cannabis
By: Kebra Smith-Bolden, RN Who are your Heroes? Growing up I had several heroes, however they weren't your typical super heroes. I never wanted to be Wonder Woman or She-Ra; they didn’t look like me and the heroism they displayed didn’t really seem relative to my life and experiences. My super heroes were those who created me, like my mother who despite having me at 16 years old, raised me and made sure that all of my needs were met. Being that my mother was so young, I was also raised by my grandparents who were my also my super heroes. From my grandfather, Nathaniel Smith, who worked four jobs in order to pay off the hospital bills accumulated from my birth because he refused to allow my mother to accept government assistance. To my 3 grandmothers, Ruby Smith, who struggled throughout her life in Rural North Carolina but despite the struggle put her family first and was committed to helping others before considering herself. My other grandmother, Mary Smith, who no one would ever know was not my "natural" grandmother but made a conscientious choice to love me regardless of DNA. My grandmother Mary drove me as a jaundiced infant from the hospital on her chest, undoubtedly humming some sweet song as she brought me home for the first time. Last but not least was my paternal grandmother Hattie Turner, who was the perfect combination of class, sass, style, heart and soul. Her commitment to her community and her desire for the advancement of others inspires me to this day.
How were you Introduced to Cannabis? My vibrant 88-year old Grandmother Hattie Turner suffered from a cerebral aneurysm1-3 and a subsequent subarachnoid haemorrhage.4,5 Both her body and mind were devastated by this brain bleed and she went from living alone to requiring 24 hours, 7 day/week care. Being that my father, aunt, and
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uncle (my grandmothers only remaining children) lived across the country the blessing of being able to care for her fell to me, and despite several challenges we were able to make it work. Once my grandmother was home we obtained homecare services for her which included several therapies as my grandmother has lost the ability to walk without devices and was aphasic. It appeared that my grandmother was uninterested in participating in therapy and it was a frustrating time for us all, as my grandmother was unable to fully communicate. We soon began to realize that my grandmother wasn't just refusing to participate in the physical aspects of her therapies but due to arthritic pain was unable to and after about a month of a lack of progress and attempting to utilize OTCs and analgesics I remembered that my grandmother told me that she would have to take a bath and ‘smoke a joint’ in order to start her day and to be mobile when her arthritis would flare up.
How Did you Begin to Incorporate Cannabis in your Grandmother’s Treatment Plan? I began putting my grandmother in the shower allowing the water to directly run over her joints and she and her caregiver shared a joint prior to the therapist coming and within days my grandmother was ambulatory with the use of her walker. This woman, with the use of cannabis, was able to regain some of her independence, dignity, and pride and she was back visiting her church, going to her favorite restaurant with us and interacting with her friends and family in a way she hadn't been able to in the months since the aneurysm.
My grandmother ultimately suffered from a final massive stroke and passed away almost a year to the day following her aneurysm but, I am proud to say that she had QUALITY of life with minimal pain during the last year on earth, and was able to be at home with her family until her death, I attribute a large portion of that to Cannabis.
How did the Success of Cannabis in your Heroesâ&#x20AC;&#x2122; Lives Impact your Nursing Profession? Prior to my Grandma Hattie passing, I lost both my grandfather and Grandma Ruby to cancer, and in 2015, I lost my Grandma Mary to cancer as well. So, my heroes were gone but they inspired me to become more knowledgeable about Cannabis after seeing how it had changed things for the better with my grandmother Hattie. Despite her physical and communication limitations, I was able to incorporate her desire to medicate with Cannabis into her activities of daily living (ADLs). I witnessed the pain relieving and mood elevating effect Cannabis had on my Grandma Hattie and wanted to be able to share this information with knowledge and insight. Around the same time, I had a friend who suggested that I look into opening a dispensary and thought that since I was a Registered Nurse I would be awarded one. But I knew that being a woman of color, it would be more difficult for me to be able to enter the industry than some of my white, male counterparts so I decided it would be beneficial to learn all that I could about Cannabis. I began attending Northeastern Institute of Cannabis' 12 Course Cannabis Competency Program.6 Soon after, I learned of a professional Women's Networking Organization, started attending their monthly networking event, and began building a community in Connecticut (CT), a Medical Cannabis Only state. I was intrigued by the "medical/pharmaceutical model" used in CT. Upon researching the Medical Marijuana Program (MMP) I realised that individuals were certified to participate in the MMP and introduced to the dispensary model by knowledgeable pharmacists and pharmacy technicians but patients, especially those new to Cannabis consumption, were in need of ongoing education, support, and assistance. Both dispensary pharmacists and MMP Physicians all agreed that due to limitations, like patient's inability to consume on dispensary or evaluation clinics grounds, it was difficult to fully engage with patients and instruct them in regards to consumption in a practical manner. In the world of health care that is considered a "care gap", which is a disparity between healthcare needs and access or availability of health care services and I quickly began endeavouring to close these gaps.
Like other Cannabis practices, we offer Medical Marijuana Evaluations, by Medical Marijuana Certifying Physicians and APRN's, but unlike other practices we don't stop there. We offer ongoing education, support, training, and our practitioners work in conjunction with our patient's primary care or specialty physicians to determine the most comprehensive plan of care for each patient and assist with the tapering of medications (if appropriate) as we begin treating with Cannabis. We provide 24/7 On-call support from Cannabis Nurses, via our CannaHealth app and as an added benefit through our concierge medicine option offer in home instruction and education with options for weekly, monthly or as needed Cannabis Support Visits (CSV's). During our CSVs we can assist with strain matching, where we find Cannabis strains that effectively target identified symptoms, and educate patients in regard to the various methods of consumption to assure that they find the right consumption method for them. In addition, we offer individual and group counselling, as well as classes that range from Seasonal Cannabis Cooking classes to classes introducing the Endocannabinoid System (eCS).
Overview
My Heroes changed my life, the lives of their families and those in their communities. I am far from a hero, but as Cannabis Nurses we are afforded the opportunity to change lives in a natural, holistic way, that encourages patients to be their own advocates and provides them with the ability to make informed decisions about their health and treatment options, so although we may not be heroic, I can proudly say that my role as a Cannabis Nurse is an honourable one, because I am finally able to return the power to choose to the patient, the real heroes of the story.
Resources: 1. https://www.ninds.nih.gov/Disorders/Patient-CaregiverEducation/Fact-Sheets/Cerebral-Aneurysms-Fact-Sheet 2.
http://stroke.ahajournals.org/content/44/12/3613
3. http://www.mayoclinic.org/diseases-conditions/brainaneurysm/basics/definition/con-20028457 4.
https://medlineplus.gov/ency/article/000701.htm
5.
http://emedicine.medscape.com/article/1164341-overview
6. https://instituteofcannabis.com/academics/cannabis-industrycompetency-program/
How are you as a Cannabis Nurse Bridging the Gap? In July of 2017, with my partners Lynne Kravitz-Singley, RN, and Gayle Klein, MD (our medical director, and a certifying Medical Marijuana Physician here in CT) we launched CannaHealth, a full spectrum Cannabis Health and Wellness Center. Cannabis Nurse Kebra Smith-Bolden, RN
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Onwards and Upwards: Forging the New Oregon Trail
By: Michael D. Rochlin, RN, MN, COHN-S, CSP
A
bout Cannabis Nurse Mike in Oregon Michael Rochlin, RN, MN, COHN-S, CSP has been educating Oregon Legislators, Regulators, Health Professionals and Cannabis Business Associations (Growers, Processors and Retailers) in Oregon and Washington, since Measure 91 (Adult Use Legalization) passed in Oregon, 2014.1 Mike helped advocate successfully for HB 21982,3 just signed on Aug. 2, 2017 by Oregon Gov. Brown, resulting in saving the Oregon Medical Cannabis Program (OMMP), and establishing the Oregon Cannabis Commission (OCC).3 OCC members will be appointed in the next 30 days by Gov. Kate Brown, to unify Oregon’s Cannabis Regulations and provide objective answers to lingering public health and safety issues (such as medical-use product quality and therapeutic research). Mike’s current projects include developing standard supply-chain metrics (such as testing, COA), clinical practice guidelines (including private-duty administration of cannabis), patient-provider education (seniors) and teaching about wellness and healing with cannabinoid therapeutics.
When did you Learn about Cannabis? Mike learned about Cannabis growing up in the California Bay Area in the 60’s. Even though “Marihuana “ was “illegal,” the 60s were not even close to Nixon’s escalation of terror, known as the “War on Drugs;” codified “Marihuana” as one of the most dangerous drugs, in the 70s, via the Controlled Substance Act; the lies supporting the Schedule I was purely for political reasons, to disrupt Nixon’s enemies (activists, blacks) admitted to by ex-Nixon counsel & staffer, John Ehrlichman (sound familiar, Kellywatchers?)5,6,7 The resulting complexity of oppressive laws, prohibitions, property seizures and imprisonment still exist in states without legal protection. The “War” most likely has resulted in the current opioid crisis8,9 consuming public health resources, taxes and lives that could have otherwise benefitted from a non-lethal and relatively safe herbal alternative: Cannabis. It has become so intertwined in national and global drug policy that, it has been difficult to unwind. That is one of the most important underlying reasons that legalization today has become a very confusing and onerous process. Thus, regulations cannot be rational, since the truth about harms was purely a hardcore political / punitive narrative.
Why Cannabis Nursing? Nurse Mike updated his clinical knowledge about therapeutic cannabinoids about 6 years ago, when a family member was in severe pain, and Mike was researching treatment alternatives; another family member had pancreatic cancer; legalization changed the conversation, helping provide safe alternative medical-use discussions with providers. Even after two years of Legalization in Oregon, Cannabis is still stigmatized for licensed professionals (Nurses, Doctors, Lawyers, etc.), due to outdated and oppressive labor/drug policy laws, so Nurse Mike saw the need to 'fill the gap'.
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What can Nurses Do to Forward the Movement? Know the Facts Nurses can help with the conversation, and update the narrative; we are the most trusted of professions for 15 years (Gallup)10, and need to keep our standards of practice high, but not unjustified, based on facts not oppressive narrative. Get educated with the TRUTH. The American Cannabis Nurses Association (ACNA) has an Education & Research Committee, chaired by incoming President-Elect, Carey S. Clark, PhD, RN, AHN-BC, RYT and Cannabis Nurses Network, a global network for nurses, are a few of the main groups here to help.
Get Involved in Your State Mike has helped successfully defended physician medical licenses (WA, OR) from unjustified complaints, (incurring unnecessary costs and time), thus enabling safe pathways to defend other legal practitioners, such as Nurses.
Stay Neutral In his current practice, Mike strives to be non-judgmental re: addictions and socio-economic status; stigma is already significant for chronic pain patients with medication, and is getting worse, after recent CDC prescribing guidelines11,12 were adopted per se by Oregon Health Authority. Meaningful provider education or transition was not provided, thereby adding more oppression and excessive costs to treating our most vulnerable citizens.
Educate and Inform Nurse Mike has helped educate patients with severe pain and complex co-morbidities, case-managing to improve quality of life, reduce disability, and relieve suffering. Polysubstance “abuse” (alcohol, nicotine and narcotics)13,14 can typically be more prevalent in addiction cases; these other substances can be significantly more addicting than Cannabis. Gaming (and cell phones)15,16,17 have recently been shown to be as rewarding, to the brain or more so than most “drugs”. Perhaps Cannabis-use “addiction” (CUD) could be an exaggerated myth? Primarily a behavioral issue, cannabis “abuse” (ed. is this rhetoric more reinforcement for the political propaganda even correct vs dependence…) does not even compare to known dangers of alcohol or nicotine/tobacco addiction.
Why doesn’t my Provider know about Cannabis? Nearly a century of demonization and punitive measures for “drug abuse” has inhibited provider-patient communication, reduced healing, destroyed families and succeeded in causing an acute public health crisis beyond rationale belief. Cannabis is most likely an EXIT drug, NOT a gateway drug; thanks to ASA lawsuit.18,19 and has been shown to be promising for clinically opioid withdrawal. Clinical studies must be an immediate priority, and cannot wait any longer. Patients are OUT of TIME.20
One cohort of major interest to Mike is Military Veterans. Mike has collaborated with various local and national Veteran groups to obtain safe access while coordinating with the VA. Movement on this front is promising, given dire circumstances (22 suicides per day).21,22 It is rewarding to partner with our Veteran’s and a struggle, from Federal inertia. However, Oregon Congressman Earl Bluemnauer has been a long-term advocate and recently formed a Congressional Cannabis Caucus, including Republican supporters. The struggle continues, but the light at the end of the tunnel appears to be getting brighter.
What Now?
He encourages interested Nurses to leverage our unique positions as reliable and responsible health educators, and actively engage with state and local lawmakers, establishing a trusting relationship, in order to effect change. Mike does not regret the personal time/years invested to educate lawmakers, regulatory and business leaders and others who have influence to enable rationale movement forward. The life-long learning about this truly ancient medicine is just beginning to emerge. Indigenous populations may be helpful to recapture the essence. If you get to the Oregon Growers Fair, in Salem, Aug. 12-13, 2017, you will see Mike active in his community hosting the “Canna Help You©” booth, providing information, facts and data to support medical use or attending the Cannabis Science Conference in Portland, Oregon Aug.29-30th, 2017 where the Cannabis Nurses Network™ Panel will be presenting: Bridging the Gap Between Cannabis and Western Medicine through Nursing.
Sources: 1. http://www.oregon.gov/olcc/marijuana/Documents/Measure91.pdf 2. https://olis.leg.state.or.us/liz/2017R1/Downloads/MeasureDocument/ HB2198 3. http://gov.oregonlive.com/bill/2017/HB2198/ 4. http://www.occnewspaper.com/tag/cannabis-commission/ 5. http://www.cnn.com/2016/03/23/politics/john-ehrlichman-richard-nixondrug-war-blacks-hippie/index.html 6. https://www.cia.gov/library/readingroom/docs/CIARDP90-00845R000100460002-5.pdf 7. https://www.forbes.com/sites/eriksherman/2016/03/23/nixons-drug-war-anexcuse-to-lock-up-blacks-and-protesters-continues/#8c40a1c42c88 8. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis 9. http://www.cnn.com/2017/08/10/health/trump-opioid-emergencydeclaration-bn/index.html 10. https://www.nurse.com/blog/2016/12/21/nurses-rank-1-once-again-ingallup-poll-for-ethics-and-honesty/ 11. https://www.cdc.gov/drugoverdose/prescribing/guideline.html 12. https://www.cdc.gov/drugoverdose/prescribing/providers.html 13. https://en.wikipedia.org/wiki/Polysubstance_dependence 14. http://polysubstance-abuse.com/ 15. https://www.scientificamerican.com/article/how-the-brain-gets-addictedto-gambling/ 16. https://www.cbsnews.com/news/brain-hacking-tech-insiders-60-minutes/ 17. https://www.psychologytoday.com/blog/brain-wise/201209/why-were-alladdicted-texts-twitter-and-google 18. http://herb.co/2017/02/14/dea-removed-lies-website/ 19. https://www.drugabuse.gov/publications/research-reports/marijuana/ marijuana-gateway-drug 20. http://www.medicalcannabis.com/ 21. https://www.22toomany.com/ 22. http://www.huffingtonpost.com/paul-rieckhoff/22-a-day-isunconscionabl_b_5793528.html 23. www.CannabisScienceConference.com
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END OF SUMMER HEALTHY RECIPES
And for more
Chef herb cOOK WitH HerB
&
go to www.cookwithherb.com
and fOr mOre, keep an eye out for Chef herbs events Calendar at cOOKWitHHerB.cOm and faceBOOK or tWitter. thanks for your loyalty to kush magazine and my reCipesâ&#x20AC;Ś -cHef HerB
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Shrimp, Artichoke, And edAmAme SAlAd in g r Ed iEn t s : 6 cups baby spinach 3/4 pound cooked shrimp 3/4 cup frozen edamame (soybeans), thawed 1 14-ounce can water-packed artichoke hearts, drained 3 vine-ripe tomatoes, cut into wedges For the Citrus Dressing: Juice of 1 medium orange Juice of 1 large lemon 4 tbsp extra-virgin THC olive oil 1 tbsp water d ir Ec t io n s : Wash and dry spinach leaves. Arrange in 4 bowls or on 4 salad plates. Arrange shrimp, edamame, artichoke hearts and tomato wedges on top. Combine dressing ingredients in a small jar and shake vigorously until blended. Drizzle over salad just before serving.
Grilled pepper SAlAd
in g r Ed iEn t s 4 bell peppers, (mixed colors), halved, seeded and stemmed 1/4 cup halved and pitted oil-cured black olives 1/4 cup rinsed and chopped oil-packed sun-dried tomatoes 4 tablespoons extra-virgin THC olive oil 1 tablespoon balsamic vinegar 1/8 teaspoon salt d ir Ec t io n s Grill peppers on medium-high, turning once, until soft and charred in spots, about 5 minutes per side. When cool enough to handle, chop the peppers and toss with olives, sun-dried tomatoes, THC oil, vinegar and salt in a large bowl
roASted corn And ShAllot VinAiGrette in g r Ed i En t s 3 cups fresh corn kernels 4 tablespoons extra-virgin THC olive oil 1/4 cup chopped fresh basil 1 tablespoon minced shallot 1 tablespoon red-wine vinegar 1/4 teaspoon salt Freshly ground pepper, to taste d ir Ec t io n s Preheat oven to 450°F. Toss corn and THC olive oil to coat and spread out on a large baking sheet. Bake, stirring once, until some kernels begin to brown, about 20 minutes. Combine basil, shallot, vinegar, salt and pepper in a medium bowl. Add the corn; toss to coat. Serve warm or cold.
WAtermelon GAzpAcho in g r Ed i En t s : 8 cups cubed seeded watermelon 1 apple, diced 1/2 cup finely chopped Vidalia onion 1/2 cup finely chopped green pepper 2 teaspoons fresh basil 1 teaspoon salt 1/4 teaspoon coarsely ground pepper 1/2 teaspoon chili powder 1 tablespoon cider vinegar 4 tablespoons THC olive oil d ir Ec t io n s : In a blender, puree watermelon with the apple and 1/4 cup each of the onion and green pepper, then pour into a large mixing bowl. Stir in the remaining ingredients (including the other 1/4 cup of onion and green pepper). Refrigerate, covered, for at least an hour to blend flavors.
ShitAke muShroom And BASil Fettuccine in g r Ed i En t s 4 tablespoons extra-virgin THC olive oil 3 cloves garlic, minced 2 ounces shiitake mushrooms, stemmed and sliced (1 1/2 cups)
2 teaspoons freshly grated lemon zest 2 tablespoons lemon juice, juice 1/4 teaspoon salt, or to taste Freshly ground pepper, to taste 8 ounces whole-wheat fettuccine, or spaghetti (see Ingredient note) 1/2 cup freshly grated Parmesan cheese, (1 ounce) 1/2 cup chopped fresh basil, divided d ir Ec t io n s Bring a large pot of lightly salted water to a boil for cooking pasta. Heat THC oil in large nonstick skillet over low heat. Add garlic and cook, stirring, until fragrant but not browned, about 1 minute. Add mushrooms and increase heat to medium-high. Cook, stirring occasionally, until tender and lightly browned, 4 to 5 minutes. Stir in lemon zest, lemon juice, salt and pepper. Remove from the heat. Meanwhile, cook pasta, stirring occasionally, until just tender, 9 to 11 minutes or according to package directions. Drain, reserving 1/2 cup cooking liquid. Add the pasta, the reserved cooking liquid, Parmesan and 1/4 cup basil to the mushrooms in the skillet; toss to coat well. Serve immediately, garnished with remaining basil.
StrAWBerry Apple SpinAch SAlAd in g r Ed iEn t s 1 pound fresh spinach, torn 2 cups chopped unpeeled Granny Smith apples 3/4 cup fresh bean sprouts 1/2 cup sliced fresh strawberries 1/4 cup crumbled cooked bacon f o r t HE d r Es s in g : 3/4 cup extra virgin THC olive oil 1/3 cup white wine vinegar 1 small onion, grated 1/2 cup sugar 2 teaspoons Worcestershire sauce 2 teaspoons salt d ir Ec t io n s In a large salad bowl, combine the first fi e ingredients. In a small bowl, whisk together all dressing ingredients. Just before serving, pour over salad and toss
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rASpBerry lemon muFFinS in g r Ed i En t s 1 lemon 1/2 cup sugar 1 cup nonfat buttermilk 1/3 cup THC canola oil 1 large egg 1 teaspoon vanilla extract 1 cup white whole-wheat flour, or whole-wheat pastry flour 1 cup all-purpose flour 2 teaspoons baking powder 1 teaspoon baking soda 1/4 teaspoon salt 1 1/2 cups fresh or frozen (not thawed) raspberries d ir Ec t io n s Preheat oven to 400°F. Coat 12 large (1/2-cup) muffin cups with cooking spray or line with paper liners. Use a vegetable peeler to remove the zest from the lemon in long strips. Combine the zest and sugar in a food processor; pulse until the zest is very finely chopped into the sugar. Add buttermilk, THC canola oil, egg and vanilla and pulse until blended. Combine whole-wheat flour, all-purpose flour, baking powder, baking soda and salt in a large bowl. Add the buttermilk mixture and fold until almost blended. Gently fold in raspberries. Divide the batter among the muffin cups. Bake the muffins until the edges and tops are golden, 20 to 25 minutes. Let cool in the pan for 5 minutes before turning out onto a wire rack. Serve warm.
zucchini BlueBerry BreAd in g r Ed i En t s 3 eggs, lightly beaten 1 cup THC vegetable oil 3 teaspoons vanilla extract 2 1/4 cups white sugar 2 cups shredded zucchini 3 cups all-purpose flour 1 teaspoon salt 1 teaspoon baking powder 1/4 teaspoon baking soda
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1 tablespoon ground cinnamon 1 pint fresh blueberries d ir Ec t io n s Preheat oven to 350 degrees F (175 degrees C). Lightly grease 4 mini-loaf pans. In a large bowl, beat together the eggs, THC vegetable oil, vanilla, and sugar. Fold in the zucchini. Beat in the flour, salt, baking powder, baking soda, and cinnamon. Gently fold in the blueberries. Transfer to the prepared mini-loaf pans. Bake 50 minutes in the preheated oven, or until a knife inserted in the center of a loaf comes out clean. Cool 20 minutes in pans, then turn out onto wire racks to cool completely.
cAkey BAkey peAnut SquAreS in g r Ed iEn t s 4 eggs 1-3/4 cups sugar 1 teaspoon vanilla extract 1-3/4 cups all-purpose flour 3 teaspoons baking powder 1/2 teaspoon salt 1 cup milk 1/4 cup THC butter, melted f r o s t in g : 7-1/2 cups confectioners’ sugar 2/3 cup milk 2 teaspoons vanilla extract 1/8 teaspoon salt 6 cups finely chopped peanuts d ir Ec t io n s In a large bowl, beat the eggs, sugar and vanilla until thick and lemon-colored, about 4 minutes. Combine the flour, baking powder and salt; add to egg mixture. Beat on low speed just until combined. Beat in milk and THC butter. Pour into a greased 13-in. x 9-in. baking pan. Bake at 350° for 30-35 minutes or until a toothpick inserted near the center comes out clean. Cool on a wire rack. Cut into squares. Cover and freeze overnight. For frosting, in a small bowl, beat the confectioners’ sugar, milk, vanilla and salt until smooth. Frost the top and sides of frozen cake squares; roll in peanuts. Place on wire racks to set.
The Future of Cannabis Nursing By: Carey S. Clark, PhD, RN, AHN-BC, RYT Having presented on the Endocannabinoid System (eCS) and the nurse’s role within cannabis medicine at a number of national and statewide nursing conferences, I am often asked how Registered Nurses can become “Cannabis Nurses”. Additionally, as President-Elect of the American Cannabis Nurses Association (ACNA), I have noted that nurses are often turning to the organization for guidance on how they can begin working in this specialized area of healthcare. The answers of course are often related to the nurse’s cannabis and endocannabinoid knowledge, coupled with previous nursing experiences and expertise, and what roles the nurse desires to play cannabis therapeutic support of the medicinal cannabis patient. One must also consider the legality of cannabis in the nurse’s state of practice; the FDA Schedule I status of cannabis tends to complicate the matter of cannabis nursing practice, and nurses should always error on the side of caution when it comes to nursing practice and working with cannabis patients. That being said, as a group we are making progress toward formally defining Cannabis Nursing as a specialty. This article will explore the current state of cannabis nursing, as well as future steps we can consider as we strive toward ensuring cannabis nursing becomes a recognized nursing specialty.
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Scope and Standards of Cannabis Nurse Practice Historically, some of the missing pieces for supporting the official recognition of Cannabis Nursing as a specialty within nursing have been both defining the domain, and creating a standard and scope of cannabis nursing practice. The standard and scope should align with American Nurses Association (2015) requirements, and be inclusive of the who, what, where, when, why, and how of nursing practice. It must be able to be applied broadly to many situations wherein nurses find themselves working with patients who use cannabis to support and potentiate their healing processes. It should furthermore acknowledge that the nurse’s role in working with cannabis patients clearly aligns with the accepted ANA standard and scope. In response to these issues, ACNA has officially accepted version 1.0 of the Scope and Standard of Cannabis Nurse Practice that aligns with ANA’s (2015) Standards and Scope of Practice (3rd edition). The document can be accessed here: https://cannabisnurses.org/ Scope-of-Practice-for-Cannabis-Nurses In addition to aligning Cannabis Nursing with ANA’s (2015) standards and scope, some of the highlights of the document include that the cannabis nurse uses caring-holistic approaches as they work with cannabis patients, and that the nurse is interested in not only supporting patients’ cannabis use, but also potentiating the health of the patient’s Endocannabinoid System (ECS). It is therefore imperative that the Cannabis Nurse: •
Focus on educating themselves regarding the basics of the eCS
•
Have knowledge and lived experience with holistic modalities that potentiate the health of the ECS and enhance stress resilience
•
Be able to apply the nursing process with cannabis patients
•
Be adept at creating a caring-healing environment for the patient
Unfortunately, most of our schools of nursing do not currently include cannabis as medicine and the Endocannabinoid System as in-depth curricular topics. This leaves nurses and nursing students with the option of educating themselves around the use of this herbal medicine. When looking at educational options, nurses should consider what conferences, organizations, and continuing education courses will best suit their learning needs toward understanding the action, indications, use, dosages, and side effects of cannabis as a medicine, along with understanding the nurse’s holistic role. The nurse must understand their own state practice act, and be aware of legal issues related to the role of the Cannabis Nurse. Therefore, historical, ethical, and legal implications should be covered, and the nurse should have an understanding of their role as an advocate for cannabis patient populations. One must also consider which texts might help support the nurse’s knowledge around working with patients with specific health concerns. For instance, The Cannabis Health Index (Blesching, 2015) is often a great place to start with considering patient issues, however, new scientific cannabis knowledge emerges so quickly, that the nurse must also feel comfortable accessing current peer reviewed literature related to cannabis and specific disease or health issues.
The Nursing Process and Holistic Roles Cannabis Nurses use the five-step nursing process to support patients: Assessment, Diagnoses, Planning, Intervention, and Evaluation. While this may seem fairly straight forward to nurses who have been using the nursing process for some time, holistic considerations must also play a role.
ASSESSMENT
For instance, during the assessment step, the nurse can use strategies like motivational interviewing to garner deeper understanding of the patient’s current health status and their goals toward potentiating their health. The nurse may also assess for what practices the patient currently has in place that help to potentiate the health of the Endocannabinoid System: does the patient regularly exercise, receive acupuncture, or see an osteopath? Does the patient meditate, do yoga, or find other ways to mindfully reduce their stress? Is the patient willing or able to explore ways in which their own Endocannabinoid System’s health can be potentiated? And, of course, assessing the patient’s past and current knowledge and use of cannabis is a key component of this process. By creating a caring-healing presence during the assessment process, the nurse is able to go deeper with their ability to ascertain how this particular patient might benefit from medicinal cannabis use.
DIAGNOSES
With diagnoses, the nurse should consider the patient’s health issues and determine which diagnoses might be addressed with cannabis. In this case, some diagnoses might be obvious, such as chronic pain, insomnia, or fatigue, while others may need more exploration to substantiate. But we might also consider that someone seeking out cannabis as a therapeutic tool for chronic health issues or palliation may be experiencing very important psychosocial-emotional issues that may be defined through diagnoses such as hopelessness, ineffective role performance, stress overload, social isolation, and/or spiritual distress.
PLANNING / INTERVENTION
When it comes time for planning and designing the cannabis intervention, the nurse must have knowledge of the state’s medicinal cannabis programs and resources. The nurse may work alongside an interdisciplinary team and educate those team members as needed to ensure that the patient has the best care, and that the entire healthcare team is knowledgeable regarding how cannabis might benefit the patient. The nurse also ensures that the patient and their caregiver are knowledgeable regarding cannabis access, dosing, safety, and side effects, while also considering the patient’s financial ability to pay for their medicine. The nurse helps the patient find ways to track their cannabis use through a diary or logbook, and encourages them to note the effects of any given strain or particular cannabisbased medicine they may be using. The Cannabis Nurse advocates for the patient while ensuring that the process remains patient centered.
EVALUATION
The Cannabis Nurse may find that during the evaluation phase, they are continuing to educate the patient, caregiver, and interdisciplinary team, while frequently returning to adjust the plan. Is the patient able to find strains that work for them? Are they able to mitigate or manage any side effects? Is the patient able to partake in activities that potentiate the health of the Endocannabinoid System? Are they able to afford their medicine and store it in a safe manner without fear of diversion? Do they have resources and knowledge to keep using cannabis as an effective holistic treatment modality?
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Caring-Healing Presence Throughout the duration of the work with the patient, the Cannabis Nurse remains a caring-healing presence and is committed to enacting human caring theory at the bedside. Human caring is: “The guiding moral idea of nursing; human attempt to connect with others in order to protect, enhance, preserve, human dignity and humanity with integrity as one supports a person toward finding meaning in illness, suffering, pain, and existence (ANA, 2015a; Watson, 2012)” (as cited in Clark, 2017). To be truly caring at the bedside, the Cannabis Nurse must make both their own self-care, and their own psychoneuroimmunological health, a priority. At the basis of the nurse’s caring-healing presence is a respect, or perhaps even a deep reverence, for the person we are called to care for; this reverence also extends to ourselves and our colleagues (Koerner, 2007). As we become present with another human being, we can recognize the value of the human before us, healing is catalyzed, and transformation occurs. We must be fully present with patients, in a reverent and caring manner to find the success we so desire in being a conduit for their healing. This is the essence of the applied art of nursing. While I have written about this in-depth elsewhere (Clark, 2014), one of the key aspects of creating a caring-healing presence, of being able to see and be with the patient in deep meaningful ways, is to first care for the self. The Cannabis Nurse should practice self-care activities and be on their own healing journey in order to create a truly present caring-healing environment, which will enhance the patient’s healing potential (Watson, 2012).
Next Steps
Eventually, it is the goal of the ACNA to support Cannabis Nursing as an officially recognized specialty within nursing. Next steps with this process include the addition of the APRN role to the Scope and Standards of Cannabis Nurse Practice and approaching the American Nurses Association to engage in the process of receiving feedback and guidance related to the specialization process. Additionally, further development and expansions of curricula that will help enhance nurses’ growth in cannabis nursing expertise, development of cannabis nursing specific textbooks, and creation of a certification test will be required. The Scope and Standards have been shared with the National Council of State Boards of Nursing, and we remain hopeful that they will align their formal recommendations around nurses working with cannabis patients with our document. While there may be challenges ahead as we strive to professionalize this role, we are making great movement toward supporting Cannabis Nurses in maximizing their roles.
Sources: American Nurses Association. (2015). Scope and standards of practice (3rd edition). Silver Springs, MD: Author. Blesching, U. (2015). The Cannabis Health Index. Berkeley, CA: North Atlantic Books. Clark, C.S. (2014). Stress, psychoneuroimmunology, and self-care: What every nurse needs to know. Journal of Nursing and Care, 3, 146. doi:10.4172/2167-1168.1000146 Clark, C.S. (2017). The Scope and Standards of Cannabis Nurse Practice. The American Cannabis Nurses Association. Retrieved from https://cannabisnurses.org/resources/ACNA% 20Scope%20and%20Standards%20of%20Practice/ ACNAScopeAndStandardOfPractice07172017.pdf Koerner, J. G. (2007). Healing Presence: The Essence of Nursing. New York, NY: Springer Publishing. Watson, J.M. (2012). Human Caring Science: A Theory of Nursing (second edition). Sudbury, MA: Jones and Bartlett.
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Created by: Blair Barbour September/October 2017 CANNABISNURSESMAGAZINE.COM
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Scope and Standards of Practice for Cannabis Nurses American Cannabis Nurses Association Prepared by: Carey S. Clark, PhD, RN, AHN-BC President-Elect, ACNA July14, 2017
Disclaimer: Nurses must be aware that cannabis and most cannabinoids are federally illegal. They must also be knowledgeable about their state’s delineated scope of nursing practice, and consider the legal status of cannabis in the given state where the practice. ACNA is not responsible for individual nurse interpretation or misuse of the document.
Introduction:
This document is intended to define and articulate the scope and standards of practice of the emerging role of the Cannabis Nurse in the United States. The scope of any specialized nursing practice describes the who, what, where, when, how, and why of that specific nursing specialty practice (American Nurses Association, (ANA), 2015a), while encompassing the nursing process and professional performance requirements of nurses. The standards of any specialty area of nursing are built upon the foundation of standards of practice expected of all registered nurses (Mariano, 2015) and cannabis nursing is no exception to this rule.
Definitions:
Cannabis: The preferred designation of the flowering herbal plant species cannabis sativa L., belonging to the genus Cannabis L., which belongs to the Cannabaceae family (United States Department of Agriculture, nd). Commonly known as “marijuana.” Environment: The surrounding milieu, habitat, conditions, and context in which beings participate and interact: Inclusive of the external physical space and habitat, as well as the cultural, psychological, social, and historical influences. Additionally, the individual’s internal physical, mental, emotional, social, and spiritual experiences are aspects of the environment (ANA, 2015a).
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Evidence-Based Practice (EBP): The use of the best well-designed and valid research evidence, integrative-healing philosophies, personal experience,, clinical expertise, and patient preferences to guide one’s nursing decision making processes and practices (ANA, 2015a: Mariano, 2015). Use of EBP leads to the nurse making the best clinical decisions and the resultant positive healthcare outcomes (ANA, 2015a). Healing: The act or process of restoring health or curing; the process of becoming well; tending to heal or cure (Merriam Webster Medical Dictionary, 2017a). Healing involves the physical, mental, spiritual, and social processes that support recovery, repair, renewal, and transformation of the self toward integration, balance, wholeness, and coherence (Mariano, 2015). Health: An experience defined in terms of the continuum between wellness and illness in the presence or absence of disease or illness (ANA, 2015a); an individually defined state in which the person experiences well-being, harmony, and unity (Mariano, 2015); Health or Wellness -Illness Continuum: The absence or presence of illness or disease does not adequately define health or wellness. Rather, individuals can move along a continuum toward greater wellness and health status, as they pass through the stages of awareness, education, and growth (Travis & Ryan, 2004). Homeostasis: The maintenance of relatively stable internal physiological conditions and processes in response to fluctuating internal and environmental conditions (Merriam Webster Medical Dictionary, 2017b).
Human Caring: The guiding moral idea of nursing; human attempt to connect with others in order to protect, enhance, preserve, human dignity and humanity with integrity as one supports a person toward finding meaning in illness, suffering, pain, and existence (ANA, 2015a; Watson, 2012 Nurse: For the purposes of this document, nurse is defined as a registered nurse who has the educational background and experience to be licensed by a state or regulatory body to practice the art and science of nursing (ANA, 2015a). The terms “nurse”, “registered nurse”, and “professional nurse” are all used interchangeably within this document in alignment with this same definition. Patient: The consumer of healthcare: may be a person, family, community or population who received the nurse’s professional services (ANA, 2015a). Stakeholder: Stakeholders are those entities that are integrally involved in the healthcare system. They include but are not limited to: patients, nurses, physicians, employers, insurance companies, pharmaceutical firms, government and regulating bodies, and, at the time of this writing, cannabis cultivators and cannabis medicine dispensaries.
Overarching Philosophical Principles
The Cannabis Nurse applies a guiding philosophy of caring for patients during patient-centered encounters. Cannabis nursing is both a learned skill and a practiced art, where the Cannabis Nurse builds expertise upon previous experiences with healing and nursing while enacting reflective practices to support growth toward expertise. The Cannabis Nurse aims to not only support and educate patients, but also works toward supporting wellness and healing through a caring presence, which supports the patient’s needs. Cannabis nursing requires that the
Nurse be educated in multiple areas above and beyond all registered nurse competencies, including cannabis therapeutics, advocacy, ethics, and the law. The Cannabis Nurse is a leader in supporting patients toward wellness and health as they support patients toward a maximal state of homeostasis. The Cannabis Nurse practices self-care to maintain a professional and caring presence with patients.
Core Values:
Evidenced-Based practice: Cannabis Nurses remain up-to-date on current scientific evidence regarding the use of cannabis to treat specific illness states or support wellness with patients or populations. Application of caring and justice-based ethics: The Cannabis Nurse is familiar with the ethical considerations related to nursing practice and they practice from a platform of ethics of care and justice-based ethics. Patient-centered care: The Cannabis Nurse recognizes that patients are at the center of their own care. The Cannabis Nurse supports patients in their autonomy and freedom to partner with others in determining their own plan of care. Interdisciplinary Team Work: The Cannabis Nurse is an integral member of the interdisciplinary team. The interdisciplinary team is characterized by a high degree of collaboration and communication among the health professionals caring for an individual that, together, develop a comprehensive treatment plan to address the biological, psychological, and social needs of the patient. Holistic Based Practice: The Cannabis Nurse considers patientsâ&#x20AC;&#x2122; holistic needs (body, mind, spirit) when designing plans of care. The nurse is cognizant that in addition to supporting patientâ&#x20AC;&#x2122;s use of cannabis for health and healing, the nurse is also obligated to promote the patientâ&#x20AC;&#x2122;s knowledge of endocannabinoid system function and the ability to create homeostasis; therefore evidence-based use of holistic-integrative modalities should be utilized as needed.
Standards of Care: Nursing Process Components Standard 1: Assessment The Cannabis Nurse collects relevant patient data related to the patientâ&#x20AC;&#x2122;s healthcare needs and concerns. 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Â&#x2018;Â&#x2C6; Â&#x2020;Â&#x192;Â&#x2013;Â&#x192; Â&#x2039;Â&#x2022; Â&#x192;Â? Â&#x2018;Â?Â&#x2030;Â&#x2018;Â&#x2039;Â?Â&#x2030; Â&#x2019;Â&#x201D;Â&#x2018;Â&#x2026;Â&#x2021;Â&#x2022;Â&#x2022; Â&#x2013;Â&#x160;Â&#x192;Â&#x2013; Â&#x2039;Â&#x2022; Â&#x2019;Â&#x2021;Â&#x201D;Â&#x2C6;Â&#x2018;Â&#x201D;Â?Â&#x2021;Â&#x2020; Â&#x2122;Â&#x2039;Â&#x2013;Â&#x160; Â&#x2026;Â&#x2018;Â?Â&#x2019;Â&#x192;Â&#x2022;Â&#x2022;Â&#x2039;Â&#x2018;Â?ÇĄ Â&#x2026;Â&#x192;Â&#x201D;Â&#x2039;Â?Â&#x2030;ÇĄ Â&#x192;Â?Â&#x2020; Â&#x201D;Â&#x2021;Â&#x2022;Â&#x2019;Â&#x2021;Â&#x2026;Â&#x2013; Â&#x2C6;Â&#x2018;Â&#x201D; Â&#x2013;Â&#x160;Â&#x2021; Â&#x2020;Â&#x2039;Â&#x2030;Â?Â&#x2039;Â&#x2013;Â&#x203A; Â&#x192;Â?Â&#x2020; Â&#x2014;Â?Â&#x2039;Â&#x201C;Â&#x2014;Â&#x2021;Â?Â&#x2021;Â&#x2022;Â&#x2022; Â&#x2018;Â&#x2C6; Â&#x2021;Â&#x192;Â&#x2026;Â&#x160; Â&#x160;Â&#x2014;Â?Â&#x192;Â?ÇŻÂ&#x2022; Â?Â&#x2021;Â&#x2021;Â&#x2020;Â&#x2022;Ǥ ʹǤ Â&#x2018;Â&#x201D;Â?Â&#x2022; Â&#x2122;Â&#x2039;Â&#x2013;Â&#x160; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013;Â&#x2022; Â&#x2013;Â&#x2018; Â&#x2020;Â&#x2021;Â&#x2013;Â&#x2021;Â&#x201D;Â?Â&#x2039;Â?Â&#x2021; Â&#x2013;Â&#x160;Â&#x2021;Â&#x2039;Â&#x201D; Â&#x2DC;Â&#x192;Â&#x17D;Â&#x2014;Â&#x2021;Â&#x2022;ÇĄ Â&#x2019;Â&#x201D;Â&#x2021;Â&#x2C6;Â&#x2021;Â&#x201D;Â&#x2021;Â?Â&#x2026;Â&#x2021;Â&#x2022;ÇĄ Â?Â&#x2021;Â&#x2021;Â&#x2020;Â&#x2022;ÇĄ Â&#x192;Â?Â&#x2020; Â?Â?Â&#x2018;Â&#x2122;Â&#x17D;Â&#x2021;Â&#x2020;Â&#x2030;Â&#x2021; Â&#x201E;Â&#x192;Â&#x2022;Â&#x2021; Â&#x201D;Â&#x2021;Â&#x17D;Â&#x192;Â&#x2013;Â&#x2021;Â&#x2020; Â&#x2013;Â&#x2018; Â&#x201E;Â&#x2018;Â&#x2013;Â&#x160; Â&#x160;Â&#x2021;Â&#x192;Â&#x17D;Â&#x2013;Â&#x160;ÇĄ Â&#x2122;Â&#x2021;Â&#x17D;Â&#x17D;Â?Â&#x2021;Â&#x2022;Â&#x2022;ÇĄ Â&#x2039;Â&#x17D;Â&#x17D;Â?Â&#x2021;Â&#x2022;Â&#x2022;ÇĄ Â&#x192;Â?Â&#x2020; Â&#x2026;Â&#x192;Â?Â?Â&#x192;Â&#x201E;Â&#x2039;Â&#x2022; Â&#x2014;Â&#x2022;Â&#x2021;Ǥ ;Ǥ Â&#x2022;Â&#x2013;Â&#x192;Â&#x201E;Â&#x17D;Â&#x2039;Â&#x2022;Â&#x160;Â&#x2021;Â&#x2022; Â&#x192; Â&#x2013;Â&#x201D;Â&#x2014;Â&#x2022;Â&#x2013;Â&#x2039;Â?Â&#x2030; Â&#x201D;Â&#x2021;Â&#x17D;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2018;Â?Â&#x2022;Â&#x160;Â&#x2039;Â&#x2019; Â&#x2013;Â&#x160;Â&#x192;Â&#x2013; Â&#x2019;Â&#x201D;Â&#x2018;Â?Â&#x2018;Â&#x2013;Â&#x2021;Â&#x2022; Â&#x192;Â?Â&#x2020; Â&#x2026;Â&#x201D;Â&#x2021;Â&#x192;Â&#x2013;Â&#x2021;Â&#x2022; Â&#x192; Â&#x2026;Â&#x192;Â&#x201D;Â&#x2039;Â?Â&#x2030; Â&#x192;Â&#x2013;Â?Â&#x2018;Â&#x2022;Â&#x2019;Â&#x160;Â&#x2021;Â&#x201D;Â&#x2021; Â&#x2C6;Â&#x2018;Â&#x201D; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013;Â&#x2022;ÇĄ Â&#x2C6;Â&#x192;Â?Â&#x2039;Â&#x17D;Â&#x203A;ÇĄ Â&#x192;Â?Â&#x2020; Â&#x2022;Â&#x2039;Â&#x2030;Â?Â&#x2039;Â&#x2C6;Â&#x2039;Â&#x2026;Â&#x192;Â?Â&#x2013; Â&#x2018;Â&#x2013;Â&#x160;Â&#x2021;Â&#x201D;Â&#x2022;Ǥ ͜Ǥ Â&#x2021;Â&#x2026;Â&#x2018;Â&#x2030;Â?Â&#x2039;Â&#x153;Â&#x2021;Â&#x2022; Â&#x2013;Â&#x160;Â&#x2021; Â&#x2039;Â?Â&#x2019;Â&#x192;Â&#x2026;Â&#x2013; Â&#x2018;Â&#x2C6; Â&#x2013;Â&#x160;Â&#x2021; Â?Â&#x2014;Â&#x201D;Â&#x2022;Â&#x2021;ÇŻÂ&#x2022; Â&#x2018;Â&#x2122;Â? 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Â&#x2020;Â&#x203A;Â?Â&#x192;Â?Â&#x2039;Â&#x2026;Â&#x2022; Â&#x201D;Â&#x2021;Â&#x17D;Â&#x192;Â&#x2013;Â&#x2021;Â&#x2020; Â&#x2013;Â&#x2018; Â&#x2013;Â&#x160;Â&#x2021; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013;ÇŻÂ&#x2022; Â&#x2018;Â&#x2122;Â? Â&#x160;Â&#x2021;Â&#x192;Â&#x17D;Â&#x2013;Â&#x160; Â&#x192;Â?Â&#x2020; Â&#x2014;Â&#x2022;Â&#x2021; Â&#x2018;Â&#x2C6; Â&#x2026;Â&#x192;Â?Â?Â&#x192;Â&#x201E;Â&#x2039;Â&#x2022;Ǥ ͸Ǥ Â&#x201D;Â&#x2039;Â&#x2018;Â&#x201D;Â&#x2039;Â&#x2013;Â&#x2039;Â&#x153;Â&#x2021;Â&#x2022; Â&#x2020;Â&#x192;Â&#x2013;Â&#x192; Â&#x2026;Â&#x2018;Â&#x17D;Â&#x17D;Â&#x2021;Â&#x2026;Â&#x2013;Â&#x2039;Â&#x2018;Â? Â&#x201E;Â&#x192;Â&#x2022;Â&#x2021;Â&#x2020; Â&#x2018;Â? Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013;ÇŻÂ&#x2022; Â&#x2018;Â&#x2122;Â? Â&#x160;Â&#x2021;Â&#x192;Â&#x17D;Â&#x2013;Â&#x160; Â&#x2026;Â&#x2018;Â?Â&#x2020;Â&#x2039;Â&#x2013;Â&#x2039;Â&#x2018;Â?Č&#x2039;Â&#x2022;Č&#x152; Â&#x192;Â?Â&#x2020; Â&#x2021;Â&#x161;Â&#x2019;Â&#x201D;Â&#x2021;Â&#x2022;Â&#x2022;Â&#x2021;Â&#x2020; Â&#x2026;Â&#x2018;Â?Â&#x2026;Â&#x2021;Â&#x201D;Â?Â&#x2022;Ǥ ͚Ǥ Â&#x2013;Â&#x2039;Â&#x17D;Â&#x2039;Â&#x153;Â&#x2021;Â&#x2022; Â&#x2021;Â&#x2DC;Â&#x2039;Â&#x2020;Â&#x2021;Â?Â&#x2026;Â&#x2021;ÇŚÂ&#x201E;Â&#x192;Â&#x2022;Â&#x2021;Â&#x2020; Â&#x192;Â&#x2022;Â&#x2022;Â&#x2021;Â&#x2022;Â&#x2022;Â?Â&#x2021;Â?Â&#x2013; Â&#x2013;Â&#x2021;Â&#x2026;Â&#x160;Â?Â&#x2039;Â&#x201C;Â&#x2014;Â&#x2021;Â&#x2022; Â&#x2013;Â&#x2018; Â&#x2039;Â&#x2020;Â&#x2021;Â?Â&#x2013;Â&#x2039;Â&#x2C6;Â&#x203A; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013; Â&#x160;Â&#x2021;Â&#x192;Â&#x17D;Â&#x2013;Â&#x160; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2013;Â&#x2021;Â&#x201D;Â?Â&#x2022;Ǥ ͺǤ Â&#x2019;Â&#x2019;Â&#x17D;Â&#x2039;Â&#x2021;Â&#x2022; Â&#x2021;Â&#x2013;Â&#x160;Â&#x2039;Â&#x2026;Â&#x192;Â&#x17D;ÇĄ Â&#x17D;Â&#x2021;Â&#x2030;Â&#x192;Â&#x17D;ÇĄ Â&#x192;Â?Â&#x2020; Â&#x2019;Â&#x201D;Â&#x2039;Â&#x2DC;Â&#x192;Â&#x2026;Â&#x203A; Â&#x2030;Â&#x2014;Â&#x2039;Â&#x2020;Â&#x2021;Â&#x17D;Â&#x2039;Â?Â&#x2021;Â&#x2022; Â&#x192;Â?Â&#x2020; Â&#x2019;Â&#x2018;Â&#x17D;Â&#x2039;Â&#x2026;Â&#x2039;Â&#x2021;Â&#x2022; Â&#x2013;Â&#x160;Â&#x201D;Â&#x2018;Â&#x2014;Â&#x2030;Â&#x160;Â&#x2018;Â&#x2014;Â&#x2013; Â&#x2013;Â&#x160;Â&#x2021; Â&#x2020;Â&#x192;Â&#x2013;Â&#x192; Â&#x2026;Â&#x2018;Â&#x17D;Â&#x17D;Â&#x2021;Â&#x2026;Â&#x2013;Â&#x2039;Â&#x2018;Â? Â&#x2019;Â&#x201D;Â&#x2018;Â&#x2026;Â&#x2021;Â&#x2022;Â&#x2022;ÇĄ Â&#x2039;Â?Â&#x2026;Â&#x17D;Â&#x2014;Â&#x2022;Â&#x2039;Â&#x2DC;Â&#x2021; Â&#x2018;Â&#x2C6; Â&#x2020;Â&#x192;Â&#x2013;Â&#x192; Â?Â&#x192;Â&#x2039;Â?Â&#x2013;Â&#x2021;Â?Â&#x192;Â?Â&#x2026;Â&#x2021;ÇĄ Â&#x2014;Â&#x2022;Â&#x2021;ÇĄ Â&#x192;Â?Â&#x2020; Â&#x2020;Â&#x2039;Â&#x2022;Â&#x2022;Â&#x2021;Â?Â&#x2039;Â?Â&#x192;Â&#x2013;Â&#x2039;Â&#x2018;Â?Ǥ ͝Ǥ Â&#x2018;Â?Â&#x2018;Â&#x201D;Â&#x2022; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013; Â&#x2019;Â&#x201D;Â&#x2021;Â&#x2C6;Â&#x2021;Â&#x201D;Â&#x2021;Â?Â&#x2026;Â&#x2021;Â&#x2022;ÇĄ Â&#x2122;Â&#x160;Â&#x2039;Â&#x17D;Â&#x2021; Â&#x201D;Â&#x2021;Â&#x2026;Â&#x2018;Â&#x2030;Â?Â&#x2039;Â&#x153;Â&#x2039;Â?Â&#x2030; Â&#x2013;Â&#x160;Â&#x2021; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013;ÇŻÂ&#x2022; Â&#x192;Â&#x2014;Â&#x2013;Â&#x160;Â&#x2018;Â&#x201D;Â&#x2039;Â&#x2013;Â&#x203A; Â&#x201D;Â&#x2021;Â&#x2030;Â&#x192;Â&#x201D;Â&#x2020;Â&#x2039;Â?Â&#x2030; Â&#x2013;Â&#x160;Â&#x2021;Â&#x2039;Â&#x201D; Â&#x2018;Â&#x2122;Â? Â&#x160;Â&#x2021;Â&#x192;Â&#x17D;Â&#x2013;Â&#x160;Ǥ ͳͲǤ Â&#x192;Â&#x2013;Â&#x160;Â&#x2021;Â&#x201D;Â&#x2022; Â&#x2022;Â&#x2019;Â&#x2021;Â&#x2026;Â&#x2039;Â&#x2C6;Â&#x2039;Â&#x2026; Â&#x160;Â&#x2039;Â&#x2022;Â&#x2013;Â&#x2018;Â&#x201D;Â&#x2039;Â&#x2026;Â&#x192;Â&#x17D; Â&#x192;Â?Â&#x2020; Â&#x2026;Â&#x2014;Â&#x201D;Â&#x201D;Â&#x2021;Â?Â&#x2013; Â&#x2020;Â&#x192;Â&#x2013;Â&#x192; Â&#x201D;Â&#x2021;Â&#x2030;Â&#x192;Â&#x201D;Â&#x2020;Â&#x2039;Â?Â&#x2030; Â&#x2019;Â&#x192;Â&#x2013;Â&#x2039;Â&#x2021;Â?Â&#x2013;ÇŻÂ&#x2022; Â?Â?Â&#x2018;Â&#x2122;Â&#x17D;Â&#x2021;Â&#x2020;Â&#x2030;Â&#x2021; Â&#x2018;Â&#x2C6; Â&#x192;Â?Â&#x2020; Â&#x2021;Â&#x161;Â&#x2019;Â&#x2021;Â&#x201D;Â&#x2039;Â&#x2021;Â?Â&#x2026;Â&#x2021; Â&#x2122;Â&#x2039;Â&#x2013;Â&#x160; Â&#x2026;Â&#x192;Â?Â?Â&#x192;Â&#x201E;Â&#x2039;Â&#x2022;Ǥ ͳͳǤ Â&#x2018;Â&#x2026;Â&#x2014;Â?Â&#x2021;Â?Â&#x2013;Â&#x2022; Â&#x2020;Â&#x192;Â&#x2013;Â&#x192; Â&#x2030;Â&#x192;Â&#x2013;Â&#x160;Â&#x2021;Â&#x201D;Â&#x2021;Â&#x2020; Â&#x2039;Â? Â&#x192; Â&#x2022;Â&#x2021;Â&#x2026;Â&#x2014;Â&#x201D;Â&#x2021; ÇŚÂ&#x2026;Â&#x2018;Â?Â&#x2019;Â&#x17D;Â&#x2039;Â&#x192;Â?Â&#x2013; Â?Â&#x192;Â?Â?Â&#x2021;Â&#x201D;Ǥ
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September/October 2017 CANNABISNURSESMAGAZINE.COM
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Standard 3: Outcomes Identification
The Cannabis Nurse clearly identifies expected outcomes for an individualized plan related to the patient’s or population’s unique situation. Competencies: The Cannabis Nurse: 1. Works with the patient, family, and interdisciplinary healthcare team members to determine desired goals and outcomes. The patient remains at the center of the process. 2. Defines the outcomes as related to the patient’s values, beliefs, age, preferences, while considering ethical concerns, spiritual practices and preferences, environment. 3. Integrates the most relevant available cannabis science evidence/ related scientific evidence given the patient’s or population’s concerns. 4. Considers the best Cannabis Nurse practices. 5. Weighs the risks, benefits, and costs related to attaining the intended outcomes. 6. Generates a time frame for expected outcomes. 7. Modifies outcomes based on ongoing evaluation of the plan. 8. Documents expected outcomes and actual outcomes.
Standard 4: Planning
The Cannabis Nurse develops a plan that outlines strategies to attain expected outcomes. Competencies: The Cannabis Nurse: 1. In partnership with the patient, develops a plan that considers values, beliefs, spirituality, health practices, preferences, choices, age, cultural relevance, and environmental concerns. 2. In conjunction with patient, family, and other clinicians and concerned persons develops a plan for incorporation of appropriate use of cannabis therapeutics and modalities that support optimal functioning of the endocannabinoid system. 3. Builds upon established trusting-caring relationship to explore alternative and integrative options for healing. 4. Includes evidence-based strategies to address established issues, diagnoses and problems. 5. Develops a plan for implementation. 6. Identifies costs and financial implications with patient, family, and significant others. 7. Modifies plan to address ongoing assessment and patient responses to cannabis use. 8. Provides health education, teaching, and promotion as needed to support the patient’s healthcare team. 9. Coordinates implantation of the plan.
Standard 5: Implementation
The Cannabis Nurse supports the patient in implementation of the plan of care. Competencies: The Cannabis Nurse: 1. Partners with patient, family, and significant others to implement the plan in a safe and timely manner. 2. Utilizes inter-professional resources to support patient’s achievement of outcomes. 3. Provides an ongoing presence as implementation data is gathered. 4. Modifies cannabis care plan based on ongoing assessment of effectiveness of implementation strategies.
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5. Supports patient with ongoing educational needs. 6. Coordination of care is provided by the Cannabis Nurse as needed to achieve cannabis related outcomes. 7. Health teaching and health promotion strategies are implemented to support patient’s ongoing educational needs related to wellness and possible adverse effects of cannabis care plan implementation. 8. Monitors patient or population for adverse effects related to the use of cannabis or related to the implementation plan. 9. Engages cannabis patient alliance and advocacy groups in health teaching and healthpromotion activities. 10. Documents implementation process.
Standard 6: Evaluation
The Cannabis Nurse evaluates progress toward attaining outcomes. Competencies: The Cannabis Nurse: 1. Evaluates the plan, implementation process, and outcomes achievement as prescribed by the indicated timeline. 2. In conjunction with the patient or population, evaluates the effectiveness of the planned strategies as related to unique patient or population responses in efforts to reach goals. 3. Uses ongoing assessment and evaluation data to revise cannabis nursing plan of care, including diagnoses, outcomes, plans, and implementation strategies. 4. Documents findings and results of the evaluation process.
Standards of Professional Performance
Standard 7: Ethics and Advocacy
The Cannabis Nurse practices ethically. Competencies: The Cannabis Nurse: 1. Utilizes the Code of ethics for nurses with interpretative statements (ANA, 2015b) to guide practice, while establishing and maintaining an ethical environment of nursing care. 2. Practices cannabis nursing with compassion, caring, respect, and in acknowledgement of the inherent dignity, worth, and unique attributes of all persons. 3. Advocates for patients, populations, and consumers’ rights regarding informed decision making and self-determination in relation to cannabis as a medicine. 4. Understands that their primary commitment is to the patients and populations they serve. 5. Maintains therapeutic-caring relationships and professional boundaries. 6. Safeguards cannabis patients’ rights to healthcare privacy. 7. Maintains ongoing cannabis nursing competence through professional and personal educational and development opportunities. 8. Demonstrates ongoing commitment to self-reflection and selfcare practices. 9. Collaborates with other health professionals and the public to protect human rights and reduce health disparities. 10. Enacts personal and nursing core values to maintain integrity of cannabis nursing practice.
Standard 8: Culturally Congruent Practice
The Cannabis Nurse practices in a manner that is congruent with cultural diversity and principles of inclusion. Competencies: The Cannabis Nurse: 1. Participates in lifelong learning to ensure understanding of diverse patientsâ&#x20AC;&#x2122; cultural preferences, world views, and choices and how these impact patientsâ&#x20AC;&#x2122; decision making processes. 2. Considers the effects and impacts of discrimination and oppression on cannabis nurse practice within vulnerable diverse populations. 3. Advocates for cannabis policies that promote health and prevent harm among culturally diverse, under-served, vulnerable, or underrepresented patients and populations. 4. Promotes equal access to medicinal cannabis services. 5. Educates nurse colleagues and other healthcare professionals about the intersection between medicinal cannabis and diverse population needs.
Standard 9: Communication
The Cannabis Nurse communicates effectively in all areas of practice. Competencies: The Cannabis Nurse: 1. Assess their own communication skills and communication effectiveness. 2. Demonstrate cultural empathy when communicating with patients. 3. Use communication methods that demonstrate caring, respect, deep listening, authenticity, and trust. 4. Maintain communication with interdisciplinary team as needed to ensure continuity of care. 5. Convey accurate information regarding medicinal use of cannabis. 6. Disclose concerns related to potential or actual hazards or safety issues related to medicinal cannabis use. 7. Apply HIPPA-compliant, ethical, legal, and privacy guidelines and policies throughout the communication process, inclusive of information maintenance, use, and dissemination.
Standard 10: Collaboration
The Cannabis Nurse collaborates with patients, families, clinicians, populations, and key stakeholders. Competencies: The Cannabis Nurse: 1. Identifies areas of cannabis expertise and contributions of other professionals and key stakeholders. 2. Clearly articulates the Cannabis Nurse role with other healthcare team members. 3. Partners with cannabis patients and key stakeholders to advocate for change that supports positive healthcare outcomes and enhanced quality of care. 4. Exhibits dignity, respect, and professionalism when interacting with others and giving and receiving feedback. 5. Shares cannabis knowledge with peers and colleagues in a professional manner.
Standard 11: Leadership
The Cannabis Nurse provides leadership within professional practice settings. Competencies: The Cannabis Nurse: 1. Contributes to the evolution of professional medicinal cannabis nursing through participation in professional organizations, including but not limited to ACNA. 2. Influences cannabis policy processes that promote health and ensure patient safety and well-being. 3. Mentors other Cannabis Nurses toward the advancement of cannabis nursing practice. 4. Acts as a professional role model for other nurses and healthcare professionals.
Standard 12: Education
The Cannabis Nurse seeks knowledge and competence that reflects current cannabis nursing practices and promotes futuristic and innovative thinking. Competencies: The Cannabis Nurse: 1. Regularly participates in educational activities related to cannabis nursing and inter-professional knowledge bases. 2. Demonstrates a commitment to lifelong learning inclusive of selfreflection and inquiry for personal and professional growth. 3. Acquires knowledge and skills related to the role of the Cannabis Nurse.
Standard 13: Evidence-Based Practice and Research
The Cannabis Nurse integrates current best evidence and research findings into practice. Competencies: The Cannabis Nurse: 1. Articulates the importance and value of cannabis-science-based research and its application with patients and populations. 2. Uses current evidence-based knowledge to guide cannabis nursing practice and decision making processes. 3. Participates in the building of the body of cannabis-related scientific evidence and contributes to the emerging field of cannabis research and therapeutics science. 4. Promotes ethical practices and principles within cannabis research efforts.
Standard 14: Quality of Practice
The Cannabis Nurse contributes to quality cannabis nursing practices. Competencies: The Cannabis Nurse: 1. Recommends strategies to improve quality of care for cannabis patients. 2. Collects data to ensure quality of cannabis nursing practice. 3. Provides critical review of policies, procedures, and guidelines which impact cannabis patients and nurses. 4. Documents
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Standard 15: Professional Practice Evaluation
The Cannabis Nurse evaluates their own and otherâ&#x20AC;&#x2122;s cannabis nursing practices. Competencies: The Cannabis Nurse: 1. Regularly engages in self-reflection and self-evaluation of cannabis nurse practice. 2. Adheres to The Nursing Scope and Standards of Practice (ANA, 2015a) and The Code of Ethics for Nurse With Interpretive Statements (ANA, 2015b). 3. Seeks formal and informal evaluation and feedback from cannabis patients, colleagues, and others. 4. Provides other Cannabis Nurses with formal and informal constructive feedback regarding their practice and role performance.
Standard 16: Resource Utilization
The Cannabis Nurse utilizes available resources to plan, provide, and sustain evidence-based nursing services. Competencies: The Cannabis Nurse: 1. Assists the cannabis patient in factoring costs, risks, and benefits in decisions about care. 2. Assists the patient in identifying and procuring traditional medical therapies, holistic services, and integrative medicinal technologies as appropriate to support their healing processes. 3. Integrates telehealth and mobile health technologies when appropriate to promote positive interactions with cannabis patients. 4. Uses community resources to support and implement interprofessional plans and educational efforts.
Standard 17: Environmental Health
The Cannabis Nurse supports an environmentally healthy and safe atmosphere. Competencies: The Cannabis Nurse: 1. Creates a safe and healthy workplace environment. 2. Reduces environmental health risks to self, cannabis patients, and colleagues. 3. Uses products or treatments consistent with evidence-based practices to decrease environmental threats.
Summary
The Cannabis Nurse works in a variety of settings with patients and their support systems to facilitate health, healing, and well-being through the patientâ&#x20AC;&#x2122;s safe and effective use of cannabis and endocannabinoid system optimal functioning. The Cannabis Nurse is educated on the use of cannabis as medicine and current cannabis scientific findings; therefore, the Cannabis Nurse is able to educate patients, their caregivers or support systems, and other healthcare providers around the most effective and safe uses of cannabis for specific health, healing, and illness concerns. The Cannabis Nurse upholds the highest ethical standards, and advocates for patients and populations.
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Citations / Resources: American Nurses Association. (2015a). Scope and standards of practice (3rd edition). Silver Springs, MD: Author. American Nurses Association. (2015b). Code of ethics for nurses with interpretive statements. Silver Springs, MD: Author. Mariano, C. (2015). Holistic Nursing: Scope and Standards of Practice. Retrieved from http:// samples.jbpub.com/9781449651756/45632_CH02_Pass1.pdf Merriam-Webster Medical Dictionary. (2017a). Healing. Retrieved from https://www.merriam-webster.com/medical/healing Merriam-Webster Medical Dictionary. (2017b). Homeostasis. Retrieved from https://www.merriam-webster.com/dictionary/ homeostasis#medicalDictionary Travis, J. & Ryan, R.S. (2004). The wellness workbook: How to achieve enduring health and vitality (3rd ed.). New York, NY: Ten Speed Press. United States Department of Agriculture. (nd). Cannabis Sativa L. marijuana. Retrieved from https://plants.usda.gov/core/profile?symbol=casa3 Watson, J.M. (2012). Human Caring Science: A theory of nursing (second edition). Sudbury, MA: Jones and Bartlett.
Resources
Recommended Books
Cannabis Revealed How the world's most misunderstood plant is healing everything from chronic pain to epilepsy Authored by Bonni Goldstein M.D. Did you know you have a widespread receptor system that interacts with the compounds in cannabis? Cannabis Revealed is the only book written by a medical cannabis specialist, explaining the science behind the use of this amazingly therapeutic plant and describing in easy-to-understand detail the recently discovered endocannabinoid system, involved in almost every human physiologic process. Although 28 states have medical cannabis laws, most physicians are reluctant to discuss how this plant may be beneficial to health. Over 4 million people in the U.S. are healing difficult-to-treat illnesses with cannabis medicine. This book is an educational tool for patients and their loved ones who have not found answers with conventional medicines.
Healthy Places, Healthy People: A Handbook for Culturally Competent Community Nursing Practice This revolutionary book is the first of its kind designed to provide nurses the tactics and tools to help them approach public health nursing through the tapestry of culture and community instead of the individual. By looking through the clarifying lenses of anthropology, economics, political science, sociology, and epidemiology, and other soft and hard sciences, the authors show a clear and powerful connection to health of the larger community and the health of individuals. Once this connection is made, the health care team--of which the public health nurse is uniquely
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Marijuana Myths, Marijuana Facts: by Lynn Etta Zimmer, John Morgan Great eye opener, I had the pleasure of reading this book my first year at college back in 1997. Definitely changed my views and has opened me up to being an advocate for legalization. I would attribute this book as a key work that has educated America about the Truth about marijuana and I think anyone who is concerned about the legalization movement that is finally coming to fruition should read this book.
Handbook of Cannabis Truly global in scope and with contributions from leading researchers around the world, The Handbook of Cannabis is the definitive resource on this fascinating drug. Combining scientific perspectives and clinical applications, it covers a vast array of topics, from why over the centuries cannabis has been used as a medicine, through the regulations facing those wishing to selfadminister cannabis or provide cannabis-based medicines, to the chemical structure of its many constituents and the rapidly growing group of synthetic cannabinoids that are currently being used for 'legal highs'.
Nursing Conferences
2017
September 2017 Conferences The Cannabinoid Conference 2017 IACM 9th Conference on Cannabinoids in Medicine September 29-30, 2017 | Cologne, Germany www.CannabinoidConference2017.org
October 2017 Conferences
Make Note!
Cannabis Nurses Network Conference 2017 October 5th -7th, 2017 | Las Vegas, NV www.CNNC2017.com | www.CannabisNursesMagazine.com | NatureNurseHealth.com Weekend Itinerary: Oct. 5th: Cannabis Education For Nurses (5.33 CEUs)- UNLV Greenspun Hall Oct. 6th: Making eCs Connections & Interactive Sports Book Panel- UNLV Foundation Bldg. Oct. 7th: CNM 2-Year Anniversary & Leaders of Nursing Awards Ceremony
Infused Expo 2017 by Edibles Magazine October 21st, 2017 | Los Angeles, CA www.InfusedExpo.com
November 2017 Conferences MJ Biz Conference 2017 November 16-18, 2017 | Las Vegas, NV www.MJBizCon.com
February 2018 Conferences The Reno Cannabis Convention February 17-18th, 2017| Reno, NV www.TheRenoExpo.com
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