March_ April 2017 CNM

LIFESTYLES

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OPPORTUNITY

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EDUCATION March/April 2017

Arizona: Medical Cannabis Programs Expand by Adding New Qualifying Conditions Heather Manus, RN

A ROADMAP OF HOW TO CREATE

New Jersey: DOH Panel to Consider Petitions Adding Qualifying Conditions Medicinal Marijuana Program Ken Wolski, RN, MPA

Using Medical Cannabis for Opioids Sparing and Opioids Tapering in Chronic Pain

CHANGE IN YOUR COMMUNITY Anita Briscoe, MS, APRN-BC

Dr. Gregory Smith

Nurses Must Advocate for Patient Access to Cannabis to Stem the Opioid Epidemic

Mary Lynn Mathre ,RN, MSN, CARN

Medical Cannabis: The Healing Power of Knowledge

Editor’s Letter The abuse of and addiction to opioids such as heroin, morphine, and prescription pain relievers is a serious global problem that affects the health, social, and economic welfare of all societies. Currently, the CDC has estimated 91 opioid overdoses per day in the U.S. and there is a greater need within our healthcare system to find solutions to end this epidemic. Medical Cannabis is a solution to our Opiate Dependency and we bring to you the evidence-based research to validate this claim in this important Issue of Cannabis Nurses Magazine: Opiate Dependency.

What can we do as Nurses? As Nurses, advocating for the Rights of Patients is the most honest, ethical, and compassionate care we as Nurses can provide. In this Issue we explore three states, Arizona/New Jersey/New Mexico, where Nurses stand up for patients rights and assure that health is ‘a Universal Right’ (ANA, 2015) and patients are receiving access to health care and education, which includes safe access that is not based on zip codes.

We begin with Nurse Heather Manus, President of AZCNA, who has been trailblazing an uncharted path in Arizona, while championing the cause for cannabis patient’s rights, and has taken repeated administrative and legal action since 2013 to include additional medical conditions to the Arizona Medical Marijuana Act. We then explore in detail with Dr. Gregory Smith on ‘Using Medical Cannabis for Opioids Sparing and Opioids Tapering in Chronic Pain’. He defines pain and the opioids use problem and how Medical Cannabis is used in treating chronic pain, use as an adjunct medication, therapeutic effects, safety, and uses in clinical practice that can be applied to your nursing practice.

Our Cover Nurse: Anita Briscoe, MS, APRN-BC, provides Nurses ‘A Roadmap of How to Create Change in your Community’ and shares her original ‘Petition to the NM Medical Advisory Board to the New Mexico Medical Cannabis Program to Add Opiate Dependence as a Qualifying Condition’. Learn how to create positive change to end the Opioid Dependence epidemic in your community by following her outlined example. She also discusses the misdiagnosis of Cannabis Dependency under the DSM-5 Diagnosis Cannabis Use Disorder. For patients who are legally using medical cannabis in the states which allow them, the term ‘dependency’ is an inaccuracy. Re-evaluation of our DSM codes are in order.

Our New Jersey Nurse, Ken Wolski, RN, MPA, champions the 'New Jersey Department of Health Panel to Consider Petitions Adding Qualifying Conditions to State’s Medicinal Marijuana Program with the aid of Members of the Coalition for Medical Marijuana- New Jersey' (CMMNJ). Unfortunately, this program has been under the direction of Governor Chris Christie, who has delayed and obstructed the full implementation of the CUMMA. It is the Commissioner of the DOH who makes the final determination in this matter, after the panel of healthcare professionals makes their recommendations.

Perhaps it’s time to investigate who sits on these panels of healthcare professionals and assure they are properly educated and/or held accountable for their recommendations. If denied, then are they not blocking a human’s ‘Universal Right’ to access to health care and education concerning the prevention of health issues?

We end with our legendary and long-time educator, Mary Lynn Mathre, RN, MSN, CARN, who writes ‘Nurses Must Advocate for Patient Access to Cannabis to Stem the Opioid Epidemic’. It is here where she states the need to educate our colleagues and patients about the use of cannabis for the management of chronic pain. Cannabis should be removed completely from the Controlled Substances listing and patients allowed to grow this natural plant and, have it finally recognized for what it is: a medicinal herb. It’s that simple.

Nurses have been provided a roadmap to create change and are supported by the ANA Position Statement of 2016 which actively supports patients’ rights to legally and safely use marijuana, as well as the Nurse’s promotion of quality of life for patients using such therapy. The ANA House of Delegates has gone on record as supporting Nurses’ advocacy for patients using marijuana and other related cannabinoids for therapeutic use (ANA, 2003). So now is the time to advocate for patients in your community utilizing the tools and resources outlined in this important Issue on Opiate Dependency.

We must Grow.

Julie Monteiro, RN, BSK “Ask Nurse Juhlzie” Editor@Cannabis Nurses Magazine

Contributors Heather Manus, RN March/April 2017

Publisher

Robert Herman/D1Media

Managing Editor

Julie Monteiro, RN, BSK

Creative Director

Heather Manus, RN

Contributors Heather Manus, RN Sue DeGregorio-Rosen, RN Marcie Cooper, MSN, RN, AHN-BC Lisa Buchanan, RN ,OCN Jennie Stormes, RN, BSN Anita Briscoe, MS, APRN-BC Ken Wolski, RN, MPA Mary Lynn Mathre, RN, MSN, CARN Dr. Gregory Smith Donald I. Abrams, MD Photography

Nelson Ramirez Morning Coffee Productions

Cannabis Nurses Magazine publishes the most recent and compelling health care information on cannabis health, studies, research, and professional nursing issues with medical cannabis. As a refereed, clinical practice bimonthly 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 for free online at: CannabisNursesMagazine.com or subscribe to a printed copy to be delivered to your door.

We are currently accepting articles to be considered for publication. For more information on writing for Cannabis Nurses Magazine, check out our writer’s guidelines at: cannabisnursesmagazine.com/writers-guidelines or submit your article to: editor@cannabisnursesmagazine.com 4780 W. Ann Rd., Suite 5 #420 N. Las Vegas, NV 89031 Editor@cannabisnursesmagazine.com Online 24/7 at: cannabisnursesmagazine.com

A native New Mexican and Registered Nurse specializing in all aspects of medical cannabis care. She is founder of the Arizona Cannabis Nurses Association and was honored for her efforts, and awarded the CannAwards “Best Charitable/Community Outreach Program", and Cannabis Business Awards “Activist of the Year 2015” and "Educational Achievement Award 2016". She believes cannabis is a gateway to health and will be a first-line medication of the future.

Sue Degregorio-Rosen, RN A pioneer activist and native of New Jersey, Sue lives in the lower Hudson Valley of New York State. She has held multiple positions in the administration of ER/Trauma/Burns throughout her 40 yr career. She is the legal liaison and associate editor for The National Cannabis Patients Wall. She is also an activist and a chapter leader for the 420 Seniors Network of NY and The Cannabis Nurses Network. Sue holds a certificate in Advanced Cannabis Nursing, lending her expertise to communities along the east coast.

Marcie Cooper, MSN, RN, AHN-BC

Marcie Cooper RN, MSN, AHN-BC is Board Certified as an Advanced Holistic Nurse and is working to build a bridge between conventional healthcare and holistic nursing care including cannabis therapeutics. She obtained education, certifications and training in various complimentary therapies including Hypnotherapy, Auricular Acupuncture, Healing Touch and Aromatherapy. She incorporates cannabis education with patients while working in hospice and palliative care throughout Colorado, and has witnessed the incredible benefits of cannabis.

Lisa Buchanan, RN, OCN

Lisa Buchanan is an Oncology Certified Nurse (OCN) in Washington state who has worked with the seriously ill and dying for more than 20 years. She a member of the Oncology Nurses Society (ONS), American Cannabis Nurses Association (ACNA), and the Washington State Nurses Association.

She has earned certificates in the Core Curriculum for Cannabis Nursing and in the Advanced Curriculum for Cannabis Nursing through ACNA.

Jennie Stormes, BSN, RN

Jennie Stormes, RN, BSN lives in the state of Colorado, and formerly in both New Jersey and Pennsylvania, is a member of the ACNA, a board member of American Medical Refugees as Vice Chair, Colorado Springs Chair for CannaMoms, and a parent member of the Special Education Advisory Committee for Colorado School District 49 (Falcon). She specializes in Pediatrics and Neurology and has a passon for education.

Contributors Gregory L. Smith, MD, MPH Dr. Gregory Smith earned his medical degree from Rush Medical School in Chicago, and a Masters of Public Health from Harvard University. He completed residency training in Preventive Medicine at Walter Reed Army Medical Center.

Since getting out of the US Army as a Major, Doctor Smith has been in primary care practice in California, Georgia and Florida for the past 25 years. He first trained on use of medical cannabis in California in 2000 and made medical cannabis and CBD oil, part of his practice since that time. Dr. Smith is an avid writer, having published two medical textbooks, a novel called "Malpractice," and articles with many magazines and over a dozen peer reviewed medical publications. His most recent book, is entitled Medical Cannabis: Basic Science and Clinical Applications (Aylesbury Press, 2016 – www.AylesburyPress.com) It is the first, scientifically-based textbook directed at educating medical students and medical professionals on the science and applications of cannabinoid medications.

Contact Information

Heather Manus, RN Heather Manus is a native New Mexican and Registered Nurse specializing in all aspects of medical cannabis care.

She was a board member of the American Cannabis Nurses Association, serving as Chairwoman for the ACNA conference committee. She also holds a certificate of completion for The Core Curriculum for Cannabis Nursing.

Nurse Heather has shared her knowledge and assistance regarding cannabinoid therapies in Colorado, Arizona, Massachusetts, California, Nevada and New Mexico.

She was honored to be a presenter and panelist for multiple conferences around the nation. Her deep understanding, unique perspectives and professional delivery make learning, a positive and enriching experience. In addition to educating, advising, and speaking; under Nurse Heathers direction, the Arizona Cannabis Nurses Association was successful in petitioning and appealing for the inclusion of Post-Traumatic Stress Disorder (PTSD) as a recognized debilitating condition under Arizona's medical marijuana act.

Ken Wolski, RN, MPA

Ken Wolski, RN, MPA has been a Registered Nurse (RN) since 1976, currently licensed to practice in New Jersey and Pennsylvania. He retired in 2006 from the State of New Jersey after 25 years of service with the Department of Human Services and the Department of Corrections as a Staff Nurse, Head Nurse, Supervisor of Nurses, Quality Assurance Coordinator and Health Services Manager. In addition to his state service, Ken worked for eight years in Acute Care Facilities as an Intensive Care Unit and Cardiac Care Unit (ICU/CCU) Nurse. Ken also worked as a Public Health Nurse for the City of Trenton. Ken is currently self-employed and is the Executive Director of the non-profit educational organization CMMNJ.

Mary Lynn Mathre RN, MSN, CARN

Mary Lynn Mathre, RN, MSN, CARN has 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-surgical 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. Since that time Mrs. Mathre has studied the medical use of cannabis. She is the cofounder and President of Patients Out of Time, an educational charity created in 1995 to educate health care professionals and the public about the therapeutic use of cannabis. She is the editor of Cannabis in Medical Practice: A Legal, Historical and Pharmacological Overview of the Therapeutic Use of Cannabis (1997) and co-editor of Women and Cannabis: Medicine, Science and Sociology (2002) and has written numerous papers and chapters on the topic. Ms. Mathre is also the President and Founding member of the American Cannabis Nurses Association. She works as an independent consultant on medical cannabis and addictions nursing; has authored several position papers on medical cannabis, testified at legislative hearings and served as an expert witness on the topic.

Publisher ND1Media Editorial Robert Herman

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Reach Us By Post Cannabis Nurses Magazine 4780 W. Ann Rd., Suite 5 #420 N. Las Vegas, NV 89031 info@cannabisnursesmagazine.com www.cannabisnursesmagazine.com

We are honored to have Nurse Heather be awarded the 2016 Educational Achievement Award with the support of Cannabis Nurses Magazine. We are leading by example and could not be more proud. Thank you to all who support our mission and cause in educating the world one nurse at a time!

"Educational Achievement Award" Heather Manus RN Cannabis Nurses Magazine

Cannabis Business Awards 2016

Table of

Contents 06

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March/April

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32

Features

06: Arizona: Medical Cannabis Programs Expand by Adding New Qualifying Conditions By: Heather Manus, RN

10: Using Medical Cannabis for Opioids Sparing and

Opioids Tapering in Chronic Pain

By: Dr. Gregory Smith

22:

COVER: A ROADMAP OF HOW TO CREATE

CHANGE IN YOUR COMMUNITY By: Anita Briscoe, MS, APRN-BC

29: New Jersey: DOH Panel to Consider Petitions

Adding Qualifying Conditions to the State’s Medicinal Marijuana Program By: Ken Wolski, RN, MPA

32: Nurses Must Advocate for Patient Access to Cannabis to Stem the Opioid Epidemic By: Mary Lynn Mathre ,RN, MSN, CARN

2017 24

22

34

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inside 09| ANA Position Statement 2016 24| New Mexico Petition Letter: To Add Opiate Dependence as a Qualifying Condition

34| Chef Herb & Cook with Herb 38 | CREATING HER-STORY! 40 | Nurse Talk: Issue Interview 43 | Top 10 Apps for Health-Care 44 | Resources: Recommended Books 45 | Job Opportunities: Perm & Travel 46 | Nursing Confrences for 2017 47 | Cannabis Education Network

AZCNA The Arizona Cannabis Nurses Association

Medical Cannabis Programs Expand by Adding New Qualifying Conditions Written By: Heather Manus, RN As Nurses, we have a duty to advocate for patients and to educate as needed when understanding or knowledge is lacking. Knowledge and understanding regarding the science and practical use of cannabinoid therapeutics within the context of healthcare is an area that is deficient within our public health and medical communities. Worldwide research related to cannabis and cannabinoid therapeutics is plentiful and growing rapidly, despite the current Schedule I status that impedes our ability for high level clinical research trials to be conducted on humans in the United States.

Meanwhile, state medical cannabis programs have swept our country, providing safe legal access to cannabis and cannabis derived products.

Medical cannabis programs vary from state to state, including who may qualify as a medical cannabis patient based on a list of each states' list of recognized medical conditions.

Information contained within patent US 6630507, Cannabinoids as antioxidants and neuroprotectants; states that “Cannabinoids have been found to have antioxidant properties, unrelated to NMDA receptor antagonism. This new found property makes cannabinoids useful in the treatment and prophylaxis of wide variety of oxidation associated diseases, such as ischemic, age-related, inflammatory and autoimmune

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diseases. The cannabinoids are found to have particular application as neuroprotectants, for example in limiting neurological damage following ischemic insults, such as stroke and trauma, or in the treatment of neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease and HIV dementia.”1 Based on this information, in addition to a multitude of research studies it may be assumed thatstate medical cannabis programs would include all “oxidation associated diseases, such as ischemic, age-related, inflammatory and autoimmune diseases” and specifically allow patients who have experienced “ischemic insults, such as stroke and trauma, or in the treatment of neurodegenerative diseases, such as Alzheimer's disease, Parkinson's disease and HIV dementia.” This assumption would be incorrect.

However, States are slowing beginning to add new conditions due to the tremendous efforts made by those within the community who understand the importance of recognizing specific diseases within the cannabinoid therapeutics context.

In Arizona for instance, Nurses are leading the way. The Arizona Cannabis Nurses Association (AZCNA) has been championing the cause for cannabis patients' rights, and has taken repeated administrative & legal action since 2013 to encourage expansion of the Arizona Medical Marijuana Act (AMMA) to include

additional medical conditionssuch as Post-Traumatic Stress Disorder (PTSD), Parkinson’s Disease (PD), Huntington’s Disease (HD), Traumatic Brain Injury (TBI), Neuropathy, Arthritis, Tourette’s Syndrome, Autism, and Diabetes.

After a fierce legal battle, in July 2014 AZCNA celebrated a precedent setting court case win which resulted in the successful recognition of PTSD as a qualifying condition under the Arizona Medical Marijuana Act. All other medical conditions submitted by AZCNA have been summarily denied by the Arizona Department of Health Services, resulting in multiple court cases which are currently in process due to the dedication of AZCNA and their legal counsel, Ken Sobel, Esq who continues to fight for the rights of patients in Arizona.

The work done by AZCNA in Arizona has created a ripple effect which resulted in 10 additional States adding PTSD as a qualifying condition for medical cannabis access. Adding new medical conditions to the cannabis program in Arizona has proven to be a very difficult challenge. Due to a harsh anti-cannabis political climate and resistance from the Arizona Department of Health to expand the program, safe legal access for seriously ill patients continues to be blocked on the basis of “not enough research.”

Although cannabis is proven to be nontoxic to humans, with no reported

overdose deaths in 5000 years of cannabis history, we as medical practitioners are driven to provide an evidence-based practice for our patients.

The American Nurses Association (ANA) recognizes the vast benefits related to medicinal usage of cannabis, as well as addressing the issues related to why cannabis research has been difficult to conduct in recent years by stating, “Marijuana was widely prescribed in the United States until 1937 when the Marihuana Tax Act of 1937 prohibited its use (Musto, 1972). By 1970, the Controlled Substances Act completely prohibited all therapeutic use of marijuana by making it a Schedule I drug (Public Law 91-513). Schedule I drugs are defined as “drugs with no currently accepted medical use and a high potential for abuse” (Drug Enforcement Agency, 2016). Because of this designation, a limited number of DEA licenses to perform clinical research using marijuana exist (Nutt, 2015). In addition, the DEA has one single source of marijuana approved for medical research (DEA, 2016). The Food and Drug Administration (FDA) supports scientific research into the use of marijuana and related cannabinoids for medical purposes, but has not approved marijuana as a safe and effective drug for any indication (FDA, 2016). While numerous scholars and organizations have called for an expansion in research, regulatory restrictions have impeded this effort.”2

Why should nurses take on the challenge of advocating for medical condition expansions with in State medical cannabis programs?

The American Nurses Association has taken the position that, “ANA actively supports patients’ rights to legally and safely use marijuana and related cannabinoids for therapeutic symptom management, as well as the nurse’s promotion of quality of life for patients using such therapy.”2

AZCNA Advocacy TIMELINE 2013 January-AZCNA Founded

July- PTSD Petition Submited October- PTSD Public Hearing

2014 January- PTSD Denied by AZDHS May- PTSD Appealed June- PTSD Appeal WIN,

Administrative Judge orders PTSD to be added to AMMA

July- PTSD Approved by AZDHS with Restrictions July- Parkinson’s disease (PD) Petition Submitted August- PTSD Restrictions Appealed December- PD Denied by AZDHS 2015 January- PD Appeal May- PD Appeal Denied

July- PTSD Restrictions Appeal Denied

July- PD, Huntington’s disease, Autism, Arthritis, TBI, Diabetes, Tourette’s syndrome, Neuropathy Petitions Submitted August- PTSD RestrictionsAppeal in AZ Superior Court DecemberPD, Huntington’s disease (HD), Autism, Arthritis, TBI, Diabetes, Tourette’s syndrome, Neuropathy Denied by AZDHS 2016 January- PD & HD Appealed January- Autism, Arthritis, TBI, Diabetes, Tourette’s syndrome, Neuropathy Petitions Submitted May- Autism, Arthritis, TBI, Diabetes, Tourette’s syndrome, Neuropathy Denied by AZDHS May- PD & HD Appeal WIN July- PD & HD Judges’ Decisions Denied by AZDHS August- PD & HD Appeal AZ Superior Court 2017 January- PD & HD Legal Brief Submitted, Trial Date Pending.

January- PTSD restriction Court of Appeals Hearing. Judgement Pending.

The Therapeutic Use of Marijuana and Related Cannabinoids Revised Position Statement of 2016 was written by ANA Center for Ethics and Human Rights, and Adopted by ANA Board of Directors which “addresses the roles and responsibilities of nurses related to the use of cannabinoids for health care.”

According to annual Gallup Poll surveys, nursing is consistently rated the most trusted profession in the US. “Americans have been asked to rate the honesty and ethics of various professions annually since 1990, and periodically since 1976. Nurses have topped the list each year since they were first included in 1999, with the exception of 2001 when firefighters were included in response to their work during and after the 9/11 attacks. Since 2005, at least 80% of Americans have said nurses have high ethics and honesty.”3 Advocating for the rights of patients is the most honest, ethical, and compassionate care we as nurses can provide. According to the American Nurses Association, “The nursing profession holds that health is a universal right, which includes access to health care and education concerning the prevention of health issues (ANA, 2015).

ANA has supported providing safe access to therapeutic marijuana and related cannabinoids for over 20 years. In 1996, ANA’s Congress on Nursing Practice supported research and education for evidence-based therapeutic uses of marijuana and related cannabinoids. In addition, the ANA House of Delegates has gone on record as supporting nurses’ advocacyfor patients using marijuana and other related cannabinoids for therapeutic use (ANA, 2003).”

References: 1. Patent US 6630507 https:// goo.gl/72Q8wX 2.

ANA Position Statement, The Therapeutic Use of Marijuana and Related Cannabinoids, Revised 2016 https://goo.gl/cIVNVt 3. Gallup Poll on Ethics https:// goo.gl/q6nE7F

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Therapeutic Use of Marijuana and Related Cannabinoids Effective Date:

2016

Status: Written by: Adopted by:

Revised Position Statement ANA Center for Ethics and Human Rights ANA Board of Directors

Purpose The purpose of this statement is to reiterate the American Nurses Association’s (ANA) support for the review and reclassification of marijuana’s status from a federal Schedule I controlled substances to facilitate urgently needed clinical research to inform patients and providers on the efficacy of marijuana and related cannabinoids. This position statement speaks only to the use of marijuana and related cannabinoids in the context of health care. It addresses the roles and responsibilities of nurses related to the use of cannabinoids for health care.

Statement of ANA Position Marijuana and its derivatives continue to be used to alleviate disease-related symptoms and side effects. The findings of anecdotal and controlled studies regarding the efficacy for patient use are mixed. Current federal regulations impede the research necessary to evaluate and determine the therapeutic use of marijuana and related cannabinoids. This position statement does not extend to the current debate on the legalization of marijuana for recreational purposes. The goal is to develop an evidence-based approach to its use in the treatment of disease and symptom management.

Recommendations “It is the shared responsibility of professional nursing organizations to speak for nurses collectively in shaping health care and to promulgate change for the improvement of health and health care” (ANA, 2015, p. 36).

Therefore, the ANA strongly supports:

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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.

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Development of prescribing standards that includes indications for use, specific dose, route, expected effect and possible side effects, as well as indications for stopping a medication.

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Establishing evidence-based standards for the use of marijuana and related cannabinoids.

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Protection from criminal or civil penalties for patients using therapeutic marijuana and related cannabinoids as permitted under state laws.

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Exemption from criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for health care practitioners who discuss treatment alternatives concerning marijuana or who prescribe, dispense or administer marijuana in accordance with professional standards and state laws.

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Background Marijuana and related cannabinoids are widely used to treat disease or alleviate symptoms, but their efficacy for specific indications is not clear (Whiting et al., 2015). Marijuana has been used for alleviating symptoms of nausea and vomiting; stimulating appetite in HIV patients; alleviating chronic pain; easing spasticity due to multiple sclerosis; decreasing symptoms of depression, anxiety, sleep disorders and psychosis; and relieving intraocular pressure from glaucoma (Whiting, 2015). Some of these indications have moderate evidence to support treatment with marijuana; however, many do not (Hill, 2015).

Marijuana was widely prescribed in the United States until 1937 when the Marihuana Tax Act of 1937 prohibited its use (Musto, 1972).

By 1970, the Controlled Substances Act completely prohibited all therapeutic use of marijuana by making it a Schedule I drug (Public Law 91-513). Schedule I drugs are defined as “drugs with no currently accepted medical use and a high potential for abuse” (Drug Enforcement Agency, 2016). Because of this designation, a limited number of DEA licenses to perform clinical research using marijuana exist (Nutt, 2015). In addition, the DEA has one single source of marijuana approved for medical research (DEA, 2016). The Food and Drug Administration (FDA) supports scientific research into the use of marijuana and related cannabinoids for medical purposes, but has not approved marijuana as a safe and effective drug for any indication (FDA, 2016). While numerous scholars and organizations have called for an expansion in research, regulatory restrictions have impeded this effort. ANA recommends additional scientific research of marijuana and its related cannabinoids in order to guide evidence-based practice for therapeutic use in patients.

Twenty-four states and the District of Columbia have legalized the use of marijuana for some medical purposes. Despite this, the United States Supreme Court voted that Congress had the legal authority to criminalize the use of home grown marijuana even in states where it is legal for therapeutic purposes (Gonzales, 2005). As a result, patients and families who gain access to or use marijuana for therapeutic purposes in a state that allows for its use are still at risk for criminal consequences. ANA actively supports patients’ rights to legally and safely use marijuana and related cannabinoids for therapeutic symptom management, as well as the nurse’s promotion of quality of life for patients using such therapy.

Previous Position Statements The nursing profession holds that health is a universal right, which includes access to health care and education concerning the prevention of health issues (ANA, 2015). ANA has supported providing safe access to therapeutic marijuana and related cannabinoids for over 20 years. In 1996, ANA’s Congress on Nursing Practice supported research and education for evidence-based therapeutic uses of marijuana and related cannabinoids. In addition, the ANA House of Delegates has gone on record as supporting nurses’ advocacy for patients using marijuana and other related cannabinoids for therapeutic use (ANA, 2003).

Supersedes American Nurses Association. (2008). Position Statement: In support of patients’ safe access to therapeutic marijuana. Silver Spring, MD: author.

American Nurses Association. (2004). Position Statement: Providing patients safe access to therapeutic marijuana/cannabis.

Washington, DC: author.

References American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: www.nursingworld.org/Code-of-Ethics.

American Nurses Association. (2003). Providing patients safe access to therapeutic marijuana/cannabis. Washington DC: Author.

Drug Enforcement Agency. (2016). Drug schedules. Retrieved from http://www.dea.gov/druginfo/ds.shtml.

Gonzales v. Raich 545 U.S. 1 (2005).

Hill, K. P. (2015). Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: a clinical review. JAMA, 313(24), 2474-2483. doi:10.1001/jama.2015.6199.

Musto, D. F. (1972). The marihuana tax act of 1937. Archives of General Psychiatry, 26(2), 101-108. doi: 10.1001/archpsyc.1972.01750200005002.

Nutt, D. (2015). Illegal drugs laws: Clearing a 50-year-old obstacle to research. PLoS Biol, 13(1), e1002047. doi:10.1371/journal.pbio.1002047.

Pub.L. 91-513, 84 Stat. 1236, enacted 1907-10-27, codified at 21 U.S.C. § 801 et. seq.

U.S. Food and Drug Administration. (2016). FDA and marijuana. Retrieved from http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421163.htm.

Whiting, P.F., Wolff, R.F., Deshpande, S., DiNisio, M., Duffy, S., Hernandez, A.V., Keurentjes, Lang, S., Misso, K., Ryder, S., Schmidlkofer, S., Westwood, M., & Kleijnen, J. (2015). Cannabinoids for medical use: A systematic review and metaanalysis. JAMA, 313, 2456-2473. doi: 10.1001/jama.2015.6358.

8515 Georgia Avenue, Suite 400 Silver Spring, MD 20910 www.nursingworld.org

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Using Medical Cannabis for Opioids Sparing and Opioids Opioids Tapering Tapering in in Chronic Chronic Pain Pain and By: Dr. Gregory Smith

The Pain and Opioids Use Problem:

Chronic pain has reached epidemic proportions in the past decade, with an estimated 80 million current chronic pain sufferers in the US. There has been concomitant exponential growth in the use of prescription opioids for chronic pain. A significant proportion of chronic pain patients are also being treated with benzodiazepines. Much of this increase has been due to more loose prescription guidelines for non-malignant pain, and aggressive pharmaceutical marketing campaigns1. Even though there is little research to support long term use of opioids for chronic non-malignant pain2.

This increased use of addictive and potentially life-threatening medications has been associated with a four-fold increase in the number of deaths from prescription opioids between 1999 and 20112,3. The most recent CDC data estimates that 44 people a day die from prescription opioid overdose. There are over 700,000 opioids-related hospitalizations annually. As many as two thirds of these deaths were in patients prescribed the opioids, who were not using drugs illicitly3.

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One third of the persons who overdosed on prescriptions opioids were also taking a benzodiazepine4. There is also a documented tendency to gradually increase dosage of opioids over time due to tolerance. Also periods of abstinence from opioids, due to access or other issues, may lead to unexpected overdose when the patient resumes the previous tolerated dose3,4.

This epidemic of opioid prescriptions flies in the face of many meta-analyses that have found little evidence that opioids are effective treatment for chronic pain. Another study found almost one million Veterans found that 71% of patients who are started on opioids and maintained on them for at least 90 days, will still be taking opioids three years later5. This suggests that medical provider prescribing practices could be a major contributor to iatrogenic opioid dependency and adverse outcomes.

Chronic pain patients are commonly denied additional prescriptions for opioids due to failed urine drug testing, most often from THC obtained illicitly.

Even though the patients were often using the cannabis for opioid sparing. The net effect is that these opioid dependent patients are suddenly without prescription opioids, and may seek out illicit means of obtaining opioids. Research has shown that over time. Due to access and cost

issues, these patients often end up using heroin off the street. This ‘street heroin’ is often cut with Fentanyl® and an even more potent elephant tranquilizer, greatly increasing the chance of fatal unintended overuse. An additional 26 people a day are dying for heroin overdoses4,6. As many as 80% of these deaths were in patients who became addicted to opioids after being prescribed opioids for an injury or surgery7.

There has been a public and political outcry to change the situation quickly and effectively. The efforts over the past few years have failed to significantly reverse the above statistics. The addition of medical cannabis , as an adjunct medication may be a significant part of the solution. Cannabis has been shown to have efficacy in opioid sparing, as an alternative analgesic, for mood elevation and to reducing opioid withdrawal and craving.

The CDC has recently released a report1 entitled “Prescribing opioids for Chronic Pain,” that recommended “In general, do not prescribe opioids as the first-line treatment for chronic pain.”

This guideline excluded palliative or end-of-life care. It also recommended, “avoid concurrent opioid and benzodiazepine use whenever possible.”

Benzodiazepines, like opioids, are respiratory depressants. They work synergistically, opioids at receptors in the medulla oblongata and benzodiazepines as CNS depressants.

The FDA has recently added a black box warning to address this9.

In addition a more recent study added a new issue to the prescribed opioid epidemic. It showed dramatic increases in emergency room visits for unintentional overdoses of opioids in young children, and intentional use of family member’s opioids in adolescents10.

Treating Chonic Pain with Medical Cannabis: Medical cannabis impacts nocioception and spasticity in the central nervous system, and inflammatory related pain through peripheral actions. Cannabis can be used topically for acute musculoskeletal injury, but in general most of the benefits of medical cannabis are for chronic pain conditions.

Unfortunately, as it is with using medical cannabis with most conditions, there has been very little high quality research due to the fact that it is a Schedule I drug.

However, that has been changing quickly in the past few years and there are some high quality studies and Randomized Clinical Trials (RCTs) to support use of cannabis for certain chronic pain conditions.

One study showed that low-dose (1.29% tetrahydrocannabinol (THC)) vaporized cannabis resulted in 30% reduction in pain in patients already being treated with conventional FDA approved medications.

The low-dose was as effective as the medium-dose (3.53% THC)11. Not all studies have been promising. A study of intractable cancer pain showed no significant pain reduction with CBD only12.

Centrally-mediated pain, includes several forms of paresthesias, burning and numbness. Also, fibromyalgia is at least partially a centrally-mediated pain condition. Some research suggests that fibromyalgia may represent a cannabinoid deficiency syndrome13.

The American Academy of Neurology reviewed the available literature and “based on the highest quality evidence” considering “safety and effectiveness” determined that CBD alone can help lessen centrally-mediated pain14.

A survey of 457 Canadian fibromyalgia patients showed that 13% of them were effectively using adjunctive cannabis to control the pain. The Canadian Fibromyalgia Treatment Guideline states that cannabis should be considered for fibromyalgia patients with sleep disturbances15.

The regions of the brain that have to do with nocioception have high levels of CB1 receptors as well as Mu-opioid receptors (MORp). Studies have shown that opioids and cannabinoids work synergistically. A study of tumor pain in mouse models showed that CB1, CB2 agonists had comparable efficacy to morphine16.

Several high quality RCTs are underway to examine the efficacy of cannabinoids with Chronic Regional Pain Syndrome, postherpetic neuralgia, spinal cord injury and MS.

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Neuropathic pain is becoming increasingly common as a sequelae of type II diabetes. Unfortunately, there are very few choices for neuropathic pain. Two RCTs of neuropathic pain in HIV patients showed that inhaled cannabis decreased pain by 30% compared to placebo17. A study of intractable neuropathic pain in patients with MS, brachial plexus injury, limb amputation and spinal cord injury found that CBD was superior to placebo, without sideeffects.

Migraines represent a combination myofascial and neuropathic pain. A review of several studies showed that cannabinoid medications can have positive therapeutic effects on pain, nausea and vomiting18.

Medical cannabis can have significant therapeutic benefit for inflammatory pain and swelling. CB2 receptors are present in large number on mast cells.

Stimulation of these receptors results in decreased release of histamine, serotonin and other proinflammatory neurotransmitters19.

Medical Cannabis as an Adjunct Medication: Medical cannabis can be used as an adjunct medication for opioid sparing. Currently NSAID, antidepressant, anticonvulsant, and topical analgesic preparations are being used in conjunction with opioids, to reduce the amount of opioid necessary for adequate pain control. Opioid sparing, implies, that a lesser dose of opioid can be used to get the same effect, through synergistic effects of non-opioid medications.

Unlike the other options for opioid sparing, medical cannabis also has positive impact on mood, improving anxiety, usually treated with benzodiazepines, that is commonly associated with chronic pain syndromes. In addition, medical

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grade cannabis, with balanced ratios of CBD to THC, has a far superior adverse effect profile compared to other medications. Also, cannabis positively impacts inflammation, and spasm which often accompany chronic pain8.

Decreasing the dose of opioids, via opioid sparing, leads to fewer accidental overdoses, and less adverse effects such as intractable constipation. A recently released analysis of the literature from the National Cannabis Industry Association (NCIA) discussed some promising observational and population-based findings supporting the use of cannabis as an adjunct to opioids and for tapering off opioids20.

The primary objective of adding cannabinoid medication to chronic opioid therapy is to reduce morbidity and mortality associated with opioids, and improve function. This should be done, while also preventing development of significant adverse effects such as euphoria, psychosis, or cannabis dependency. The initial goal of opioid sparing, is to use cannabinoids safely to decrease the frequency of use and dose of fast acting opioids for breakthrough pain. The next goal is to gradually and safely reduce the dose and frequency of both slow and fast acting opioids for the baseline pain.

The goal of the initial phase of opioid sparing is to have the opioid patient learn to appreciate the ability to obtain symptom relief without any opioid, using the adjuncts of cannabis and other non-opioid medications initially. The patient can then take part or all the usual opioid dose if necessary. Over time, studies have shown, that a significant percentage of patients will spontaneously

discontinue opioids altogether in lieu of cannabis and other nonopioid medications21.

Cannabis, can also be used to discontinue opioids for pain control.

Cannabis has innate analgesic and anxiolytic effects as well as beneficial effects on opioid craving, and on the severity of opioid withdrawal-related nausea and muscle aches.

A study of people using cannabis to taper off opioids showed that the common side-effects of chronicopioid use: constipation, depression, and nausea were significantly reduced with concomitant use of cannabis22.

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Transdermal Patches What is a Transdermal Patch?

A transdermal patch is a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream. Often, this promotes healing to an injured area of the body.

How does a Transdermal Patch work?

As the layers of skin absorb medication from transdermal patches (trans meaning through and dermal referring to the skin), the medication is absorbed via the blood vessels into the bloodstream. From there, the blood carries medication through the circulatory system and through a patient's body.

Where do you apply a Transdermal Patch?

Choose a spot on your upper body or upper arms to apply your patch. Do not apply the patch to your arms below the elbows, to your legs below the knees, or to skin folds. Apply the patch to clean, dry, hairless skin that is not irritated, scarred, burned, broken, or calloused. Choose a different area each day.

Can be worn for up to 24-48 hours.

~ All transdermal patches include an adhesive remover and alcohol swab ~ Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700785

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Therapeutic Effects of Cannabis: Cannabis has therapeutic effects on pain via the Endocannabinoid System (eCS). See Appendix I to read more abut the eCS. Cannabis works via the CB1 and CB2 receptors, and by modulating the effects of opioids at MOPr. THC is a partial agonist of both CB1 and CB2 receptors and has beneficial effects on nociceptive pain, and neuropathic pain via CB1 receptors, and inflammation, spasticity and myofascial pain via CB2 receptor agonism23.

There are over a hundred phytocannabinoids in cannabis sativa.

Only, THC and cannabidiol (CBD) have been studied extensively8. THC has been shown to have 20 times the anti-inflammatory potency of aspirin, and twice that of hydrocortisone in neuropathic pain13. However, unlike NSAIDs and aspirin, THC does not demonstrate cyclo-oxygenase (COX) inhibition24. COX-1 and COX-2 inhibition are associated with the gastrointestinal and cardiovascular adverse effects associated with NSAIDs24.

CBD, has minimal agonism on eCS receptors, but increases the amount of the naturally occurring endocannabinoid, anandamide (AEA). CBD inhibits fatty acid amidohydrolase (FAAH), which is the hydrolytic enzyme of AEA. CBD primarily impacts CB2 receptors which are present on immune system cells in the brain and body, resulting in anti-inflammatory effects.

Medical cannabis is not the only way to use the eCS to relieve pain. The terpene, beta-carophyllene, found in large quantities in many strains of cannabis sativa, as well as many other food spices, is a selective agonist of CB2, positively modulating inflammation, neuropathic pain, anxiety and spasticity16.

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Cannabis and Mu-Opioids Receptors: Mu-opioids receptors (MOPr) are also G protein-coupled receptors. They are the site of action of innate opioids and of opioid medications. Opioid medications reduce pain by binding to and stimulating mu-opioids receptors in the central nervous system, leading to a decreased perception of pain via inhibition of ascending pain pathways that start in the spinal cord.

MOPr are heavily expressed on respiratory neurons in the brainstem.

Potent mu-opioid agonists therefore, can cause respiratory depression, the most common cause of opioid overdose death. There are essentially no cannabinoid receptors in the brainstem, which is the primary reason that no overdose deaths have ever been associated with cannabis use.

Both THC and CBD are allosteric modulators of mu-opioids receptors.

This results in indirect amplification of the effects of opioids at the muopioids binding site. This effect is associated with observed synergistic effects of cannabis and opioid medications.

Cannabinoid Pharmaceuticals: Dronabinol, which goes under the proprietary name of Marinol®, is a synthetic analogue of THC. It is different from plant-derived THC and is a full agonist of cannabinoid receptors, unlike plant-derived THC which is a partial agonist. Dronabinol has been studied as a mono-molecule drug, and not as part of a whole plant extract. Whole plant extracts have been shown to have reduced adverse effects due to the antagonistic effects of CBD on THC adverse effects, and through the ‘Entourage Effect’ of CBD, minor cannabinoids, and terpenes.

Dronabinol, has been FDA approved since 1985. It was originally placed in Schedule II of the Controlled Substances Act. But, based on the clinical experience and lack of expected issues with adverse effects and only mild to moderate physical dependency syndromes, it was rescheduled to Schedule III in 1999. It has not been reviewed by the FDA for use in pain, but it has been shown to increase analgesia among patients taking opioids for chronic non-malignant pain25.

Nabiximols, which goes under the proprietary name of Sativex® is a whole plant extract in phase III trials in the US. It was approved in Canada in 2005 for central neuropathic pain and intractable spasticity in multiple sclerosis, and in Canada 2007 for intractable cancer pain.

It is made up of extracts from two strains of cannabis sativa that result in a 1:1 ratio of THC to CBD. Numerous randomized clinical trials (RCTs) have demonstrated safety and efficacy of Sativex® in central and peripheral neuropathic pain, rheumatoid arthritis and cancer pain.

Phase III trials of Sativex® showed a statistically significant 30% or better improvement in their pain score compared with placebo. There was an average of 43% improvement with Sativex® . These studies used an average of 22-32mg/day of THC and 20-30mg/day of CBD in an oromucosal spray26.

Phase III trials of Sativex® showed a 30% mean improvement in diabetic neuropathic pain, and one third of the patients achieved 50% improvement. But the placebo group also had an unexpectedly large response and the study did not reach statistical significance26.

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Similar results would be expected from extracts available at the thousands of medical cannabis dispensaries around the country. While Sativex® is not FDA approved yet, these other extracts are currently available. The fact is, Sativiex® is just another version of a 1:1 CBD to THC whole plant extract of cannabis sativa. Similar whole plant extracts of 1:1 CBD to THC, that are of high quality, laboratory tested, and contaminant free are available in dozens of states with medical cannabis laws. These extracts sell at a fraction of the cost of Sativex®. In addition, there are a variety of ratios, 2:1, 18:1 CBD to THC extracts in a various dosages available, unlike Sativex® which only comes in one formulation28. RCTs of Sativex® have shown minimal issues with drug-drug interactions or impact on cytochrome P450 enzymes, when used as an adjunct with opioid medications.

Studies have shown that cannabis dependency syndromes are a sequelae of long term, frequent use of high doses of cannabis with high THC, low CBD ratios. This is the type of cannabis most often associated with recreational use. CBD alone is not associated with euphoria, psychosis or dependency syndromes. The 1:1 CBD to THC ratio in Sativex® and microdoses of THC compared to recreational doses are probably the reason that no withdrawal symptoms or dependency syndromes have been associated with up to one year use of Sativex®. Similarly, cannabis that is higher in CBD than THC, either in extracts, or smoked or vaporized would not be expected to be associated with dependency syndromes, or the adverse effects associated with high THC to CBD ratio cannabis22.

Other Opioid Sparing Medications:

Safety of Medical Cannabis:

Acetaminophen, is one of the most commonly used over-the-counter pain medications. Unlike NSAIDs and aspirin, which are COX inhibitors, acetaminophen has no gastrointestinal adverse effects or untoward cardiorenal effects28,29. It is a common opioid sparing ingredient combined with opioids in several common prescrip-tion medications. The previous 500mg dose of acetaminophen in these combination tablets, was reduced to 325mg in 2014 to reduce the chance of hepatotoxicity from taking many tablets a day.

Medical cannabis has been used in Western medicine for almost two hundred years for a wide variety of conditions. At the turn of the 20th century there were over 2000 ‘patent’ medications containing cannabis sativa extract, and it was the second most common ingredient in prescription medications8.

Acetaminophen’s mechanism of action has been elusive in the one hundred years that it has been in use. However, over the past decade several studies have confirmed its mechanism of action as a prodrug. The metabolite, paraaminophenol is actually a CB1 selective cannabinoid. It produces analgesia through the indirect agonism of CB1 receptors in the brain. Paraaminophenol is also an inhibitor of AEA uptake, leading to increased levels of this endocannabinoid and increased cannabinoid receptor agonism30.

Para-aminophenol is also an agonist of TRPV1 receptors, also known as the capsacin receptor. Acetaminophen has analgesic effects through this pathway as well. TRPV1 is involved with providing to nociceptive sensation of heat and pain31.

Capsacin, is a common ingredient of topical analgesic preparations. It is also a TRPV1 agonist, and works by prolonged topical application leading to alleviation of pain via desensitization of TRPV1 mediated release of inflammatory molecules following noxious stimuli.

Beta carophyllene, a terpene, present in high amounts in some strains of cannabis sativa. Beta-carophyllene is a CB2 agonist, and greatly increases the synergistic Entourage Effect for chronic pain and inflammation16.

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Cannabinoid medications are in general much safer, with fewer adverse-effects, and a much broader therapeutic window than opioids or NSAIDs. In addition, with medical doses of CBD/THC balanced cannabis the occurrence of temporary psychosis, euphoria, dependency syndromes, or withdrawal are rare, self-limiting and of short duration30.

The concept of cannabis as a “gateway drug” has been debunked by the National Academies of Medicine in 199930. To the contrary, studies from Holland suggest that legal cannabis use actually decreased the likelihood of trying cocaine and amphetamines31.

A recent one year long prospective cohort study from Canada32 evaluated the safety of herbal cannabis use for chronic noncancer pain in 215 patients. The study participants were using up to very large amounts of 312mg THC a day in inhaled or edible cannabis. There were no increases in serious adverse effects.

However, there were increased rates of mild to moderate adverse effects. The authors concluded, “when used by patients with experience of cannabis use as part of a monitored treatment program over one year, appears to have a reasonable safety profile.”

Although there are no fatalities associated with overdosing on cannabis, problems with decreased co-ordination have been associated with numerous cases of “death by accident.”33

Chronic Pain and Medical Cannabis Use: Among the over 1 ½ million patients in the US who use medical cannabis legally, chronic pain is by far the most common condition for which medical cannabis is recommended. Most studies suggest that 85-94% of medical cannabis patients are using it for ‘pain’8. These figures may be blurred by the fact that “chronic pain” is a subjective condition, and easier to prove than other Qualifying Conditions in states with medical cannabis laws.

Therefore, people may be feigning a chronic pain condition, solely to bypass prohibition against the recreational use of cannabis. However, this same phenomenon occurs regularly with opioid and benzodiazepine prescriptions.

A study of Canadian pain clinics showed that 10-15% of the patients were using medical cannabis as well as other pain medications. Two large-scale populationbased studies in Australia and the UK showed that about one third of people using cannabis for medical purposes were using it for arthritis pain, often without medical provider supervision8. Eighty percent of medical cannabis users reported substituting cannabis for prescribed medications, especially among patients with pain-related conditions2.

The University of California Center for Medicinal Cannabis Research (CMCR), released a report in 201034. It reviewed the findings of a decade of randomized, doubled-blind, placebo-controlled clinical trials of inhaled cannabis. It concluded that medical cannabis should be a “first line treatment” for chronic neuropathic pain. A meta-analysis of 79 studies from 2015 found a 30 percent reduction of pain with use of cannabinoids compared to placebos.

The concluded “We now have reasonable evidence that cannabis is a promising treatment in selected pain syndromes.”

A 2016 University of Michigan study was published of 244 patients using medical cannabis as an adjunct to control chronic pain22. They found 64 percent reduction in the use of opioids. They also noted fewer side-effects from opioids and 45 percent improvement of quality of life since adding medical cannabis to their treatment. Cannabis has also been shown to decrease development of tolerance to opioids or severity of withdrawal35,36.

In 2010, a study by Dr. Donald Abrams examined the use of inhaled cannabis vapor, three times a day for five days, in 24 pain patients using either morphine or oxycodone37. The findings included a 33% reduction in pain with in the cannabis and morphine patients, and a drop in pain from 44% to 21% by day five in the cannabis and oxycodone patients.

A systemic review and meta-analysis of cannabinoids for medical use completed in 2015 arrived at the conclusion that ‘there was moderate-quality evidence to support the use of cannabinoids for the treatment of chronic neuropathic or cancer pain; using smoked THC or nabiximols’22. These findings also suggest that lower total doses of opioids can be used when the patient is using cannabis, thereby further reducing the chance of adverse effects and overdoses of opioids. “There is a lot of data suggesting if you pair high-potency cannabinoids with opioids you get an enhanced effect.”

A small study of patients using long acting opioids, showed that concomitant use of vaporized cannabis was associated with additional decreases in measured pain levels11. Another study of CBD used in combination with morphine in mice showed synergistic effects on nociceptive pain38.

A study of 24 hospitalized patients using morphine or oxycodone for chronic pain showed that three daily doses of vaporized cannabis, measurably improved pain control by 33-44%. The euphoria associated with the vaporized cannabis became less noticeable within three to five days, but the antinociceptive effects persisted36.

A survey of 542 patients took opioids and cannabis together. 39% reduced their opioid dosage and 39% stopped opioids altogether39.

Observations from States with Medical Cannabis Laws: We can learn much from the epidemiologic data that has come out of the states with medical cannabis laws.

A well conducted survey during the period 1999-2010 showed a 25% reduction in the rate of lethal opioid overdose in those states that enacted medical cannabis laws. The effect strengthened over time from 1999 to 2010, to 34% reductionby 20107.

Another study found that states with medical cannabis had 28-35% reduction in opioid addiction admissions, and 16-31% reduction in overdose deaths40.

A recently published analysis of Medicare Part D drug sales from 2010-2013 showed markedly lower prescribing of “pain killer” and “anxiety” medications in the 17 states that have medical cannabis laws. There were 1826 fewer doses of pain medications, and 562 fewer doses of anxiety medications per medical provider in those states41. An unpublished draft of a follow up paper on Medicaid drug sales showed even stronger findings.

Using Medical Cannabis in Clinical Practice: The biggest problem with getting medical professionals to add medical cannabis to the list of drugs for chronic pain, is that it that the ‘medication’ is either plant material, plant tinctures or extracts, or edibles. Most clinicians have very little experience with recommending or dosing a medication in this format. In addition, the quality, consistency, potency and presence of contaminants is highly variable with these mostly unregulated products42. The medication is obtained at a dispensary and not a qualified pharmacy and the health insurance does not pay for the medication, which averages $100-200 a month or more.

There are also the health concerns associated with smoking plant material. GW Pharmaceuticals has attempted to address all of these issues, producing a whole plant medication, that meets the stringent requirements of FDA approval. Their pharmaceuticals, Sativex® and Epidolex®, will be available in retail pharmacies, not dispensaries. However, previous experience with Sativex®, that is available in over 20 countries by prescription for over 6 years.

Research suggests that the high cost of the product has limited access43.

Cannabis sativa is a species of plant that has two medically active sub-species, cannabis sativa sativa, and cannabis sativa indica. The sativa strains historically have been associated with high levels of CBD and low levels of THC and the indica strains high levels of THC and low levels of CBD. March/April 2017 CANNABISNURSESMAGAZINE.COM

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Over the past few decades there has been significant cross-breeding and hybridization, resulting a hundreds of new strains often with names associated with the euphoric or relaxing effects.

Medical providers do not need to be aware of strains of cannabis. The important therapeutic aspects of cannabis, at this time, are the amount each of THC and CBD. For whole plant material the amount is provided as a percent, for example if cannabis flower is 12% THC and 5% CBD. This means that the 12% of dry weight of the plant material is THC oil, and 5% is CBD oil.

It also means that this cannabis has a CBD:THC ratio of 12:5 (or about 2:1).

This information is provided by the dispensary, and should be documented in a laboratory test result from an independent, state or ISO certified laboratory. Appendix II has a discussion of how to calculate doses of smoked cannabis.

For vaping fluids, extracts, tinctures, edibles and dermal applications, the label provides the number of milligrams of THC, CBD, some other cannabinoids and often terpenes, per milliliter or per serving. Many of these ingested manufactured products are made by small manufacturers and may have issues with quality, consistency, and contamination with pesticides, molds, and heavy metals. A recent study of Colorado dispensaries found 85% had inaccurate doses, 23% had more and 60% had less THC than stated on the label46. Recently enacted state laws should improve this situation. A good dispensary will have the labels confirmed by independent, high quality laboratories.

Most clinicians are not familiar with helping patients calculate the dose of their medication. Most good dispensaries will have staff members trained on how to teach the patient to calculate the correct dose.

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How to Use Medical Cannabis for Opioid Sparing: The goal of opioid sparing, is to decrease the amount of opioid being used, while maintaining the same level of pain control.

The motivation for opioid sparing includes reducing potential for life-threatening overdoses, decreasing the development of tolerance and escalation of opioid dosing and reducing serious adverse effects associated with long term use of high dose opioids.

With these goals in mind, clinicians can add medical cannabis to the treatment regimen.

The therapeutic plan includes titrating a dose of cannabis prior to each opioid dose. When a fast acting opioid is used, the patient will use fast acting smoked, vaporized cannabis, or a tincture sublingually. When a slow release opioid is used, the patient will use ingested cannabis, such as an edible, swallowed tincture or extract, as these are slow release medications.

The educated patient will have been taught to “start low, and go slow.� For a vaporized or smoked cannabis, the patient will take the recommended dose, then wait 20 minutes.

The cannabis will reach peak plasma concentrations in the blood in 9-23 minutes.

If pain control is not sufficient, the patient will then take a second dose, again waiting 20 minutes to decide to either try a third dose of cannabis, before taking the fast acting opioid.

If the patient has measurable improvement in pain levels from the cannabis alone, but not sufficient, then he may try taking half of the usual dose of the fast acting opioid medication. This is due to the expected synergistic effects of the cannabinoids at the MORp. The process is similar for ingested, or slow release cannabis medications. These are used to spare the use of slow release opioids. The patient will take the dose recommended by the medical provider. The patient will need to wait 60 minutes, because of the slow release and first-pass effect. The mean peak plasma concentration time of 60-120 minutes and therapeutic efficacy can last up to 6 hours.

The metabolite of THC, 11-OH-THC, is 40% more potent than THC, therefore, no second ingested dose is taken. If after an hour there is not sufficient pain relief, then the patient can decide to take either half the usual dose of slow release opiate, or the full dose. If there was insufficient pain control with that dose of

ingested cannabis, after 4-5 days at this dose, the patient can increase the dose by 50%. Again, evaluate this dose for 4-5 days, before considering increasing the dose. This is part of the slow titration of dosing with which most patients will quickly become comfortable.

THC is usually limited to 10mg per dose, up to 4 doses a day. More than 10mg of THC per dose is associated with getting euphoria or temporary adverse effects. In addition, use of high levels of THC can result in down-regulation of cannabinoid receptors and promote tolerance to the cannabis medication.

Once the patient is taking 10mg of THC per dose, then only the amount of CBD per dose will increase. A typical scenario is that the patient is taking 10mg each of 1:1 CBD to THC in an ingested cannabis medication, in the morning and at bedtime for chronic pain. If this is not giving sufficient pain control throughout the day, the patient can increase the frequency up to four times a day. Then increase the amount of CBD in the product, for example increase to 25mg CBD and 10mg THC per dose.

Another choice is to add a low THC/high CBD vaporizer used regularly throughout the day. CBD is very safe, and used alone has measurable impact on pain and inflammation. Adding over a 50mg (20 vaporized inhalations) of extra CBD a day via this route is not uncommon.

Once pain reduction has been established with the use of cannabis, the use of opioid pain medications can gradually be reduced, keeping in mind the potential for opioid withdrawal and the need for an established protocol for weaning.

Start at a low dose of cannabis, where the benefit for pain relief occurs, and where the euphoric or dysphoric effects of cannabis are less likely to occur. Start low and titrate up slowly. For chronic pain is 2.5mg of THC and CBD (1:1 ratio) at morning and bedtime is a recommended starting dose. If the dose is ingested via an edible, or swallowed tincture, it will take about 60 minutes to start having effects, but should have pain-relieving effects for up to six hours.

Vaporized or inhaled cannabis can be used for quick onset to treat breakthrough pain. Usually two inhalations (4-5mg) of smoked of vaporized cannabis is taken, and wait at least 20 minutes to determine if additional inhalations are appropriate.

Because of the desire to impact the nociceptive centers in the CNS, neuropathic pain and inflammatory component of the pain, both CBD and THC are recommended. In order to reduce the chance of euphoria, and other adverse effects associated with THC alone, it is recommended that a ratio of CBD:THC of 1:1 be used initially. This ratio works for most patients.

There is no comparison chart of THC/ CBD to Morphine Equivalent Dose (MED). Because of the previously discussed issues with the potency, and consistency of cannabis doses, it is important to start well below the expected therapeutic dose and gradually titrating the dose upwards.

The dose can be titrated up every 4-5 days until measurable reductions in pain are noted. Usually the dose is increased in 2.5mg increments, to 5mg, 7.5mg, then 10mg.

Cannabinoid medications have an inverse U-shaped dose-response curve.

Because of this it the initial doses may have no effect. Once a dose is reached with therapeutic effects, the dose should be titrated up more slowly until there is a maximum effect. As the dose increases past the maximum therapeutic effect, tolerance may develop due to down-regulation of “flooded� cannabinoid receptors.

Doses of THC above 10mg in 1:1 cannabis can be associated with euphoria. Higher doses can result in temporary psychosis, anxiety, dysphoria, and agitation, especially if there is only a low ratio of CBD to counteract these adverse effects of THC.

Tapering Off or Discontinuing Chronic Opioids: Patients have historically been tapered off opioid medications at a certain predetermined rate that ranges from 10% to 50% per month. The medical provider, based on training, experience and recent research should discuss the taper rate, and expected quit date, usually from 2 to 10 months in the future. The medical provider will need to re-establish the Pain Contract with the patient, with the addition of cannabis, and educate the patient on the proper use, dosing, safe storage, and awareness of adverse effects. The medical provider usually monitors the progress of the tapering with regular visits and review of a Pain diary.

Discontinuing Opioids: Totally stopping opioids is another potential goal for medical cannabis. In this scenario, the goal is to replace opioids with medical cannabis. Prior to attempting this goal, the patient should have satisfactorily gained the skills, experience and education necessary to use medical cannabis for opioid sparing purposes. After they have been able to halt escalation of opioid doses, and often reduce opioid doses, they may be interested in entirely substituting opioids and/or benzodiazepines with medical cannabis. Anecdotally, many patient who use medical cannabis for opioid sparing, may attempt to taper off opioids and benzodiazepines on their own, because of the pleasant mood elevation, relief from constipation, and reduction of several opioid adverse-effects. However, any tapering needs to be done in conjunction with the treating clinician to avoid withdrawal or other adverse sequelae.

Unlike most medications, the patient will often feel comfortable adjusting the dosing of the cannabis medication, this patient centered titration is unique to medical cannabis, but in general is a very safe and effective way to reduce dangerous opioids and benzodiazepines and obtain long term consistent pain and associated symptom relief.

Appendix I:

Endocannabinoid System: The Endocannabinoid System (eCS) has been present in all vertebrate life for the past 600 million years. Receptors for the eCS are the most common neurotransmitter receptor in the brain and the second most common in the body. The eCS is the main fat soluble neurotransmitter in the body. Unlike dopamine, GABA, acetylcholine, serotonin, which are water soluble neurotransmitters. The eCS is responsible for homeostasis of a wide variety of other system in the brain and body, in general the eCS is responsible for retrograde slowing down a system when it gets over stimulated from dozens of other neurotransmitters. The eCS works on following broad areas of bodily functioning including, nocioception centrally and peripherally, inflammation, reward behavior and spasticity. In the brain the eCS reduces anxiety through effects in the limbic and paralimbic brain areas, which are rich in endocannabinoid receptors.

The eCS has at least two receptors (CB1, and CB2), two ligands, anadamide(AEA) and 2Arachidonoylglycerol (2-AG) and two enzymes that breakdown the ligands intracellularly, FAAH and monoacylglycerol lipase (MAGL).

THC was discovered by Dr. Rafael Mecholum at the University of TelAviv in the 1964. The eCS with its associated ligands was not discovered until 1990. Significant new aspects of the eCS continue to be discovered.

The eCS produces the ligands, AEA and 2-AG on-demand in the postsynaptic membrane. This occurs in response to excess of other neurotransmitter stimuli. The ligands are produced in microseconds and released into the synaptic cleft to attach to pre-synaptic endocannabinoid receptors. This results in shutting down calcium channels, and a decrease in the release of other neurotransmitters. The ligand is then transported inside the cell via specialized proteins, and degraded

by FAAH or MAGL. So these naturally occurring ligands have very short-lived effects.

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When plant-based cannabinoids, phytocannabinoids, such as THC and CBD are released into the blood stream via inhalation, ingestion or dermal application, they are rapidly distributed throughout the body and transported across the blood-brain barrier to attach to CB1 and CB2 receptors.

The affinity and number of cannabinoid receptors varies considerably in different brain centers and organ systems. It is for this reason that small doses of cannabinoids can have therapeutic effects, without the adverse effects of euphoria, anxiety or psychosis. The correct dosing and ratio of CBD:THC are vital to maximizing therapeutic effects and minimizing adverse effects.

Phytocannabinoids work therapeutically by mimicking the effects of the naturally occurring endocannabinoids. Since they are mimicking fat soluble neurotransmitters, they work very similarly to the way gabapentin mimics GABA. In fact, there are many similarities to gabapentin, the therapeutic window is very wide and adverse effects are short-lived and non-fatal.

Unlike the naturally occurring ligands, the phytocannabinoids are not metabolized by FAAH and MAGL. In fact, part of the efficacy of the phytocannabinoids may be due to their competing with intracellular fatty acid transport proteins (FATP) so that naturally occurring ligands are metabolized more slowly and have a more longer lasting effect.

The phytocannabinoids are only partial agonists of the endocannabinoid receptors, but have a much longer halflife than the rapidly disappearing endocannabinoids.

Up and Down Regulation and Tolerance: CB1 and CB2 are GPR55 membrane receptors. The number ofcannabinoid receptors on cell membranes varies considerably in different areas of the brain. The numbers of receptors changes in response to up- and down-regulation.

The CB1 receptors are found mostly on neurons in certain brain centers and

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the CNS. But are also present in the lung, liver, skin and several other areas of the body.

The CB2 receptors are found predominantly on immune system cells in the brain and body, as well as reproductive cells and in the liver and spleen. CB2 receptors are temporarily up-regulated at sites of trauma, where they are usually not present, leading to increased sensitivity to the anti-inflammatory effects of CBD. If a receptor is overstimulated, or 'flooded' with ligands, as can occur with too much phytocannabinoid medication, this results in a downregulation of the receptors, and can lead to the development of tolerance.

Appendix II:

Calcuating the Dose of Inhaled Cannabis:

It is important that the medical provider understand the basics of dosing inhaled medical cannabis. If plant material is 18% CBD and 0.5% THC, which is the cannabis used for childhood epilepsy, then 18% of the dried plant material is CBD oil. The average amount of plant material in an average ‘joint’ has been estimated as 300-500mg. Research for the micro-dose inhaler to provide tiny doses of cannabinoids for medical use, calculated the average ‘joint’ to be 400mg of plant material in a 1 ¼ rolling paper. Since 18% of the material is CBD oil, then 18% of 400 (0.18 x 400) equals 72 milligrams of CBD. Since half of the oils are incinerated by the process of combustion, a patient smoking an entire joint would be expected to get 36 milligram of CBD. When cannabis oil or extract is vaporized, as opposed to being smoked, there is no combustion so the patient gets mostly vaporized oil.

The dose will vary considerably by the brand, and concentration of the medication. The package insert for these products should provide information on the available dose of THC and CBD in the product. As it is with edibles, the labels on these locally manufactured extracts, and tinctures can be quite inaccurate. The dispensary should also have independent laboratory analysis of the products.

In general, when it comes to dosing medical cannabis the main concern is getting approximately the correct dose of THC. All of the adverse effects, euphoria and issues with dependency are associated with THC. CBD on the contrary, is non-euphoric, is not associated with dependency and has only some mild calming (anxiolytic) effects at the doses recommended for pain management. The therapeutic window of CBD is very large up to 100’s milligrams per dose.

Appendix III:

Chronic Cannabis Users:

Patients who have already been chronically using cannabis, often for recreational purposes, will need to have their cannabinoid receptors reprogrammed prior to starting treatment.

The goal is to up-regulate the number of cannabinoid receptors in these ‘veteran’ patients, because they have been downregulated by frequent, high doses of cannabinoids. Patients with prior regular use of cannabis, should be advised to discontinue all cannabis for three days.

Then start at a low dose of 1.25mg of THC and CBD for three days. Then the patient can increase to the full recommended dose, before evaluating efficacy of the dose and medication. This period of time with less cannabinoid stimulation results in upregulation of cannabinoid receptors and improved response to cannabinoid doses.

References: 1. Morbidity and Mortality Weekly Report (MMWR), March 2016, CDC Guidelines for Prescribing Opioids for Chronic Pain – United States, 2016.

2. (2) Injury Prevention and Control: Opioids Overdose. Centers for Disease Control and Prevention. Oct 3, 2016.

3.Rudd RA, Aleshire N, Zibbell JE, et al. Increases in Drug and Opioids Overdose Deaths - United States, 2000-2014. MMWR 64(50);1378-82. 2016.

4. Chen LH, Hedegaard H, Warner M. Drug-poisoning death involving opioids analgesic: United States. 1999-2011. NCHS data brief, no 166, Hyattsville, MD: National Center for Health Statistics. 2014.

5. American Academy of Pain Medicine (AAPM) 30th Annual Meeting. Abstract 120. Presented March 7, 2014.

6. Chen LH, Hedegaard H, Warner M. Quickstat: Rates of death from drug poisoning and drug poisoning involving opioids analgesics- Units States, 1999-2013. MMWR 64(01):32. 2015.

7. Bachhuber MA, Saloner B, Cunningham CO, et al. Medical cannabis laws and opioids analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med 2014 Oct;174(10) :1668-1673 8. FDA Drug Safety Communication: FDA warms about serious risks and death when combining opioids pain or cough medicines with benzodiazepines; requires its strongest warning. http://www.fda.gov/Drugs/DrugSafety/ucm518473.htm 9. Tadros A, Layman SM, Davis SM, et al. Emergency Department Visits by Pediatric Patients for poisoning by prescription opioids. Am J Drug Alcohol-Abuse.

2016 Sep;42(5):550-555.

10. Wilsey B, et al. Low Dose Vaporized Cannabis Significantly Improves Neuropathic Pain. J. Pain, 2013 Feb 14(2): 136-148 11. Johnson R, et al. Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patient with intractable cancer-related pain.

12. Russo, E.B. (2008, February). Cannabinoids in the management of difficult to treat pain. Therapeutics and Clinical Risk Management, 4(1), 245-259.

13. www.aan.com/Guidelines/home/GetGuidelineContent/650 14. Ste.-Marie PA, et al. Herbal cannabis use in patients labels as fibromyalgia is associated with negative psychosocial parameters. Arthritis Care Res 2012 June 21.

15. Klauke AL, Racz I, Pradier B, et al. The cannabinoid CB2 receptor-selective phytocannabinoid beta-caryophyllene exerts analgesic effects in mouse models of inflammatory and neuropathic pain. EurNeuropsychopharmacol. 2014 Apr;24(4):608-20 16. Abrams DI, et al. Cannabis in painful HIV-associated sensory neuropathy – A randominzed placebo-controlled trial. Neurology 2007 Feb;68(7):515-521 17. Baron, E.P. (2015, June). Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache: What a Long Strange Trip It’s Been. Headache, 55(6), 885-916.

18. Stott CG, Guy GW, Wright S, et al. The effects of cannabis extracts Tetranabinex and Nabidolex on human cyclo-oxygenase (COX) activity. International Cannabinoid Research Society. 2005 Jun Clearwater, FL.

22. Ruhaak LR, et al. Evaluation of the cyclooxygenase inhibiting effects of six major cannabinoids isolated form Cannabis sativa. Biol Pharm Bull.

2011;34(5):774-8.

23. Narang S, Gibson D, Wasan AD, et al. Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioids therapy. J Pain 2008 Mar;9(3):254-264 24. Positive results from clinical study of Sativex in cancer pain published in peer review journal, Nov 2009.

25.Results of Sativex Phase III Neuropathic Pain Trials Demonstrate Benefits for HIgh Need Treatment-Resistant Patients, Jan 2007.

26.Whiting PF, et al. Cannabinoid for Medical Use, A Systematic Review and Meta-analysis.JAMA.2015:313(24):2456-2473.

27. Deer TR, Leong S, Gordin V. Treatment of Chronic Pain by Medical Approaches: the American Academy of Pain Medicine, textbook on patient management. 2015 p. 189-190.

29. Schultz S, DeSilva M, Gu TT, et ta. Effects of the Analgesic Acetaminophen (Paracetamol) and its para-Aminophenol Metabolite on Viability of MouseCultured Cortical Neurons. Basic and Clin Pharm and Toxicology;110:141-144 30. Bertolini A, Ferrari A, Ottani A, et al. Paracetamol: new vistas of an old drug.

2006 Fall-Winter;12(3-4):250-75 31. Joy J. Marijuana and Medicine: Assessing the Science Base. The National Academies Press 1999.

32. MacCoun RJ. What can we learn from the Dutch Cannabis Coffee shop experience? Addiction 106(11) 1899-1910 (2011) 33. Ware MA, Wang T, Shapiro S, et al. Cannabis for the Management of Pain: Assessment of the Safety Study (COMPASS), JH Pain 2015 Dec;16(12):1233-42 34. Prevalence of Marijuana Involvement in Fatal Crashes: Washington, 2010-2014. American Automobile Association report May 2016.

35. Grant I, et al. Report to the legislature of the state of California presenting findings pursuant to SB847 which created the CMCR and provided state funding.

2010.

36. Boehnke KF, Litinas E, Clauw DJ. Medical Cannabis Use is Associated with Decreased Opioid Medication Use in a Retrospective Cross-Sectional Survey of Patient with Chronic Pain. J Pain. 2016 Jun;17(6):739-744 37. Lucas P. Cannabis as an adjunct to or substitute for opioids in the treatment of chronic pain. J Psychoactive Drugs. 2012 Apr-Jun;44(2):125-33 38. Abrams D, et al. Cannabinoid-Opioids Interaction in Chronic Pain. Clinical Pharmacology and Therapeutics 90(6) 844-851 39. Neelakantan H, Tallarida RJ, Reichenbach ZW, Tuma RF, Ward SJ, Walker EA. Distinct interactions of cannabidiol and morphine in three nociceptive behavioral models in mice. BehavPharmacol. 2014 Dec 5.

40. The Cannabis and Opioids Survey. Healer.com Oct 4, 245.

19. Cannabis: A Promising Option for the Opioids Crisis. NCIA, October 2016.

41. Brittany B, et al. Opioid substitution and antagonist therapy trials exclude the common addiction patient: a systemic review and analysis of eligibility criteria.

Trial. 2015;16:475

20. Kay L, Holtzman S. Substituting marijuana for prescription drugs, alcohol and other substances among medical marijuana patients: The impact of contextual factors.

2015 Drug and Alcohol Review

42. Bradford and Bradford, Health Affairs Jul 2016.

21. Haroutouian S, et al. The Effect of Medicinal Cannabis on Pain and Quality-ofLife Outcomes in Chronic Pain: A Prospective Open-Label Study. Clin J Pain. 2016 Dec;32(12):1036-1

43. Ryan Vandrey, PhD, et al Cannabinoid Dose and Label Accuracy in Edible Medical Cannabis Products. JAMA. 2015;313(24):2491-2493 44. "Sativex rejected by healthcare provider". Lincolnshire. 20 June 2011.

Retrieved 20 June 2011.

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Bio: Anita Willard Briscoe, MS, APRN-BC

A ROADMAP OF HOW TO CREATE CHANGE IN YOUR COMMUNITY

Anita Willard Briscoe, is from New Mexico, and has been a Nurse for 40 By: Anita Willard Briscoe, MS, APRN-BC years. She has been a psychiatric "Update on Petiton Letter on Adding Opiate Dependence as a nurse for 24 years, and a psychiatric Qualifying Condition for Medical Cannabis" nurse practitioner for 12 years. She has her BSN, her Masters of Science As of today, February 22, 2017, the petition letter has not yet been signed by our Secretary in Community and School Health of Health. There are currently 3 bills in New Mexico’s ongoing legislature that address the Education, and her Masters of legalization of cannabis, increasing plant count, increasing medicine limits per patients, legalizing hemp, and regulating and taxing cannabis.

Science in Psychiatric Nursing from University of New Mexico. She The Secretary may be waiting to see what the legislature, which concludes the end of March, currently has her own private does with these cannabis bills, and whether they pass. Our Governor is very unfriendly practice in Albuquerque where she toward cannabis and has vowed publicly to veto any bills presented to her. However, to her refers her patients to the New Mexico credit, our cannabis program has grown to over 36,000 patients under her leadership.

Department of health Medical A ROADMAP OF HOW TO CREATE CHANGE IN YOUR COMMUNITY Cannabis Program, and is active in getting Opiate Dependence approved How can nurses create a sea change in the way cannabis is used as medicine? Here’s how I as a qualifying condition for medical did it: I saw that there was a great need out there among my cannabis patients who were certified for cannabis under another condition: They needed help quitting or cutting down cannabis. on their opiate use. Often, these patients were heroin addicts, or were pain patients, using heavy doses of opiates and wanted to get off.

You must have your research in hand before you want to effect any change. Even though we are in an anti-science climate, public officials respect the work of robust research, with which no one can argue.

What you as a Nurse can do in your state.

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I started doing online research. PubMed and The American Cannabis Nurses Association are mostly where I started, and now Cannabis Nurses Magazine. They have a compendium of articles on robust clinical research that is being done around the world on 1.) cannabis and pain; 2.) cannabis and opiate use, as well as 3) cannabis and symptoms of opiate withdrawal and maintenance of sobriety. Evaluating the bibliography of each article is what helped me compile a 21-page bibliography for my research. I would choose relevant articles from that bibliography, choose relevant articles from the bibliographies of the subsequent articles, and so on. When done online, nurses can just click on the link in each bibliography, and it will take you right to the articles. I then compiled the abstracts of each relevant article and came up with my bibliography. I also placed a summary comment after each citation.

If you as a nurse want to change something in your neighborhood, your hometown, your state, look carefully at the problem, gather data, and focus narrowly on what it is you want to change. I did mine on Opiate Dependence; I could have done “substance abuse” or “opiates and alcohol," but these were too broad and cumbersome.

Once you’ve defined the problem that could be successfully addressed with the use of cannabis, find out who is able to change the laws, and approach them with your idea. Have your research ready, printed up, and documented perfectly, no misspellings, APA style.

Have it available electronically.

Approach the lawmakers professionally, and follow to the letter the rules for presenting your petition. Convince your officials see how severe the community’s problem is with recent, solid data. (New Mexico has one of the highest heroin overdose deaths in the country – was my example.)

Be persistent, and don’t take no for an answer. Many state officials are either hostile to, or are uneducated about cannabis. Try to find one that is sympathetic. Present to them the advantages of using cannabis for your chosen problem, especially the financial advantages. For example, how much is it costing your state to treat overdoses?

How much is it costing to imprison cannabis users? How can legalizing cannabis provide financial incentive for your state (via taxes and job growth) and how can problems be solved. Look to Colorado for their success stories, as well the extensive research they have done such as addressing the common fear that their youth will start abusing cannabis (proven to be untrue.)

The Misdiagonosis of Cannabis Dependency Under the DSM-5 Diagnosis Cannabis use Disorder.

According to High Times, March 8, 2016, these 11 “symptoms” are criteria for diagnosing this disorder, along with my comments (in italics), which are professional opinions. This evaluation only pertains to cannabis patients.

1. Taking the substance in larger amounts or for longer than the you meant to. This would normally happen in patients with severe conditions that need high concentrations of Cannabinoids such as THC/CBD. It is normal to build tolerance, and tolerance can be addressed by changing strains, or taking a ‘tolerance break.’

2. Wanting to cut down or stop using the substance but not managing to. This is a sign of addiction. Cannabis has been demonstrated to be much less addictive than other drugs.

3. Spending a lot of time getting, using or recovering from use of the substance. See #2.

Medical cannabis patients (hopefully) are fortunately not put in this position.

4. Cravings and urges to use the substance. Again, this is a sign of addiction. If a “craving” exists among cannabis patients, it could mean their symptoms have returned and need to be treated with medicine. People use cannabis to self-medicate their symptoms.

5. Not managing to do what you should at work, home or school, because of substance use.

This can indeed occur; cannabis can cause impairment.

6. Continuing to use, even when it causes problems in relationships. Sometimes the patients’ friends/family/co-workers need more education on why cannabis is working for the patient.

7. Giving up important social, occupational or recreational activities because of substance use. I would argue that in the case of cannabis patients, just the opposite occurs: the patients are once again able to perform life activities because they feel so much better.

8. Using substances again and again, even when it puts you in danger. Research has demonstrated that cannabis is much less dangerous than alcohol, heroin, cocaine, etc.

9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance. See #8. Research has shown that patients that are truly in need of cannabis improve physically and psychologically (PTSD is a good example).

10. Needing more of the substance to get the effect you want (tolerance)This can indeed happen with cannabis. See item # 1.

11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.” Withdrawal symptoms” in cannabis patients simply means that their original symptoms have returned for which the cannabis treated (ex: nightmares in PTSD). Because these symptoms return, of course the patient is going to “crave” their medicine. This is different than craving, for example, heroin, in which there are “cues to use,” such as seeing certain people, being in a certain neighborhood, or the classic withdrawal symptoms we see among heroin addicts and alcohol addicts that require immediate medical attention.

For patients who are legally using medical cannabis in the states which allow them, the term “dependency” is an inaccuracy. If you were diabetic, are you not “dependent, but not addicted” to insulin? If you have a thyroid deficiency, are you not “dependent, but not addicted” to thyroid supplement? You see my point? These criteria were set in place in order to “treat” cannabis users, while ignoring that there are millions of people who successfully use cannabis as medicine.

The National Institutes of Health (NIH) uses these criteria to “research” the “problem” of cannabis use in our country. The job of the NIH is to prove how “harmful” cannabis is.

Fortunately, an abundance of research is now available to debunk a lot of this. New, exciting research is coming out every day from all over the globe that is proving how wonderful a medicine cannabis really is. Tap into that research. Make a difference in your community!

And now for the letter to the Department of Health we as Nurses can model from...

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PETITION TO THE NM MEDICAL ADVISORY BOARD TO THE NEW MEXICO MEDICAL CANNABIS PROGRAM TO ADD OPIATE DEPENDENCE AS A QUALIFYING CONDITION Anita Briscoe, MS, APRN-BC Madame/Chair, Members of the Medical Cannabis Program Medical Advisory Committee, My name is, Anita Willard Briscoe, and I am a native New Mexican from Espanola, living in Albuquerque. I have been a nurse for 40 years, a psychiatric nurse practitioner for 12 years. I have been referring patients to the cannabis program for 7 years.

Over these years, I have observed that about 25% of my patients have stated independently that they were able to kick opiates with cannabis.

They state it calms down their cravings, relaxes their craving anxiety and is helping them to stayoff opiates. if they are in pain, cannabis is helping relieve their pain, often to the point that they don’t need opiates any more. I beganresearchingthe medical literature more deeply to determine what it is about cannabis that’s helping. What research is discovering is that THC and CBD occupy the Mu Opioid Receptors, the same places that opioids work.

I also started counting, and asking my three cannabis-referring colleagues if they’re observing the same thing, and they too are seeing that their patients have been able to kick opiates with cannabis. Together, we have approximately 400 patients who have been successful quitting opiates, using cannabis. I am here today to petition you to add opioid dependence to the list of qualifying conditions for medical cannabis. I have included four separate bodies of research, cannabis withdrawal, detox and maintenance, safety, and harm reduction, the economics of how cannabis has reduced prescription costs, and cannabis and pain relief.

I have attached the research I conducted. Each citation has a brief quote from each abstract of the studies that have been conducted both in the United States, and internationally. Twenty-one pages of articles from prestigious peer-reviewed medical journals and popular media which include: • • • • • • • • • • • • • • • •

Seven articles from Journal of the American Medical Association American Journal of Public Health Harm Reduction Journal Journal of Drug and Alcohol Dependence Journal of Pain Journal of Clinical Psychopharmacology Neuropsychopharmacology Clinical Trials.gov Addiction Biology American Journal of Addiction NIH/NIDA Scientific American TIME Magazine National Bureau of Economic Research National Institute of Drug Abuse (NIDA) Health Affairs

I have also included letters of support from Steve Jenison MD, former Chair, Medical Advisory Committee, Bruce Trigg MD, International Public Health Consultant, and medication assisted treatment provider for the ECHO Program, and Clinica De Salud, Rep. Debbie Armstrong, and Sen. Jerry Ortiz y Pino. Also included is a letter written by Sen Elizabeth Warren to the CDC, directing them to begin studying the use of cannabis for the treatment of opiate dependence.

The cover page to the bibliography is a graphic reminder of how very serious and debilitating this disease is to our State, as well as how our opiate overdose and abuse problem has been increasing over the last 13 years. Indeed, since the imprisonment of El Chapo this year, the Mexican drug cartels have dramatically lowered the price of heroin and are adding the even more deadly Fentanyl to it, or are selling pure Fentanyl. We are seeing skyrocketing overdose deaths as a result.

I have focused some of my research on pain, and even though pain is already an approved condition, expanding the program to include opiate dependence is the next smart, logical step. After all, pain is usually the reason patients start getting addicted to opiates. You probably have heard the story: They start out with some pain pills for a condition such as a sports injury, and they get hooked. They then probably get cut off by their prescriber, and have to get pills off the street, which are very expensive. It is easier and cheaper to get heroin.

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I am writing this petition from my heart: I love my patients and feel very protective of them. The fact that people cannot get cannabis for their opiate addiction is a travesty. Just imagine if they had access to cannabis and were able to kick their habit, how our state would change for the better. Crime would go down, health care costs would diminish, overdose deaths would fall, and it would help our economy to flourish.

(Imprisonment for cannabis use cost the state $33 million last year.) Without the familial crisis of opiate dependence, New Mexico’s children would also be safer, families would be more stable.

As I mentioned, I’m from Espanola, the town with the dubious title “The Heroin Capital.” I’ve seen firsthand how heroin has destroyed, decayed and desiccated my beloved home town. The patients that come to see me now that are from Northern New Mexico describe a very dangerous environment in their communities with heroin. Indeed, when I was helping a physician prescribe Suboxone to my patient from Espanola, he was murdered for his Suboxone.

Patients are very motivated to get off of heroin, but getting into medication assisted treatment is very difficult. One of my patients from Clovis has to drive to Albuquerque every week to get her Suboxone. There is a shortage of medication assisted treatment providers. I wish to stress that I am aware that medication assisted treatment (Methadone and Suboxone) is the standard of care, and I am not looking to replace it with cannabis. But the research shows that cannabis works well as a complimentary treatment. Having access to cannabis would be a great help to our patients. Also, referring for cannabis is a harm reduction intervention that can help to link people with medication assisted treatment, harm reduction (syringe exchange and naloxone especially), mental health care services and medical care (such as treatment for hepatitis C).

This move would also be a rich opportunity to begin doing research in New Mexico, particularly prospective studies on opiate use, overdose and death reduction. You may ask, why add Opiate Dependence as a qualifying condition? Here are some answers.

1.

The patients are using cannabis to treat their dependence anyway.

2.

It has been proven by medical research to work.

3.

Arresting and imprisoning them for using cannabis to stop using opiates is expensive for NM.

4.

Medication assisted treatment is difficult to get into, sometimes with very long waiting periods to get into the program, as well as having to drive long distances.

5.

Finally, we owe this to our patients. A treatment modality that is within close reach is unattainable because it’s illegal.

Research views medical cannabis as legitimate harm reduction. Using this model, cannabis is much less dangerous to the patient and his/her community than the heroin and Fentanyl that is now on the streets and is often more readily accessible.

Our state’s cannabis program has often been a model that other states are following as they legalize medical cannabis. We are a leader in this effort! Let’s continue to lead and be innovative, and use solutions that work.

You may be aware that Maine attempted to add opiate dependence to their list of qualifying conditions this summer, and failed, due to “lack of evidence”. I am here to tell you that the bibliography I have developed shows beyond a shadow of a doubt that there is an abundance of robust research on the topic. New Mexico can and should lead the way in taking advantage of this opportunity to give opiate dependent patients access to medical marijuana.

I encourage the Medical Advisory Board to review this petition for inclusion of Opiate Dependence to the current list of qualifying conditions for the Medical Cannabis Program. The risks would surely be outweighed by the possibility improving lives or even saving just one life. We have an opportunity to explore and lead the nation in researching what could be a compassionate, and revolutionary treatment for addiction.

In concluding, I ask that you as the Medical Advisory Board consider adding Opiate Dependence as a qualifying condition. I know there are forces out there such as the big pharma, the alcohol lobby, and the private prison lobby, as well as other strong anti-cannabis forces in this state that want to hold back progress for treatment. My colleagues, myself, and all our patients ask that you DO NOT buckle under these forces and do the right thing by allowing opiate dependence to be on the list of qualifying conditions for use of medical cannabis.

Thank you very much,

Anita Briscoe, MS, APRN-BC March/April 2017 CANNABISNURSESMAGAZINE.COM

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BIBLIOGRAPHY Study: Long term cannabis use mitigates pain, reduces opioid use Martinelli, A NORML http://thejointblog.com

Cannabidiol for the treatment of cannabis withdrawal syndrome: a case report Crippa, JA et al J Clin Pharm Ther, Apr 2013

Amygdala activity contributes to the dissociative effect of cannabis on pain perception Lee MC, Ploner M, Wiech K, Bingel U, Wanigasekera V, Brooks J, Menon DK, Tracey I. Pain. 2013 Jan;154(1):124-34. doi: 10.1016/j.pain.2012.09.017. PMID: 23273106 [PubMed - indexed for MEDLINE]

Adolescent exposure to chronic delta 9 THC blocks opiate dependence in maternally deprived rats Morel, L et al Neuropsychopharmacology, 2009

America’s Opiate Crisis: How Medical Cannabis Can Help

By Dr. Dustin Sulak on July 25, 2016 Dr. Dustin Sulak on a neglected treatment for opioid addiction:

New study finds cannabis reduces the symptoms of opiate withdrawal http://thejointblog.com July, 2013

medical cannabis

https://www.projectcbd.org/article/americas-opiate-crisis-how-medicalcannabis-can-help Medical Cannabis Use Is Associated with Decreased Opiate Medication Use in a Retrospective Cross-sectional Survey of Patients with Chronic Pain Boehnke, KF J Pain, March 2016 http:///www.jpain.org/article/ Acute and short-term effects of CBD on cue-induced craving in drugabstinent heroin-dependent humans Hurd, Y et al https://clinicaltrials.govAugust, 2016 Endocannabinoid signaling system and brain reward: emphasis on dopamine Gardner, EL Pharmacol Biochem Behav, June, 2005 Anxiolyitc effect of Cannabidiol derivatives in the elevated plus-maze Guimaraes,FS, Mechoulam, R et al Gen Pharmacol, Jan, 1994 Results of this study confirm previous findings with CBD and indicate that its derivative HU-219 may possess a similar anxiolytic-like profile.

Cannabidiol is an allosteric modulator at mu- and delta-opioid receptors Naunyn Schmiedebergs Arch Pharmacol, Feb, 2006 Kathmann M, et al

Impact of cannabis use during stabilization on methadone maintenance treatment Scavone, JL et al Am J Addict, Jul 2013

Cannabidiol as an intervention for addictive behaviors: a systematic review of the evidence Prud’homme, M et al Subst Abuse May, 2015 Science recognizes cannabis reduces withdrawal symptoms, but state laws still don’t http://theweedblog June, 2012 Opioid addiction being treated with medical marijuana in Massachusetts http://www.drugfree.org/news-service Jul, 2015 Weed can alleviate withdrawal symptoms with opiate addicts http://www.thefix.com Sep, 2014 Top three benefits of cannabis for opiate dependence https://sensiseeds.com Jul, 2015 Advocates push to let patients use marijuana to treat opiate addiction The Portland Press Herald Apr, 2016 Early phase in the development of Cannabidiol as a treatment for addiction: opioid relapse takes initial center stage Hurd, Y Neurotherapeutics Oct, 2015

Cannabidiol inhibits the reward-facilitating effect of morphine: involvement of 5-HT1A receptors in the dorsal raphe nucleus Katsidone, V, et al Addict Biol, March 2013

Is weed the secret to beating opiate addiction?

Mitchell, T et al The Daily Beast Sep, 2014 http://www.thedailybeast.com/articles/2014

Differential effect of cannabinol and Cannabidiol on THC-induced responses during abstinence in morphine-dependent rats Hine, B et al Res ComunChemPatholPharmacol, 1975

The Substance Abuse and Mental Health Services Administration (SAMSHA) describes the side effects of marijuana as sleepiness, trouble concentrating, and decreased social inhibitions. These seem mild in comparison to the harsh side effects of replacement medications.

Effect of some cannabinoids on naloxone-precipitated abstinence in morphine-dependent mice Bhargava, HN Psychopharmacology (Berl) Sep, 1976 Cannabidiol, a nonpsychotropic component of cannabis, inhibits cueinduced heroin seeking and normalizes discrete mesolimbic neuronal disturbances Ren, Y et al J Neurosci, Nov, 2009

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ECONOMICS Medical marijuana laws reduce prescription medication use in Medicare Part D Bradford, A et al Health Affairs, Jul, 2016 The use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented.

BIBLIOGRAPHY SAFETY AND HARM REDUCTION A safer alternative: Cannabis substitution as harm reduction Lau N, Sales P, Averill S, Murphy F, Sato SO, Murphy S. Drug Alcohol Rev. 2015 Nov;34(6):654-9. doi: 10.1111/dar.12275. Epub 2015 Apr 28. PMID: 25919477 [PubMed - indexed for MEDLINE] Is cannabis use associated with less opioid use among people who inject drugs?

Kral AH, Wenger L, Novak SP, Chu D, Corsi KF, Coffa D, Shapiro B, Bluthenthal RN. Drug Alcohol Depend. 2015 Aug 1;153:236-41. doi: 10.1016/j.drugalcdep.2015.05.014. Epub 2015 May 22.

PMID: 26051162 [PubMed - indexed for MEDLINE] Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010 Bachhuber MA, Saloner B, Cunningham CO, Barry CL. JAMA Intern Med. 2014 Oct;174(10):1668-73. doi: 10.1001/ jamainternmed.2014.4005. Erratum in: JAMA Intern Med. 2014 Nov;174(11):1875. PMID: 25154332 [PubMed - indexed for MEDLINE Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010 Bachhuber MA, Saloner B, Cunningham CO, Barry CL. JAMA Intern Med. 2014 Oct;174(10):1668-73. doi: 10.1001/ jamainternmed.2014.4005.Nov;174(11):1875. PMID: 25154332 [PubMed - indexed for MEDLINE] Use of prescription pain medications among medical cannabis patients: comparisons of pain levels, functioning, and patterns of alcohol and other drug use Perron BE, Bohnert K, Perone AK, Bonn-Miller MO, Ilgen M. J Stud Alcohol Drugs. 2015 May;76(3):406-13. PMID: 25978826 [PubMed - indexed for MEDLINE]

Cannabis as a substitute for alcohol and other drugs: A dispensary-based survey of substitution effect in Canadian medical cannabis patients Lucas, P et al Addiction Res Theory, 2013 Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: The impact of contextual factors Lucas, P et al Drug and Alcohol Review, May, 2016 Confirming big pharma fears, study suggests medical marijuana laws decrease opioid use McCauley, L Study: Medical cannabis access associated with reduced opioid abuse http://norml.org/news/2015/07/16 Legal marijuana linked to fewer opioid prescriptions Sifferlin, A Health Medicine, Jul, 2016 Could medical cannabis break the painkiller epidemic?

Hsu, J, Scientific American, Sep, 2016 Opioid addiction being treated with medical marijuana in Massachusetts Join Together Staff Partnership for Drug-Free Kids, Aug, 2016 Study: Cannabis improves outcomes in opioid-dependent subjects undergoing treatment Armentano, P http://thejointblog.com/ Dec, 2015 The great health experiment Barcott, B et al TIME MAGAZINE, Aug, 2016

Use of a synthetic cannabinoid in a correctional population for posttraumatic stress disorder-related insomnia and nightmares, chronic pain, harm reduction, and other indications: a retrospective evaluation Cameron C, Watson D, Robinson J. J ClinPsychopharmacol. 2014 Oct;34(5):559-64. doi: 10.1097/ JCP.0000000000000180. PMID: 24987795 [PubMed - indexed for MEDLINE]

State medical marijuana laws and the prevalence of opioids detected among fatally injured drivers Kim, J et al American Journal of Public Health, Sep, 2016

Medical Cannabis Use Is Associated with Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients with Chronic Pain Boehnke KF, Litinas E, Clauw DJ. J Pain. 2016 Jun;17(6):739-44. doi: 10.1016/j.jpain.2016.03.002. Epub 2016 Mar 19. PMID: 27001005 [PubMed - in process]

Lower opioid overdose death rates associated with state medical marijuana laws JAMA, Aug, 2014

Prescribing medical cannabis in Canada: Are we being too cautious?

Lake S, Kerr T, Montaner J. Can J Public Health. 2015 Apr 30;106(5):e328-30. doi: 10.17269/cjph.106.4926. PMID: 26451996 [PubMed - indexed for MEDLINE] Cannabis as a substitute for alcohol and other drugs Reiman, AHarm Reduction Journal Dec, 2009

Do medical marijuana laws reduce addictions and deaths related to pain killers National Bureau of Economic Research, Jul, 2015 Powell, D et al

How cannabis can be used for safe and effective opioid drug withdrawal Fassa, P Health Impact News, Aug 2016 Could opiates actually becausing chronic pain? [Italics mine] Granowicz, J https://www.marijuanatimes.org Jun, 2016 Study links medical marijuana dispensaries to reduced mortality from opioid overdose Sarlin, E et al Is cannabis better for chronic pain than opioids? https://www.leafly.com/news/health/cannabis-for-chronic-pain-vs-opioids

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New Jersey Department of Health Panel to Consider Petitions Adding Qualifying Conditions to the State’s Medicinal Marijuana Program By: Ken Wolski, RN, MPA

Multiple Sclerosis

Seizure disorder, including epilepsy

Terminal Cancer

Post-Traumatic Stress Disorder (PTSD)

P ut t i n g t he p i eces t oge t h e r t o imp ro v e y o ur h eal th The New Jersey Department of Health (DOH) accepted 45 petitions from the general public to add qualifying conditions to the state’s Medicinal Marijuana Program (MMP) in the month of August 2016. Most of these petitions were for conditions that are characterized by chronic pain, the most common reason medical marijuana is used in the United States.

Members of the Coalition for Medical Marijuana - New Jersey (CMMNJ), a non-profit educational organization, submitted the following petitions: Neuropathic Pain, Migraine Headaches, Osteoarthritis, Anxiety, Autism, and Opioid Use Disorder.

The DOH appointed a panel of eight healthcare professionals to evaluate the petitions. The panel, consisting of five physicians, two pharmacists, and one registered nurse, is expected to conduct a public hearing on the petitions in early 2017. This panel will make recommendations to the Commissioner of the DOH who will have the final say on adding conditions that qualify for marijuana therapy in the state.

The actual petitions under consideration, with some information redacted and which are only identified by numbers on the DOH website, can be found at: http:// www.nj.gov/health/medicalmarijuana/review-panel/ petitions2016.shtml A complete list of the conditions under consideration, with the identifying DOH numbers, can be found on the CMMNJ website at: http://cmmnj.blogspot.com/2017/01/petitionsto-nj-doh-panel.html CMMNJ was instrumental in getting a medical marijuana bill introduced into the state legislature in January 2005. In January 2010, New Jersey became the 14th state to pass a medical marijuana law when the Compassionate Use

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Medical Marijuana Act (CUMMA) was signed by Governor Jon Corzine. Governor Chris Christie, who took office shortly after the law was signed, complained that he would not have signed this bill into law.

Marijuana advocates and state legislators have said that Governor Christie delayed and obstructed the full implementation of the CUMMA. For example, the CUMMA empowered the DOH to add qualifying conditions at any time, but this is the first action taken by the DOH to do so, seven years later.

Currently in New Jersey, only five conditions allow unqualified access to marijuana therapy: amyotrophic lateral sclerosis; multiple sclerosis; muscular dystrophy; terminal cancer; inflammatory bowel disease; and any terminal illness. Four conditions qualify for marijuana if conventional treatment has failed: seizure disorders; intractable skeletal muscular spasticity; glaucoma; and post traumatic stress disorder (PTSD). Patients with HIV/AIDS and cancer may qualify if the condition or its treatment causes chronic pain, nausea or vomiting, or the wasting syndrome.

The original version of the CUMMA, passed by the New Jersey Senate in 2009, included Chronic Pain (from any cause) as a qualifying condition for marijuana therapy. However, when the bill later went to the New Jersey Assembly, Chronic Pain was removed as a qualifying condition except in the cases of cancer or HIV/AIDS. Sources at the statehouse said that this was a political expedient to move the bill along. The decision was not based on scientific or medical research.

In fact, there is no valid scientific or medical reason to limit marijuana therapy for pain management to only two diseases -cancer and HIV/AIDS, as is currently the case in the state’s MMP. Marijuana is effective pain management for any disease, injury or medical condition that causes chronic pain. Marijuana therapy is significantly safer than narcotics. There is a 25 percent reduction in opiate overdose deaths in states that have robust medical marijuana programs.

In addition, Waltz’s petition documents the suffering caused by the three FDA-approved drugs used to treat Opioid Use Disorder— methadone, naltrexone, and buprenorphine (suboxone). These drugs can cause serious side effects, drug interactions, and even death.

PTSD was added as a qualifying condition by an act of the legislature that was signed by the Governor in September 2016.

CMMNJ waged a multi-year effort to add this condition because 22 U.S. Veterans were committing suicide every day, largely because PTSD is so poorly managed by traditional pharmaceuticals. CMMNJ submitted a formal Request for Rulemaking through the DOH regulatory process in 2014 to add PTSD as a qualifying condition, but the DOH rejected this request. CMMNJ continued its educational efforts about marijuana therapy for PTSD with New Jersey Legislators and a bill was introduced in September 2014. CMMNJ identified Veterans who were willing to testify to legislative committees about marijuana’s usefulness in managing the symptoms of PTSD. Two years later, the bill became law. PTSD, the first condition added to the state’s MMP, was also the first mental or emotional condition that qualified for marijuana therapy in the state.

• In patients with chronic pain, cannabis use was associated with 64% lower opioid use, a better quality of life, and fewer medication side effects and fewer medications used; • States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws; • When used in conjunction with opiates, cannabinoids lead to a greater cumulative relief of pain, resulting in a reduction in the use of opiates (and associated side-effects); • There is a statistical association between recent cannabis use and lower frequency of non-medical opioid use among people who inject drugs; • Medical cannabis patients have been engaging in substitution by using cannabis as an alternative to alcohol, prescription, and illicit drugs; • Cannabis is a safer alternative (than opioids) with broad applicability for palliative care; and, • National overall reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year in 2013.

The petitions accepted for review by the DOH in August 2016 display extensive research, persuasive scholarship and passionate testimony. For example, CMMNJ Board member Vanessa Waltz, submitted the petition to include Opioid Use Disorder (MMP - 063) and this petition alone is 80 pages long. Waltz’s petition identifies: • The problem (DSM – V “Opioid Use Disorder” and ICD-10 “ Opiate Related Disorders”); • The scope of the problem (16,651 deaths due to overdose on prescription opioids and 3,036 deaths due to overdose on heroin in the U.S. in 2010 according to the World Health Organization, with over 5,000 opiate overdose deaths in New Jersey in the last decade); • The ineffective attempts to manage the problem (an in-patient rehabilitation center in New Jersey estimates that 33% of addicts in the state are denied access to treatment resources and that 45,000 state residents were turned away from treatment facilities due to high costs); and, • The hope that marijuana brings to the issue.

Marijuana brings more than hope. Waltz’s petition documents scientific studies published in peer-reviewed journals, the compelling testimony of patients who have struggled with opiate addiction, and testimony from healthcare experts that attest to the effectiveness of marijuana in mitigating Opiate Use Disorder.

New Jersey, a state in the midst of a worsening opiate epidemic, can ill afford to ignore this evidence. Even when mortality is not the outcome, the morbidity associated with intravenous drug use is an important concern among New Jersey’s 128,000 heroin addicts. Hepatitis C infections may occur in up to 90% of people who inject drugs, and HIV infections can be as high as 60% among heroin users who do not have access to Needle Exchange Programs. .

The peer-reviewed articles published in scientific journals that are noted in Waltz’s Petition show remarkable evidence for marijuana’s efficacy in alleviating the suffering caused by Opiate Use Disorder:

Add to this the compelling testimony from eight patients in New Jersey’s MMP, and two other members of the community, along with a physician who recommends marijuana in the MMP, an RN expert in the field, and a Director of one of the state’s Alternative Treatment Centers, and it is difficult to imagine how the DOH could do anything but approve this petition.

However, it may not be so simple. It is the Commissioner of the DOH who will make the final determination in this matter, after the panel of healthcare professionals makes their recommendations. In New Jersey, the commissioners of all the executive branch departments, like the DOH, are appointed, and may be removed from office at any time by the Governor. Governor Christie still insists that marijuana is a dangerous gateway drug, despite scientific and even common sense evidence to the contrary. Governor Christie also insists, through his Office of the Attorney General (OAG), that marijuana remain a Schedule I drug on a statewide level.

PTSD Veterans testifying at the NJ DOH in August 2016 with CMMNJ.

Photo Credit Submission: Ken Wolski, RN, MPA

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This means that the NJ OAG believes that marijuana has no accepted medical uses in the U.S., even while the NJ DOH debates exactly what additional medical uses marijuana should have in New Jersey (!)

In 2014, the Board of Directors of CMMNJ endorsed legalization of marijuana. There are hundreds of thousands of people in New Jersey who would benefit from marijuana therapy. After all, if you live in the Garden State, you have a one in three chance of having a cancer diagnosis at some point in your life. You have a one in three chance of having chronic pain--pain that lasts six months or more. We all die, and marijuana helps with some of the common problem associated with terminal illnesses like no other drug.

This is why CMMNJ joined with New Jersey United for Marijuana Reform (njumr.org) and endorsed legalization of marijuana in New Jersey.

Along with undoing the harms to society that are caused by prohibition, legalization is the most efficient and effective way to get the therapeutic benefits of marijuana to the vast number of patients who can benefit from it. Legalization is the best way to get the right medicine to the most people.

Ken Wolski, RN, MPA Executive Director Coalition for Medical Marijuana--New Jersey, Inc. 219 Woodside Ave. Trenton, NJ 08618 www.cmmnj.org kenwolski@gmail.com Follow CMMNJ on Facebook, Friends of the Coalition for Medical Marijuana-NJ, at: https:// www.facebook.com/groups/62462971150/?ref=ts January 31, 2017 CMMNJ, a 501(c)(3) public charity, is a non-profit educational organization.

Ken Wolski, RN, MPA

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References: The entire Opiate Use Disorder (MMP – 063) petition can be found at: http://www.nj.gov/health/medicalmarijuana/documents/petitions/MMP-063.pdf

Selected references from this petition include: 1. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in aRetrospective Cross-Sectional Survey of Patients With Chronic Pain. Boehnke, Kevin F. et al. The Journal of Pain, Volume 17 , Issue 6 , 739 – 744. Source: Abstract – http://www.jpain.org/article/S1526-5900(16)00567-8/abstract Full Text – http://www.jpain.org/article/S1526-5900(16)00567-8/fulltext References – http://www.jpain.org/article/S1526-5900(16)00567-8/references 2. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States: 1999-2010 Bachhuber MA, Saloner B, Cunningham CO, Barry CL. JAMA Intern Med. 2014;174(10):1668-1673. doi:10.1001/jamainternmed.2014.4005.

Source: http://archinte.jamanetwork.com/article.aspx?articleid=1898878#Abstract 3. Cannabis as an Adjunct to or Substitute for Opiates in the Treatment of Chronic Pain: Lucas, Philippe. Journal of Psychoactive Drugs 08 Jun 2012; 44(2):125-133.

Source: https://www.researchgate.net/ publication/230652616_Cannabis_as_an_Adjunct_to_or_Substitute_for_Opiates_in_the _T reatment_of_Chronic_Pain 4. Is Cannabis use associated with less opioid use among people who inject drugs?

Kral AH, Wenger L, Novak SP, Chu D, Corsi KF, Coffa D, Shapiro B, Blumenthal RN. Drug Alcohol Depend. 2015 Aug 1;153:236-41. doi: 10.1016/j.drugalcdep.2015.05.014.

Epub 2015 May 22.

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509857/ 5. Cannabis as a substitute for alcohol and other drugs. Reiman A. Harm Reduction Journal: 2009;6:35. doi:10.1186/1477-7517-6-35.

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2795734/ 6. Cannabis in palliative medicine: Improving care and reducing opioid-related morbidity: Carter GT, Flanagan AM, Earleywine M, Abrams DI, Aggarwal SK, Grinspoon L. American Journal of Hospice and Palliative Medicine. 2011 Aug;28(5):297-303. doi: 10.1177/1049909111402318. Epub 2011 Mar 28.

Source: https://www.researchgate.net/ publication/50891411_Cannabis_in_Palliative_Medicine_Improving_Care_ and_Reducing _Opioid-Related_Morbidity 7. Medical Marijuana Laws Reduce Prescription Medication Use in Medicare Part D. Bradford AC, Bradford WD. Health Affairs 35, no.7 (2016):1230-1236 10.1377/doi:hlthaff.2015.1661 Source: http://www.ouramazingworld.org/uploads/4/3/8/6/43860587/bradford2016.pdf

Today…

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However Today …

Cannabis Gave Someone Their Life Back

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Cannabis Science Conference 2017 Portland, Oregon What to Expect: Two Days of Technical Oral and Poster Presentations Keynote Speeakers Expanded Canna Boot Camp & Cannabis Education Network Courses & Event Plenary Symposium Meet Medical Professionals and Cannabias Testing Lab Experts On-Site CME Accredition Opportunities to Establish your Brand is Cannabis Markets Parallel Medical & Scientific Technical Sessions Large Exhibit Hall GROW WITH US in 2017 at the Oregon Convention Center in Downtown Portland, OR, August 28th-30th! This year we will have 60,000 square feet of exhibit hall space and 50,000 square feet of meeting space for technical presentations. We hope that you will join us for this historic event. Don't miss out on our 2017 Canna Boot Camp! This is our full-day workshop that covers everything from Cultivation, Extraction, Sample Prep, Analytical Testing, Edibles Manufacturing and more! This event sold out VERY quickly in 2016. We also welcome Cannabis Education Network to our team providing a full-day of Pre-Courses & Event focusing on Cannabis Health & Wellness through the National Nursing Experts. Go to: www.CannabisEducationNetwork.com for Details and Registration.

Cannabis Science Conference is the world's largest cannabis science expo. Our conference pulls together cannabis industry experts, instrument manufacturers, testing labs, research scientists, medical practitioners, policy makers and interested novices. Our annual event is aimed at improving cannabis science. Join us in Portland, Oregon, for an exciting conference with keynotes, presentations, round table discussions and exhibits. At our inaugural event we hosted over 750 attendees from all over the world!

Please contact Josh at (443) 623-2282 or josh@jcanna.com before sending in payment. Please make check payable to: JCANNA Inc. (EIN # 81-0992186) and mail to 4006 Logan Court, Pasadena, MD 21122.

By: Mary Lynn Mathre, RN, MSN, CARN Pain is the most common reason people seek health care. Common treatment for moderate to severe acute and chronic pain has generally included opioids. While many patients may suffer from an opioid use disorder that started with experimentation with illicit opioids or heroin, most patients with an opioid use disorder started with prescribed opioids. For the past two decades, pain has been identified as the 5th vital sign and efforts to assess for and treat pain has become a standard of practice in health care. Pharmaceutical manufacturers of opioids encourage the use of their products and minimize the addictive potential when used to manage pain. Over prescribing and lack of close follow-up soon led to physical dependence on opioids, poor pain management, and a tolerance to the effects requiring patients to seek higher and higher doses.

Currently the CDC has estimated 91 opioid overdoses per day in the U.S. (https://www.cdc.gov/drugoverdose/ epidemic/index.html). This is a complex problem with various contributing factors and all potential treatments should be explored.

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To address this growing opioid epidemic the CDC issued guidelines for prescribing opioids for chronic pain (https:// www.cdc.gov/mmwr/volumes/65/rr/ rr6501e1.htm). Health care practitioners are strongly encouraged to use these guidelines for managing their patients with non-cancer related chronic pain.

While cannabis remains in Schedule I (forbidden category) of the Controlled Substances, countless patients are seeking cannabis information or a safe supply of the medicine based on word of mouth from other patients. While we now have 28 states with medical “marijuana” laws, each law varies from state to state, but all include barriers to patient access, including ignorant, indifferent or intimidated health care providers. As a nurse, what do you know about the cannabis plant or cannabis/cannabinoid products?

What do you know about the use of cannabis for pain management? How does it work? Is it safe? Is it legal? Why should I care?

These are questions that nurses are expected to be able to answer. We are the most trusted group of professionals, we are the largest health care discipline at 3.6 million RNs strong, and we spend the most time with patients. This is an ethical responsibility as a patient advocate.

Cannabis has been used for millennia and various records note its use as an analgesic, muscle relaxant, antiinflammatory and useful in the management of pain, especially chronic neuropathic pain. Cannabis is a plant that contains more than 400 constituents including cannabinoids (such as THC and CBD), as well as terpenes and flavonoids. These cannabinoids and some of the terpenes have been found to possess analgesic, anti-inflammatory, and muscle relaxant properties. When used as a whole plant herbal medicine, there is synergy among these constituents that produce a more effective and gentle effect, than if single constituents from the plant are used.

In a 1914 Blumgarten pharmacology text for nurses, it states in bold that cannabis “relieves pain and induces sleep.” Modern research on the interaction between opioids and THC shows a synergistic effect and when using cannabis as an adjunct to prescribed opioids, the development of tolerance to opioids is decreased (Cichewicz, et al. 1999, Cichewicz&McCarthey, 2003).

But the more compelling rationale for the clinical use of cannabis for pain management is the discovery and increasing understanding of the Endocannabinoid System (eCS). The primary role of the ECS is to protect us from stressors and help keep us in balance. This system plays an important role in decreasing the harm from an injury, aiding in the healing process, as well as decreasing the perception of pain.

Cannabis is remarkably a nontoxic botanical medicine. That’s not to say it is completely safe, but it is clearly less addictive and less toxic than opioids.

When cannabis is used as an adjunct pain medication, many patients are able to decrease their opioid dose or eliminate opioids completely. Cannabis clinicians are seeing this trend with their chronic pain patients and this has been validated with a study of patients in an Israeli nursing home (Weisberg &Sikorin, 2015).

With the passage of medical cannabis state laws, patients are speaking more openly about their use and clinicians and researchers are seeing results. In 2011 Donald Abrams, M.D. conducted a study on 21 patients who were on sustained release oxycodone or morphine and they added vaporized cannabis to the patients’ treatment protocols, they found a lower plasma level of the opioids, but a statistically significant reduction in pain.

A 6 month follow-up study of 176 patients using cannabis for pain management found improved pain management and functional outcomes along with a 44% reduction in the use of opioids (Haroutounian, et al., 2016). A retrospective survey of 244 chronic pain patients at a cannabis dispensary in Michigan found a 64% lower opioid use, an increased quality of life, and fewer medication side effects along with fewer medications used by these patients once they began using cannabis for pain management (Boehnke et al., 2016).

Bachhuber and others looked at states’ death certificate data from 1999-2010 comparing the medical cannabis states to states without laws allowing the medicinal use of the plant. They found a 24.8% decreased mortality rate from opioids in the 23 medical cannabis states compared to the other states and that there was a progressive decrease in the states that had a cannabis law in effect for longer periods of time (2014).

While that simply shows an association, it is a striking finding that supports the anecdotal reports.

Cannabis inappropriately remains in Schedule I (the forbidden category) of the Controlled Substances despite the clear evidence that it does not meet the criteria for such placement: not safe for medical use, no currently accepted medical use in treatment in the United States, and highly addictive. There has never been an overdose from cannabis. Opioids such as oxycontin, dilaudid, morphine or fentanyl are in Schedule II – highly addictive, but recognized as being safe to use as prescribed and having medical value. As noted above, there are now 91 opioid overdoses per day. The prohibition of the cannabis plant is a literally a crime, when one realizes that the use of cannabis in chronic pain patients can not only provide better management of chronic pain and an increased quality of life, but it can significantly decrease the amount of opioids a person uses and save lives.

As nurses, we cannot turn our backs on these patients. We need to educate our colleagues and patients about the use of cannabis for the management of chronic pain. We need to talk with our legislators and urge them to decrease roadblocks on the state level and end the prohibition of cannabis on the federal level. Cannabis should be removed completely from the Controlled Substances listing and patients should be allowed to grow this wonderful natural plant. Once the cannabis plant is recognized as a medicinal herb, quality control measures can and should be applied to cannabis products using guidelines set by the herbal medicine experts.

References: Abrams, DI, Couey P, Shade SB, Kelly ME, Benowitz NL. (2011). Cannabinoid-opioid interaction in chronic pain.Clinical Pharmacology & Therapeutics. 90(6):844-851.

Bachhuber MA, Bachhuber MA, Bachhuber MA, Saloner B, Barry CL, Saloner B., Cunningham CO & Barry CL. (2014). Medical cannabis laws and opiid analgesic overdose mortality in the United States, 1999-2010.

JAMA Internal Medicine. 17(10):1668-1673.

Blumgarten, A.S. (1914). MateriaMedica for Nurses. The MacMillan Company: NY. Boehnke KF, Litinas E &Clauw DJ. (2016).

Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. Journal of Pain.

17(8):739-744.

Cichewicz DL, Martin ZL, Smith FL, et al.

1999. Enhancement of mu opioid antinociception by oral delta9tetrahydrocannabinol: Dose response analysis and receptor identification. J PharmacolExpTher, 289:859–67.

Cichewicz DL, McCarthy EA. 2003.

Antinociceptive synergy between delta(9)tetrahydrocannabinol and opioids after oral administration. J PharmacolExpTher, 304:1010–5.

Haroutounian S, Ratz Y, Saifi F., Meidan R & Davidson E. (2016) The effect of medicinal cannabis on pain and quality-of-life outcomes in chronic pain: A prospective open-label study. Clinical Journal of Pain.

32(12):1036-1043.

Weisberg, M &Sikorin, I. (2015). TikunOlam Medical Cannabis Treatment Center: A Nurseled Approach. Presented on May 23, 2015 at The Ninth National Clinical Conference on Cannabis Therapeutics in West Palm Beach, FL.

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HER B

COOK WITH

CHEF HERB whose nickname is Mota, which is Spanish for marijuana, knows the benefits of medical marijuana and has decided to incorporate his two passions: cooking for people’s pleasure and creating gourmet medicinal food. In the Basics, Chef Herb teaches us how to create THC butter and oil that can be used in countless recipes from party food hors’dourves to sweet desserts.

This month of March Chef Herb will have another birthday. If you would like to send him birthday wishes you can contact him at his web site WWW.COOkWITHHERB.COM or email him at: cookwithherb@gmail.com.

If you are interested in learning more about cooking with cannabis or want to order his great DVD series call: 310.462.1649

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CANNABISNURSESMAGAZINE.COM

Saint Patrick day and great winter party food Corned beef and Cabbage IngredIents

3 pounds corned beef brisket with spice packet 10 small red potatoes 5 carrots, peeled and julienned 1 large head cabbage, cut into small wedges

dIrectIons

Place corned beef in large pot or Dutch oven and cover with water. Add the spice packet that came with the corned beef. Cover pot and bring to a boil, then reduce to a simmer.

Simmer approximately 50 minutes per pound or until tender.

Add whole potatoes and carrots, and cook until the vegetables are almost tender. Add cabbage and cook for 15 more minutes. Remove meat and let rest 15 minutes.

Place vegetables in a bowl and cover. Add as much broth (cooking liquid reserved in the Dutch oven or large pot) as you want. Slice meat across the grain.

Creamy Colcannon IngredIents 1

pound cabbage 1 pound potatoes 2 leeks 1 cup milk salt and pepper to taste 1 pinch ground mace 1/2 cup tHC butter

cookIng InstructIons

In a large saucepan, boil cabbage until tender; remove and chop or blend well. Set aside and keep warm. Boil potatoes until tender. Remove from heat and drain.

Chop leeks, green parts as well as white, and simmer them in just enough milk to cover, until they are soft.

Season and mash potatoes well. Stir in cooked leeks and milk, salt a pepper to taste, and mace. Blend in the kale or cabbage and heat until the whole is a pale green fluff. Make a well in the center and pour in the melted tHC butter. Mix well.

Irish Fondue Casserole IngredeInts

12 slices firm white bread 1/2 cup tHC unsalted butter, softened 3/4 teaspoon dry mustard 1 clove garlic, finely chopped 1/2 pound (2 cups) shredded Swiss cheese 2 teaspoons chopped fresh chives 1 teaspoon Worcestershire sauce Salt and pepper to taste 4 eggs 1-1/2 cups half and half 2/3 cup milk 1/2 cup chicken broth

cookIng InstructIons

Cut the crusts off the bread slices.

In a small bowl, stir together the tHC butter, mustard and

garlic. Spread each slice of bread with some of the butter.

Arrange 6 slices, THC butter side down, in a 9 by 13-inch baking dish.

In a medium bowl, combine the shredded cheese, chopped chives, Worcestershire sauce, salt and pepper. Evenly sprinkle the cheese over the bread in the baking dish. Top with the remaining bread, THC butter side up. In a medium bowl, beat the eggs, half and half, milk and chicken broth. Pour over the bread. Cover tightly and refrigerate overnight.

Preheat the oven to 350 degrees F. Uncover the fondue and bake it for 1 hour, or until the top is lightly browned and the inside is fairly firm.

Remove the fondue from the oven. Let it rest for 10 minutes.

Cut into 8 or 10 wedges.

Kick Ass Irish Bread Pudding IngredIents

2 cups granulated sugar 5 large beaten eggs 2 cups milk 2 teaspoons pure vanilla extract 3 cups cubed Italian bread , allow to stale overnight in a bowl 1 cup packed light brown sugar 1/4 cup (1/2 stick) tHC butter, softened 1 cup chopped pecans For the sauce: 1 cup granulated sugar 1/2 cup (1 stick) tHC butter, melted 1 egg, beaten 2 teaspoons pure vanilla extract 1/4 cup brandy

dIrectIons

Preheat the oven to 350 degrees F. Grease a 13 by 9 by 2-inch pan. Mix together granulated sugar, eggs, and milk in a bowl; add vanilla. Pour over cubed bread and let sit for 10 minutes.

In another bowl, mix and crumble together brown sugar, tHC butter, and pecans.

Pour bread mixture into prepared pan. Sprinkle brown sugar mixture over the top and bake for 35 to 45 minutes, or until set. Remove from oven.

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For the sauce

Mix together the granulated sugar, butter, egg, and vanilla in a saucepan over medium heat. Stir together until the sugar is melted. Add the brandy, stirring well. Pour over bread pudding. Serve warm or cold.

Irish Soda Bread IngredIents

3 cups all-purpose flour 1 tablespoon baking powder 1/3 cup white sugar 1 teaspoon salt 1 teaspoon baking soda 1 egg, lightly beaten 2 cups buttermilk 1/4 cup THC butter, melted

dIrectIons

Preheat oven to 325 degrees F. Grease a 9 x 5 inch loaf pan.

Combine flour,baking powder,sugar,salt and baking soda.

Blend egg and Buttermilk together,and add all at once to the flour mixture.

Mix just until moistened. Stir in melted tHC butter. Pour into prepared baking pan.

Bake for 65 to 70 minutes or unit a toothpick inserted into center of loaf. Comes out clean. Cool on wire rack and wrap in foil over night for best flavor

Fun Food THC Carmel corn IngredIents

3 quarts popped popcorn 3 cups dry roasted mixed nuts, unsalted 1 cup brown sugar, firmly packed 1/2 cup light or dark corn syrup 1/2 cup tHC butter

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1/2 teaspoon salt 1/2 teaspoon baking soda 1/2 teaspoon vanilla extract

PreParatIon

Preheat oven to 250°. In a large roasting pan combine the popcorn and nuts. Place in the oven while preparing glaze.

In a medium saucepan combine brown sugar, corn syrup, tHC butter, and salt. Bring to a full boil over medium heat, stirring constantly, then continue to boil for 4 minutes without stirring. Remove from heat; stir in baking soda and vanilla, then pour over the warm popcorn and nuts, tossing to coat well. Bake another 60 minutes, stirring freqently, about every 10 minutes. Cool and break apart. Store in an airtight container.

Eggs Benedict Herb Supreme Three recipes in one, think of the Eggs Benedict recipe as toast and ham topped with a poached egg recipe, topped with a hollandaise sauce recipe.

4 English muffins, split, toasted and buttered or 8 crumpets 8 1/4-inch slices ham, warmed and cut to fit 8 poached eggs 1 1/4 cups (about) Hollandaise Sauce

Poached egg recIPe

Water 1 tablespoon salt 2 tablespoons vinegar (any variety) 8 eggs Bring 2-3 inches of water almost to a boil in a large sauté pan.

Add the salt and vinegar. One at a time, crack the eggs into a cup and then slip the eggs, one at a time, into the barely simmering water. Reduce the heat, if need be, to maintain that low simmer.

Cook just until the whites are set and the yolks are glazed but still very soft, about 3 minutes. (Wait until the eggs are set to dislodge any that may have stuck to the bottom of the pan.)

Using a slotted spoon, transfer the poached eggs onto a dish towel to drain. trim the edges of any streamers so they’re nice and tidy. (If the eggs get too cold, slip them back into the simmering water for a few seconds and drain again.)

Make-ahead dIrectIons

Cook as above but remove the eggs from the water after 2 minutes. Immediately place them in ice water to prevent them from cooking further. Cover and refrigerate the eggs and water for up to 12 hours. To reheat, slip them into simmering water for about 30 seconds.

hollandaIse sauce recIPe

4 egg yolks 4 tablespoons fresh lemon juice 1 tablespoon water 1/8 teaspoon salt, or to taste 1/8 teaspoon ground white pepper, or to taste 1 pinch of cayenne pepper 1 cup tHC melted butter Combine the egg yolks, lemon juice, and water in a small, heavy saucepan. Whisk the mixture constantly over very low heat until thickened. Immediately remove the pan from the heat but continue whisking for 1 minute. Add the salt, pepper, and cayenne. Cool slightly.

Scrape the mixture into a blender. With the motor running at medium-high speed, add the melted (but not hot) THC butter in a slow, steady stream until it is well-incorporated. Taste and adjust the seasonings, if necessary.

To keep warm, place the Hollandaise Sauce in a bowl over (but not touching) hot water, stirring occasionally, or simply place the blender container in warm (not hot) water.

now Put It together how to Make eggs BenedIct

Start by preparing the Hollandaise Sauce. Keep it warm.

Start the water for the eggs. Warm the ham slices, and toast and butter the muffins or crumpets. Keep them warm in a warm oven.

Finish preparing the Poached Eggs. to assemble, place a slice of ham atop an English muffin half or crumpet, place a poached egg on the ham, and spoon a little Hollandaise Sauce over the top. Serve immediately.

Makes 8 servings

Easy Crab Cakes

2 pounds lump crab meat 2 tablespoons THC olive oil and/or THC butter 1/2 cup green onions, minced 1/4 cup red bell pepper, diced 2 teaspoons fresh garlic, minced 2 eggs, beaten 1/2 cup THC mayonnaise 1 tablespoon Dijon mustard 1/3 cup fresh parsley, minced Salt and ground black pepper to taste 2 1/4 cups toasted bread crumbs (more or less) 4 tablespoons THC butter and/or THC olive oil

how to Make craB cakes that don’t Fall aPart

First, thoroughly pick the crabmeat over for shell fragments and set aside.

Sauté the green onions, bell pepper, and garlic in tHC olive oil and tHC butter. Cool.

In a large bowl, combine the crab meat, sautéed mixture, beaten eggs, mayonnaise, mustard, parsley, salt, pepper, and 1/4 cup of bread crumbs.

Pour the remaining (2 cups) bread crumbs onto a plate. line a baking sheet with wax paper or plastic wrap.

Form the crab cake mixture into 1/2-inch thick patties, 8 large or 12-16 small ones.

Press both sides of the patties into the bread crumbs, and place them on the baking sheet. Cover with plastic wrap and refrigerate for 3 to 6 hours, until firm.

In a large, non-stick sauté pan, brown the patties in tHC olive oil and/or tHC butter over medium-high heat, about 4 minutes each side. Drain on paper toweling.

Serve with lemon wedges or tartar sauce. Makes 8 large or 12-16 small crab cakes.

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CANNABISNURSESMAGAZINE.COM

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Dedi c a t edi nl ov i ngmemor yof “ AuntKa t hy”

Ka t hl eenDonohue

ASK ED

Welcom to Nurse Talk! In this Issue, we were able to get an interview with CBD Living Water which is the innovator of Nano CBD Products. The name says water but we found out that they have a full range of products, including CBD Gummies, Nano CBD Chocolate Bars, Nano CBD Sleep Aid, Nano CBD Roll on Topical for pain relief and many more. Below is their interview. We hope you enjoy it:

How would you describe your Company?

CBD Living is the Innovator of Nano CBD products

what's your Specialty?

CBD Living is in the forefront of CBD products by utilizing Nano Technology to 'Nano' our CBD which allows the CBD to become immediately Bio-Available in the body. When consuming CBD in other ways beside Nano CBD, the body looses up towards 90% of the CBD through the Digestive system.

When we use Nano CBD technology, we break it down to 1 millionth its original size allowing it to be absorbed directly into the body's cells at the cellular level giving the body immediate bio-availability. Our first product was CBD Living Water but WE AREN'T JUST A WATER COMPANY ANYMORE! We have a full range of products from Full Spectrum Nano CBD Gummies, Nano CBD Chocolate Bars, Nano CBD Sleep Aid, Nano CBD Roll on Topical for pain relief, and Nano CBD Gel Caps and many more exciting products to come in 2017.

What do you offer Consumers/Clients that others don't?

We offer CBD Products with Nano CBD and Full Spectrum Nano CBD which gives the consumer the best BioAvailable CBD products on the Market.

How and why did your Company start up?

CBD Living Started with a Team of Scientist and a vision to create a product that would give consumers a CBD product that would far surpass anything on the market and "Viola" CBD Living Water was created, not only giving the consumer the best bio-availability to CBD but with other nutrients such as d-ribose, Coq10, Mythel B12 and maximum hydration.

With the changing landscape of MMJ and Recreational Cannabis, what do you see as the biggest challenges to your progress as a Company?

The changing landscape of MMJ will only help our company grow as Consumers learn more about the benefits of CBD and all of the current states that do not have MMJ or Recreation Cannabis acceptance as of yet. CBD Living can still provide our CBD products to these states which are 100% legal in all states.

What words of advice would you offer anyone seeking to enter the world of Cannabis Business?

Do it for the right reasons!

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March/April 2017 CANNABISNURSESMAGAZINE.COM

What are the Goals and Vision for your Company?

Our goals are to continue to be in the forefront of innovative CBD Products. We work daily side by side with our scientists to make our products the best they can be along with continuously working on New Products under CBD Living and we're doing it for the right reasons!

Where do you see your Company in Five Years?

We hope to be Worldwide and a Household Brand

What do you hope to accomplish in the MMJ Industry?

CBD Living hopes to accomplish in the MMJ industry and outside the MMJ industry, to be able to provide our consumers the BEST CBD products with the most Bio-Availability and bring awareness to everybody of the benefits of CBD and, we hope to continue to help many others with our products as we do now.

UNDOO T M

UNHAZ ET HEBL AZ E T M

T heCannabi sS af e t yNe t T M

ANAL L NAT URALE ME RGE NCYS UPPL E ME NTI NT E NDE D T OE AS ET HES I DEE F F E CT SOFCANNABI S OVE RCONS UMPT I ON. UNDOOTM i sa ni nnov av e , pa t e nt pe ndi ngf or mul at ha t s uppor t st hebody ' sna t ur a l a bi l i t yt oc ount e r a c tt he e uphor i ce ffe c t sofT HCr i c hCa nna bi s .

F or mul a t e dwi t hapr opr i e t a r ybl e ndofa l l na t ur a l ont a i nsnoCannabi s , no i ng r e di e nt s , UNDOOTM c c affe i nea ndnos ugar .

I ti sde s i g ne dt oe ffe cv e l ya nd qui c k l yhe l py ourbodyma na g et he" hi g h"a s s oc i a t e d wi t hT HCc ons ump on.

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Cont ac ts uppor t @undoo. c om

Apps for Health-Care Professionals Smartphone apps and web-based tools are increasingly important resources for health-care practitioners.

Check out these great tools and put a wealth of health-care information in your pocket.

01 NURSING CENTRAL

06 EPONYMS

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

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

02 LIPPINCOTT NURSING

07 NETTER’S ANATOMY FLASH CARDS

DRUG HANDBOOKS

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

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

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

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

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

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

09 EPOCRATES Rx The app includes a drug guide, formulary information and a drug interaction checker. This product also includes continual, free updates and medical news.

Additionally, the app works on your device when you are offline, so you can look up information without a wireless connection. http://goo.gl/fqchG

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

March/April 2017 CANNABISNURSESMAGAZINE.COM

43

Resources

Recommended Books

Marijuana and Medicine:Hemp for Health:

The Health Effects of Cannabis and Cannabinoids:

The medical use of marijuana is surrounded by a cloud of social, political, and religious controversy, which obscures the facts that should be considered in the debate.

Significant changes have taken place in the policy landscape surrounding cannabis legalization, production, and use. During the past 20 years, 25 states and the District of Columbia have legalized cannabis and/ or cannabidiol (a component of cannabis) for medical conditions or retail sales at the state level and 4 states have legalized both the

This book summarizes what we know about marijuana from evidence-based medicine--the harm it may do and the relief it may bring to patients. The book helps the reader understand not only what science has to say about medical marijuana but also the logic behind the scientific conclusions.

Marijuana As Medicine?

Some people suffer from chronic, debilitating disorders for which no conventional treatment brings relief. Can marijuana ease their symptoms?

Would it be breaking the law to turn to marijuana as a medication?

There are few sources of objective, scientifically sound advice for people in this sitation. Most books about marijuana and medicine attempt to promote the views of advocates or opponents. To fill the gap between these extremes, authors Alison Mack and Janet Joy have extracted critical findings from a recent Institute of Medicine study on this important issue, interpreting them for a general audience.

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March/April 2017 CANNABISNURSESMAGAZINE.COM

medical and recreational use of cannabis. These landmark changes in policy have impacted cannabis use patterns and perceived levels of risk.

The Little Black Book of Marijuana: The Essential Guide to the World of Cannabis This concise guide to cannabis delves into pot culture and history, from Herodotus to the hippies and beyond.

It also covers the essentials of using, cultivating, and cooking with weed; identifying pot varieties; and understanding legal and health issues.

Handy and to the point, The Little Black Book of Marijuana gives you "the dope" on pot, from possible side effects and risks to medical uses and their efficacy. Learn about cannabis history and the issues around its legalization.

Job Opportunities Perm & Travel

Cannabis Nurse Job Board has over 2,000 nursing job opportunities in all nursing specialties.

Get started...

High paying travel nursing positions all over the country

Emerald currently provides travel nurses to hundreds of hospitals and currently is offering assignments in every major specialty (ICU, L&D, ER OR, TELE PACU, PICU, NICU, and PEDS).

Contact Emerald at any time at 1-800-917-5055, or respond to this message via E-mail or you can also visit us on the web at: www.emeraldhs.com

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Nightingale, a nationally recognized leader in travel healthcare professionals, has Immediate and Exclusive needs for all Nursing Specialties with excellent pay.

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Call us immediately: 800-591-7860 or scan the QR code To complete a full application, please scan the QR code March/April 2017 CANNABISNURSESMAGAZINE.COM

45

Nursing Conferences March 2017 Conferences

2017

Cannabis Health, Wellness & Industry Overview Event - Cannabis Education Network (CEN) March 2nd, 2017 from 6PM-8:30PM | Wellington, FL http://www.CannabisEducationNetwork.com

April 2017 Conferences

Take Note Colorado

!

Pre-Conference Courses & Event: Cannabis Health & Wellness - Cannabis Education Network (CEN) Course: April 27th, 2017 from 10AM-4PM | Event: 6PM-8:30PM | Pueblo, CO http://www.CannabisEducationNetwork.com 1st Annual Institute of Cannabis Research Conference - Panel: Cannabis Wellness Takes Center Stage April 28th- 30th, 2017 | Pueblo, CO http://www.csupueblo.edu/ICR/2017

May 2017 Conferences

11th National Clinical Conference on Cannabis Therapeutics Patients Out of Time ~ Cannabis: Protecting Patients and Reducing Harm May 18th - 20th, 2017 | Berkley, CA

http://www.medicalcannabis.com/2017-national-clinical-conference-on-cannabis-therapeutics/

June 2017 Conferences AHNA's 37th Annual Conference- Workshop: Endocannabinoid Connections (June 10th 10:30AM-12Noon) June 5-10th ,2017 | Rancho Mirage, CA www.ahna.org/conference

August 2017 Conferences Pre-Conference Courses & Event: Cannabis Health & Wellness - Cannabis Education Network (CEN) August 28th, 2017 | Portland, OR www.CannabisEducationNetwork.com Cannabis Science Conference 2017 August 28th-30th, 2017 | Portland, OR wwww.CannabisScienceConference.com

October 2017 Conferences

Cannabis Nurses Magazine 2-Year Anniversary & Awards Ceremony | October 7th, 2017 Cannabis Health & Wellness Courses & Event| October 6th, 2017 October 6-7th, 2017 | Las Vegas, NV www.CannabisEducationNetwork.com | www.CannabisNursesMagazine.com If you know of other Conferences available that are based on Cannabis Therapeutics that you wish to be listed in future issues please email us at: editor@cannabisnursesmagazine.com

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March/April 2017 CANNABISNURSESMAGAZINE.COM

April 27th, 2017 Pueblo, CO Rawlings Library InfoZone Theater 100 E. Abriendo Ave. Pueblo, CO 81004

Educational Achievement Award 2016 Heather Manus, Cannabis Nurses Magazine Lisa LeFevre RT(R), MBA

Heather Manus, RN

Julie Monteiro RN, BSK

Pre-Conference Course & Event!

1st Annual Institute of Cannabis Research Conference - National Cannabis Nurses Lectures

“Cannabis for Healing & Wellness” Educational Course 10:00am - 4:00pm

Featuring: Heather Manus, RN Lisa LeFevre RT(R), MBA Julie Monteiro RN, BSK Agenda: • The Endocannabinoid System (eCS) • Methods of Administration • Terpenes & Aromatherapy • Touch Therapy • Wellness Perspective • Ending Prohibition- Our Ethnobiological Right Bonus! Includes 1 year subscription to Cannabis Nurses Magazine Certificate Pricing (10am - 4pm): Earlybird (Dec-March) $269 Regular (April) $299 Cash at the Door $320 Non-Certificate Pricing (10am - 3pm): Earybird (Dec-March) $240 Regular (April) $270 Cash at the Door $290 Register at: Universe.com./CannabisHealingandWellness * Limited to first 50 registrants * Lunch provided Developed & Produced by:

“Meet the Professionals” Cannabis Event 6:00- 8:30pm

Produced and facilitated by: Stonefield National (Lisa LeFevre) Meet and Speak with 12 Professionals: • Cannabis Educators • Scientists • MDs • Nurses • Growers • Converters (MIPS) • Dispensaries • Testing Labs Tickets: Earybird (Dec-March) Regular (April) Cash at the Door

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Informative and Evidence-Based Education with Resources and References - Written by Real Nurses, Doctors, and Scientists.

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