May / June 2016 CNM

LIFESTYLES

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OPPORTUNITY

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EDUCATION May/June 2016

Neurological Disorders: How Cannabis Helps Alzheimer's Disease and Medical Marjuana Dravet Syndrome Syndrome Dravet story by by aa story Jennie Stormes, RN,BSN

Lisa Buchannan RN, OCN

Editor’s Letter When I was first introduced to medical cannabis in January 2010 it was a given and basic knowledge that cannabis was being used as a treatment of choice for cancers and glaucoma. What I did not understand, being a novice learner, was that cannabis was being used to treat a wide variety of neurological disorders and for the first time ever I learned that it assists with Alzheimer’s disease.

“What?”, I said to myself. “Cannabis helps with Alzheimer’s disease!” This statement alone stopped me in my tracks as my Mother suffers with this disease and I began the journey to educate myself further.

I found out quickly that Western medicine does not include education on the Endocannabinoid System and the treatment options of cannabis as a medicine is not widely accepted. This is due to the prohibition and war on drugs over the past seventy years. Thus, when we ask our medical providers about medical cannabis for our loved ones, the majority of providers have no knowledge on the topic. So how can we expect our providers to teach us as nurses or our patients on the importance of cannabis therapeutics when it comes to Alzheimer’s? The majority of them can not.

Thus, as it is written into our nursing scope of practice, it is our duty to become informed and educated on new methods of treatments that our patients are requesting and utilizing. Despite social criticism, more patients and their families are seeking alternate treatment plans and moving away from pharmaceuticals that seem to be doing more harm than good and finding cannabis as their solution.

I was excited to share this knowledge with my family however, it was not widely received well at all. In fact, it has created division greater than the Grand Canyon amongst us siblings. My mother was far into her progression of the disease and one of our siblings obtained a power of attorney. We thought nothing of it at the time and were happy one of us stepped up to the plate to assist with her; our mother needed it. However, this sibling was raised in the “Just say No” Nancy Reagan era and is also a deeply rooted member of the Narcotics Anonymous (NA) program where they believe ‘marijuana’ to be the gateway drug and taboo to consume even if you are a legal medical cannabis patient.

Despite the numerous articles, research papers, and journals we shared, there was no convincing our sibling otherwise that cannabis could and would be a treatment option for our mother while she lives in California where cannabis is abundant and legal. Due to our sibling holding a power of attorney, she threatened and even had our mother tested for THC in her system to see if we have been secretly medicating her, stating that “if Mom comes up with THC in her system I will get a restraining order against you from seeing Mom”.

Period. It has been the most torturous trial and tribulation our family has experienced. We have the tools and the supplies to provide our mother with the best natural medicine available however, our naïve sibling holds the legal power while our mother's condition worsens.

In this issue we review the most common neurological disorders and discuss how cannabis helps with Multiple Sclerosis (MS), Epilepsy, Alzheimer’s disease, Neuropathy, Tourettes syndrome, Dravet syndrome, and many other neurological deficits that plague patients across the world. We hit close to home as we explore with Dr. Sunil Aggarwal the specifics of Alzheimer’s disease and his perspective as a Palliative Care Specialist and in Cannabinoid Integrative Medicine in treating with medical cannabis. We also revisit with Dr. Gregory Smith who discusses in detail whether medical cannabis is right for you or a loved one who is dealing with dementia and Alzheimer’s disease. The evidence-based education is astounding and cannabis is proven to help.

American society needs to realize that even though there is a social stigmatism with medical marijuana - that doctors, professors, research scientists, and nurses all recommend medical marijuana as a treatment of several devastating neurological diseases. Individuals like my sister and society need to understand that it is better to at least allow your family member to try it out for at least a week or month to see if there is a difference. Cannabis has never caused a death and is one of the safest methods of treatments. If you are a family member that is not in favor of medical cannabis I challenge you to educate yourself. Open your mind. Open your heart. There is a treatment that may help you or your loved one. Be the change and allow the healing to begin - it is never too late.

Having a mother with Alzheimer's presents a host of challenges for our family. I have hope that our sibling will recognize the benefits cannabis has for our mother. Until then, I continue to challenge the nursing profession to be viewed as the target of change rather than a force that proposes, leads and implements change. We as nurses are stepping out of the box and continue to be the voice for our patients especially, when it is our mother.

We must Grow.

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

I dedicate this issue to our loving Mother- an Alzheimer’s patient

Contributors May / June 2016

Publisher

Robert Herman/ND1Media

Managing Editor

Julie Monteiro RN, BSK

Creative Director

Heather Manus, RN

Contributors Heather Manus, RN Leslie Reyes, RN Marcie Cooper, RN, MSN, AHN-BC Lisa Buchanan, RN ,OCN Mary Lynn Mathre, RN, MSN, CARN Carey S. Clark, PhD, RN, AHN-BC, RYT Chef Herb Cooking withherb.com Dr. Igor Grant, MD. https://medicalmarijuana.ca Jennie Stormes, RN, BSN 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 journal, 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

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

Leslie Reyes, RN Leslie Reyes, RN is a Board Member and the previous Secretary for the American Cannabis Nurses Association (ACNA).

Leslie has worked as a Registered Nurse in Urgent Care, Psychiatric and Behavioral Health, and has been involved in cannabis patient advocacy for over ten years.

She is a co-creator and co-author of the Core Curriculum in Cannabis Nursing owned by the ACNA, and is also on the committees for Communications and Media, Conference Planning, Certification, Events, Membership, Nominations, and the Executive Committee.

Marcie Cooper, RN, MSN, AHN-BC

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

Lisa Buchanan, RN, OCN

Lisa Buchanan is an Oncology Certified Nurse (OCN) 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 the Advanced Curriculum for Cannabis Nursing through ACNA.

Jennie Stormes, RN, BSN

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.

Contributors

Contact Information Sunil Kumar Aggarwal, MD, PhD, FAAPMR Dr. Aggarwal attended medical school at University of Washington School of Medicine and Residency in Virginia Mason Medical Center (Preliminary Medicine) and New York University Medical Center (Physical Medicine and Rehabilitation). Dr. Aggarwal has completed his fellowship at the National Institutes of Health-Clinical Center in Board-Eligible, Physical Medicine and Rehabilitation Board-Certified, Global Health UWSOM Pathwayand Palliative Medicine. He is Hospice and Palliative Medicine Certified. He holds a PhD in Medical Geography from the University of Washington. His clinical/medical areas of interest are: pain and symptom management, advanced care planning, end-of-life care, integrative medicine, cannabinoid integrative medicine, psychedelic integrative medicine, spirituality in medicine, cross-cultural medicine, and social medicine.

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 has 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.

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

Jennie Stormes, RN, BSN

info@cannabisnursesmagazine.com

Jennie Stormes, RN, lives in the state of Colorado, and formerly in both New Jersey and Pennsylvania, is a member of the American Cannabis Nurses Association, 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). In 1999 Jennie’s son began experiencing intractable seizures related to Dravet Syndrome without much relief from traditional

www.cannabisnursesmagazine.com

pharmaceuticals with 62 failedpharmaceutical combinations, 2 brain surgeries, VNS implant, and special diets. In 2012, she began a CBD/THC cannabis regimen with great success. She has used and seen the benefits of full spectrum cannabinoid sciences in treating many forms of epilepsy, cancer, PTSD and other medical and mental disorders effectively, especially when guidance and dosing information is available. She is also very politically active, testifying in both the assembly and senate committees in New Jersey, as well as lobbying with many other legislators in numerous states and has sat on medical and professional panels across the nation. Her mission is to make changes with cannabis as a legal treatment option. Driven by the amazing results she witnessed with her son, she is committed to remain active within the community to make changes by attending rallies, events, educating medical professionals and layperson’s whenever possible. She is currently spearheading the efforts in Colorado’s D49 school district to allow cannabis medication / administration on school grounds.

Table of

May/June

Contents WHAT'S INSIDE P.2

EDITORIAL PAGE

P.6

NEUROLOGICAL DISORDERS: HOW CANNABIS HELPS

P.14

DRAVET'S & PREVENTION

P.16

CANNABIS IN WASHINGTON STATE: A Nurse's Report

P.19

ALZHEIMER'S DISEASE AND MEDICAL MARIJUANA

P.24

COOKING WITH HERB

P.28

THE THERAPUTIC ROLE OF CANNABIS IN NEUROLOGICAL DISORDERS: ALZHEIMER'S

P.31

RESOURCES

P.32

Nurse Job Opportunities: Perm & Travel

P.33

Helpful Apps for Health Care Professionals

P.34

Nursing Conferences for 2016

2016

FEATURES NEUROLOGICAL DISORDERS: HOW CANNABIS HELPS

PAGE. 06 DRAVET'S & PREVENTION PAGE. 14

CANNABIS IN WASHINGTON STATE: A Nurse's Report

PAGE. 16

ALZHEIMER'S DISEASE AND MEDICAL MARIJUANA PAGE. 19 THE THERAPUTIC ROLE OF CANNABIS IN NEUROLOGICAL DISORDERS: ALZHEIMER'S

PAGE. 28

Neurological Disorders:

How Cannabis Helps It's that time of year when we take a look at the rapidly changing status of marijuana in the US. Yes, the Drug Enforcement Agency still categorizes marijuana as a schedule I drug, one that has no accepted medical use, but since the late 1990s, a majority of Americans have thought medical cannabis should be legal. A majority support recreational legalization as well.

Washington D.C. and 24 states (plus Guam) have legalized medical marijuana (that number is even higher if we count laws with very limited access).

But what do we know about the science behind medical uses of cannabis?

There seem to be some definite benefits. Even the NIH's National Institute on Drug Abuse lists medical uses for cannabis.

Yet it's hard to study marijuana's uses while the schedule I classification remains in place.

It makes it difficult for researchers to get their hands on cannabis grown to the exact standards that are necessary for medical research. Plus, there are hundreds of chemical compounds in the cannabis plant that could play a role in medical treatments, but for now, it's hard to know which aspect of the plant is causing an effect.

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Using all the compounds in marijuana simultaneously is like "throwing 400 tablets in a cocktail and saying ' take this," Yasmin Hurd, a professor of neuroscience and psychiatry at Icahn School of Medicine at Mount Sinai.

More research would identify health benefits more clearly and would also help clarify potential dangers. As with any psychoactive substance, there are risks associated with abuse, including dependency and emotional issues. Many doctors want to understand marijuana's effects better before deciding whether to recommend it or not.

Neurological Disorders: Multiple Sclerosis (MS) Alzheimer’s Disease Dementia Epilepsy Traumatic Brain Injury (TBI) Huntington’s Parkinson’s Disease Tourette’s Syndrome Dravet Syndrome Amyotrophic Lateral Sclerosis (ALS)Lou Gehrig’s Disease Lyme Disease Migraine Neuropathy

MULTIPLE SCLEROSIS (MS)

EPILEPSY

Medical Marijuana is NOT for everyone and is often a last resort for people that have tried a variety of the pharmaceuticals below with little relief or too many side effects. Strong anecdotal evidence exists for the support of medical marijuana in treating MS symptoms but scientific research has been hampered by government.

Under no circumstances should any person with seizure disorder change, augment or substitute any prescribed antiepileptic medication for another registered drug or other (alternative, complementary or herbal) treatment without specific instructions to do so from their neurologist or attending physician.

Condition Description

Condition Description

Multiple Sclerosis (MS) is a painful, debilitating disorder of the central nervous system. MS is unpredictable, affecting vision, hearing, memory, balance and mobility.

[1] There is no cure for MS. Symptoms vary considerably from person to person; however, one frequently noted symptom is spasticity, which causes pain, spasms, and loss of function. MS is an autoimmune disease, the exacerbations experienced with MS appear to be caused by abnormal immune activity that causes inflammation and the destruction of myelin (the protective covering of nerve fibers) in the brain or spinal cord.[2]

Commonly Prescribed Drugs

Drugs commonly prescribed for muscle spasticity and tremor include Klonopin, Dantrium, Baclofen (Medtronic), Zanaflex, Klonopin (Clonazepam) and Valium (diazepam). These medications come with a list of side effects ranging from feeling lightheaded or drowsy, to slurred speech, blurred vision, changes in sexual drive and performance, gastrointestinal changes, muscle spasms and a fast or pounding heartbeat.[3] Benefits of Marijuana Some benefits of medical marijuana that many MS patients have reported include improved: Muscle spasms Tremors Balance Bladder control Speech Eyesight

Epilepsy is a neurological condition that afflicts approximately 1% of the world’s population.[1] There is a range of possible types of seizures depending on how wide spread the neurological disturbance is in the brain. Sometimes there are triggers for seizures such as low blood sugar, stress, sleep loss, or even boredom.[2] There is no known cause of epilepsy in approximately 60-75% of all cases.[3] Of the remaining 25-40%, there are a number of identified causes. These include brain injury to the fetus during pregnancy, birth trauma (lack of oxygen), aftermath of infection (meningitis), head trauma, alteration in blood sugar, other metabolic illness, brain tumor and stroke.[3]

Commonly Prescribed Drugs

Anti-convulsant drugs help control some kinds of epilepsy, but a few forms of epilepsy do not react well to these pharmaceutical drugs. These drugs have possible serious side effects, including bone softening, swelling of the gums, decreased production of red blood cells, and emotional instability.[2] Furthermore, anticonvulsant drugs only completely stop seizures in about 60% of epileptic patients.[2]

Benefits of Marijuana

Marijuana has been investigated for its anti-convulsant properties since the 19th century. Many patients with epilepsy believe medical marijuana is an effective therapy for epilepsy and are actively using it. [4] Many anecdotal reports as well as patient case studies indicate the assistance of medical marijuana in controlling seizures.[2] Some epileptic patients state that they can wean themselves off of prescription drugs and stay free of seizures as long as they have a regular supply of medical marijuana.[2]

EVERYONE WHO WANTS TO DO SOMETHING ABOUT MS CAN FUEL PROGRESS May/June 2016

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Using Medical Marijuana to Treat Dementia

While researchers have seen some success in using medical marijuana to fight the formation of beta amyloid plaques, studies are showing differing results in using it to treat the disease.

ALZHEIMER'S TREATMENT Marijuana is a controversial topic in the medical community, with some well-respected doctors advocating for its use and others concerned about its addictive properties and long term effects. As researchers continue to explore the drug as a potential treatment to chronic and terminal illnesses, some studies are focusing their efforts on the effects of medical marijuana on Alzheimer’s treatment and symptoms.

A research team from Radboud University Medical Center in Nijmegen, Netherlands, recently investigated the effects of medical marijuana on symptoms of dementia including aggression, anxiety, depression, insomnia and hallucinations, and did not see a statistically significance difference when using medical marijuana to treat symptoms associated with the disease.

The team divided their 50 participants into two groups with one group receiving 1.5 mg of medical marijuana pills and the other receiving a placebo pill. Participants took the pill three times a day for three weeks. After comparing the behavioral symptoms of both groups, researchers found there was no difference in the two groups.

Contrarily, a recent study published in The Journal of Alzheimer’s Disease has concluded that cannabis extract containing THC can relieve these symptoms of Alzheimer’s.

Medical Marijuana Brings Controversy to the Medical Community Researchers from the Abarbanel Mental Health Center and the Sackler Faculty of Medicine at Tel-Aviv University along with Medical marijuana or medical cannabis has been used throughout the the Department of Psychology at Bar-Ilan University world and for thousands of years to treat disease or alleviate conducted the study, which was one of the first clinical studies symptoms from disease. observing the effects of cannabis on Alzheimer’s.

Currently, the Food and Drug Administration (FDA) has approved two medical marijuana medications in pill form, “dronabinol” and “nabilone.” These two drugs are being used to treat nausea caused by chemotherapy and increase the appetites of people with AIDS. However, because of its addictive properties and unknown long term effects, its usage today is controversial in the medical community.

While medical marijuana has been shown to reduce nausea in people undergoing chemotherapy and help people living with HIV/AIDS some medical professionals are wary of using it as a treatment method.

Several organizations, including the American Medical Association and the American Society of Addiction Medicine, have issued statements opposing its usage for medical treatment purposes.

The Effects of Medical Marijuana on Alzheimer’s Prevention A preclinical study published in the Journal of Alzheimer’s Disease found that very small doses of tetrahydrocannabinol (THC), a chemical found in marijuana, can slow the production of betaamyloid proteins, thought to be a hallmark characteristic and key contributor to the progression of Alzheimer’s.

The study, published in 2014, is among others to support the effectiveness of THC in prohibiting the growth of toxic amyloid plagues.

Co-author of the study, Neel Nabar, cautions against drawing quick conclusions from their study saying:

The study observed the effects of medical marijuana on 11 people living with Alzheimer’s over the course of 4 weeks. 10 participants finished the trial. Despite the small size of the study, researchers concluded that:

“Adding medical cannabis oil to Alzheimer’s patients’ pharmacotherapy is a safe and promising treatment option.”

http://www.alzheimers.net/6-15-15-effects-of-medicalmarijuana-on-alzheimers/

“It’s important to keep in mind that just because a drug may be effective doesn’t mean it can be safely used by anyone.

However, these findings may lead to the development of related compounds that are safe, legal, and useful in the treatment of Alzheimer’s disease.”

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The concentrations of tetrahydrocannabinol (THC) in these studies ranged from 2 to 9 percent, with a typical concentration of 4 percent resulting in good efficacy. Side effects were modest and included light-headedness, mild difficulties in concentration and memory, tachycardia, and fatigue. Serious side effects (e.g., severe anxiety, paranoia, psychotic symptoms) were not observed. Mild cognitive changes resolved within several hours of drug administration.

NEUROPATHY Medicinal Cannabis and Painful Sensory Neuropathy By : Igor Grant, MD

Painful peripheral neuropathy comprises multiple symptoms that can severely erode quality of life. These include allodynia (pain evoked by light stimuli that are not normally pain-evoking) and various abnormal sensations termed dysesthesias (e.g., electric shock sensations, “pins and needles,” sensations of coldness or heat, numbness, and other types of uncomfortable and painful sensations). Common causes of peripheral neuropathy include diabetes, HIV/AIDS, spinal cord injuries, multiple sclerosis, and certain drugs and toxins. Commonly prescribed treatments come from drugs of the tricyclic and selective serotonin reuptake inhibitor (SSRI) antidepressant classes, anticonvulsants, opioids, and certain topical agents. Many patients receive only partial benefit from such treatments, and some either do not benefit or cannot tolerate these medications. The need for additional treatment modalities is evident.

Animal studies and anecdotal human evidence have for some time pointed to the possibility that cannabis may be effective in the treatment of painful peripheral neuropathy [1]. Recently, the Center for Medicinal Cannabis Research (CMCR) at the University of California [2] completed five placebo-controlled phase II clinical trials with smoked or inhaled cannabis [3-7]. Another study reported from Canada [8]. Patients included people with HIV neuropathy and other neuropathic conditions, and one study focused on a human model of neuropathic pain. Overall, the efficacy of cannabis was comparable to that of traditional agents, somewhat less than that of the tricyclics, but better than SSRIs and anticonvulsants, and comparable to gabapentin (see figure 1).

The concentrations of tetrahydrocannabinol (THC) in these studies ranged from 2 to 9 percent, with a typical concentration of 4 percent resulting in good efficacy. Side effects were modest and included light-headedness, mild difficulties in concentration and memory, tachycardia, and fatigue. Serious side effects (e.g., severe anxiety, paranoia, psychotic symptoms) were not observed. Mild cognitive changes resolved within several hours of drug administration.

While these were short-term trials with limited numbers of cases, the data suggest, on balance, that cannabis may represent a reasonable alternative or adjunct to treatment of patients with serious painful peripheral neuropathy for whom other remedies have not provided fully satisfactory results.

Because oral administration of cannabinoids (e.g., as dronabinol, marketed as Marinol) can result in inconsistent blood levels due to variations in absorption and first-pass metabolism effects, inhalational (or potentially sublingual spray, e.g., nabiximols, marketed as Sativex) administration remains preferred to oral administration.

Cannabis as a smoked cigarette, while demonstrating efficacy, poses a number of challenges, inasmuch as it remains illegal under federal law, even though it is permitted in an increasing number of jurisdictions on physician recommendation. Figure 2 (see next page) provides a schematic approach for physician decision making in jurisdictions where medicinal cannabis is permitted [9].

This decision tree suggests key points that a physician should consider in making a determination. In the case of a patient assumed to have persistent neuropathic pain, the first determination to be made is that the patient’s signs and symptoms are indeed consistent with a diagnosis of neuropathy. Assuming a patient does not respond favorably to or cannot tolerate more standard treatments (e.g., antidepressants, anticonvulsants) and is willing to consider medicinal cannabis, the physician proceeds to compare risk and benefit. Among these considerations is whether the patient has a history of substance abuse or a serious psychiatric disorder that might be exacerbated by medicinal Figure 1. Common cannabis. Even the presence of such a risk does not necessarily analgesics for neuropathic preclude the use of medicinal cannabis; rather, coordination pain. with appropriate substance abuse and psychiatric resources is necessary, and, based on that consultation, a risk-benefit ratio to achieve a 30% reduction in pain. can be formulated. In patients for whom the ratio appears favorable, the physician should discuss modes of cannabis administration including oral, smoked, or vaporized. Once risks and benefits are evaluated and discussed with the patient, cannabis treatment may commence as with other Number needed to treat (NNT) = 1/(E-P), where E is the proportion improved in psychotropic medications, with attention being paid to experimental condition and P is the proportion improved on placebo. Example: If 60% side effects as well as efficacy. Attention must also be paid “improve” (according to a given definition) in the experimental condition, while 30% “improve” in the placebo condition, then NNT = 1/(.6-.3) = 3.3. Data adapted from to possible misuse and diversion, which can then trigger a Abrams et al. [3] and Ellis et al. [4]. decision to discontinue the treatment.

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Figure 2. A decision tree approach for physicians who may be considering recommending medicinal cannabis to a patient (from Grant et al. [9]).

Key: 1.

2.

3.

4.

5.

6.

10

Daily or almost daily pain with typical neuropathic characteristics for at least 3 months; affects life quality.

Standard Rx = e.g., antidepressants, anticonvulsants; opioids; nonsteroidal anti-inflammatory drugs.

For example, at least 30% reduction in pain intensity.

Consider past experience, possible past history of side effects; willingness to smoke.

Determine history of substance abuse. If yes, or at “high risk� of aberrant drug behavior; proceed with close observation; possibly coordinate with substance abuse treatment program.

Efficacy = at least 30% reduction in pain intensity.

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In summary, there is increasing evidence that cannabis may represent a useful alternative or adjunct in the management of painful peripheral neuropathy, a condition that can markedly affect life quality. Our society should be able to find ways to separate the medical benefits of making a treatment available to improve lives when indicated from broader social policy on recreational use, marijuana legalization, and unsubstantiated fears that medicinal cannabis will lead to widespread cannabis addiction [10-12].

References: 1. Joy JE, Watson Jr SJ, Benson JA, eds. Marijuana and Medicine: Assessing the Science Base. Washington, DC: National Academies Press; 1999.

2. Center for Medicinal Cannabis Research. http://www.cmcr.ucsd.edu.

3. Abrams DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology. 2007;68(7):515521.

4. Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis for neuropathic pain in hiv: a randomized, crossover clinical trial. Neuropsychopharmacology.

2009;34(3):672-680.

5. Wallace M, Schulteis G, Atkinson JH, et al. Dose-dependent effects of smoked cannabis on capsaicin-induced pain and hyperalgesia in healthy volunteers.

Anesthesiology. 2007;107(5):785-796.

6. Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H. Low-dose vaporized cannabis significantly improves neuropathic pain. J Pain.

2013;14(2):136-148.

7. Wilsey B, Marcotte T, Tsodikov A, et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. J Pain. 2008;9(6):506521.

8. Ware MA, Wang T, Shapiro S, et al. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ. 2010;182(14):E694-E701.

9. Grant I, Atkinson JH, Gouaux B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurology J. 2012;6:18-25.

10. Kleber HD, DuPont RL. Physicians and medical marijuana. Am J Psychiatry.

2012;169(6):564-568.

11. Harper S, Strumpf EC, Kaufman JS. Do medical marijuana laws increase marijuana use? Replication study and extension. Ann Epidemiol. 2012;22(3):207-212.

12. Grant I, Atkinson JH, Gouaux B. Research on medical marijuana. Am J Psychiatry.

2012;169(10):1119-1120.

Igor Grant, MD, is a professor and executive vice chair of the Department of Psychiatry and director of the HIV Neurobehavioral Research Program (HNRP) at the University of California, San Diego School of Medicine. Dr. Grant is the founding editor of the Journal of the International Neuropsychological Society and founding co-editor of the journal AIDS and Behavior.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA. Copyright 2013 American Medical Association. All rights reserved.

May/June 2016 CANNABISNURSESMAGAZINE.COM

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Dravet's & Prevention

By: Jennie Stormes, RN, BSN

Can a Gene Make Your Diet Work Better? darvet

By Neal D. Barnard, M.D.

I

n 2009, Jackson was diagnosed with Dravet Syndrome after having genetic testing done for the SCN1A mutation. Prior to the genetic testing, Jaxs had a diagnosis of "medically refractory, idiopathic, cryptogenic epilepsy". This is a fancy way for the doctors to say that they "do not know what is causing his seizures, nor do they know how to treat his seizures because they are not responding to the medications or to other medical interventions". Jackson has suffered from these seizures since October 21, 1999 (4.5 months old) and his second seizure was on November 3, 1999 when he was started on the first narcotic medication in an attempt to control his seizures.

 Possible Cardiac issues from the repeated seizures and work Jackson is being followed locally by Dr. Eric Segal at the Northeast load on the heart Regional Epilepsy Group in Hackensack, NJ.  Brain injury related to the ongoing seizures Since 2009, Jackson has meet with Dr. Charlotte Dravet from France  Inability to recognize danger or to care for himself  Side effects of medications including lethargy, and Dr. Ian Miller from Miami Children's Hospital and the Brain drowsiness, and aggressive behaviors.

Institute in Miami, FL. Currently Jackson is taking only one pharmaceutical at There are many signs and symptoms accompanying the diagnosis of a very low dose for his age and weight since beginning Dravet Syndrome. The presentation of Dravet can be life altering the THC + CBD treatment. In the past 15 years the and will effect many areas of functioning and abilities. The pharmaceutical medications and treatments have been ineffective in controlling his almost daily seizure challenges can vary from one child to another. activity. In November 2011, the insurance company, through the EPSDT/Medicaid approved a medication Jackson suffers from the following: approved for use in Europe which has shown efficacy  Neurological Dysfunction with frequent seizures in the treatment of Dravet children: stiripentol. The  Cognitive Delays approval was based on compassionate use basis since  Expressive Language Speech Delays there is no effective pharmacological treatment  Dysautonomia: difficulties regulating his body temperature & available in the US FDA approved market. With the breathing irregularities while sleeping addition of the stiripentol, the treatment has proven to  Autistic-like characteristics and behaviors also be ineffective, along with the other FDA approved  ADD/ADHD Combined Form medications. Jaxs still suffers from seizures. He has  Sensory Integration Disorder been benzo free since November 18, 2013 and  Ataxia barbituate free since Feb, 2013.  Orthopedic issues with awkward gait and flat feet

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Dravet's & Prevention Despite all of the medications and other limitations, Jackson has the ability to wake up every morning with a smile and a warm greeting: "Good Morning Mom!". I am blessed with this greeting even on the mornings when he has seizures before waking up; sometimes he has 10+ seizures between 2 am and 6 am and still wakes with a smile and willingness to tackle the day. He is the inspiration and sunshine which empowers me to continue each day to fight for his needs, inspires me to request access to appropriate medical care and hope for the future for him to live the happiest and best life possible.

Medications and/or treatments tried before MMJ: Phenobarbital, Klonopin, Tranxene, Onfi, Versed, Diastat, Valium, Lorazapam, Tegretol, Depakote, L-Carnitine, Topomax, Keppra, Keto Diet with many nutritional supplements, Zonegram, Zaratin, Felbatol, Ritilan, Lamictal, Diamox, Vitamin B6, Prednisone, Clonodine, Gabapentin, Banzel, Stiripentol, Prozac Surgical Intervenations: VNS, Right Frontal Lobectomy, 2/3 anterior corpus Callosotomy

Current Treatments and Options for Dravet Syndrome: At this point in time, there is no cure or known effective treatment for Dravet Syndrome. Some children with Dravet Syndrome have achieved seizure control with a cocktail of medications or treatments. The same cocktail may not work for another child. To date, there are three treatments options for some children diagnosed with Dravet Syndrome:

This is the list of medication Jackson is currently taking:

CBD : THC (Concentrate) - 240mg : 80mg (Indica) - Banzel 300 mg BID (PRN) - Keppra (PRN) - Fycompa 4mg (to wean off Kepra and Banzel)

Ketogenic diet with medications available in the United States; Stiripentol (FDA-Orphan Drug Status) used in conjunction with Depakote and Onfi (clobozam).

CBD rich medication cultivated from the medicinal marijuana plants.

Research continues and Dravet non-profit organizations are taking great steps to organize parents and professionals to continue in the pursuit of answers for our children to improve their quality of life.

Progress with CBD Treatment: In November 2012, Jaxs cocktail began to include a trial of CBD rich butter. His dosing has increased and he is beginning to show signs of cognitive improvements, lessened seizure intensity and quicker recovery from seizure events. His VEEG background is now showing normal without slowing or spike waves. He has completely weaned from phenobarbital (highly addictive barbiturate) Klonopin (highly addictive benzodiazapine) and Onfi (highly addictive benzodiazapine), Stiripentol, and a decrease in depakote by 50%. Jaxs is also no longer on the ketogenic diet with 5 additional nutritional supplements.

Resources: Dravet Syndrome for Dummies Website with summary of Dravet facts and information.

Charlotte Dravet, MD summary of information and knowledge.

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Cannabis in Washington State: A Nurse's Report

By: Lisa Bucannan RN, OCN Washington State said yes to the adult use of recreational marijuana in November 2012 when 56% of voters endorsed I-502. It established a comprehensive regulatory structure for the licensing and taxation of marijuana production & distribution (wholesale and retail sales), and authorized possession of marijuana for personal use (1 ounce or less) for persons age 21 and older. The initiative dedicated a percentage of tax revenue for substance-abuse prevention, research, education, and healthcare. (1) The initiative also established that motorists with detectable levels of THC in the blood above 5 ng/mL are guilty of driving under the influence of drugs. I-502 became effective on December 9, 2012, but adults were unable to legally purchase cannabis until July 8, 2014 when Cannabis City, Washington’s first cannabis retailer, opened for business.

Recreational users are not allowed to cultivate cannabis plants. Washington’s 2015 retail marijuana sales were in excess of $322 million. 2016 sales numbers look to be larger, despite lower cannabis prices.

2010 legislation expanded the list of professionals who may authorize the use of marijuana for medicinal purposes to include physicians, osteopathic physicians, physician assistants, osteopathic physician assistants, naturopaths, and advanced registered nurse practitioners. The 2011 legislative session was messy, but in the end, patients with valid authorizations were allowed 15 plant patient home grows and the collective garden model was established. Medical collective gardens (dispensaries) flourished in the mostly unregulated medical market. Patients living in the greater Seattle area had many options to obtain their medicine. Patients who lived in more conservative and/or rural areas of the state faced challenges in finding the appropriate forms of cannabis based medicine for their personal medical use.

Washington voters legalized medical marijuana in November 1998 when 59% of voters said yes to I-692, the Medical Use of Marijuana Act. It took effect on December 3, 1998 and created an affirmative defense to the violation of state laws relating to marijuana used and possessed for medicinal purposes. Legislation in 2007 added additional health conditions to the list for which marijuana use may be authorized, revised requirements for physician’s documentation, and directed the Washington Department of Health to define a 60-day supply of marijuana for medicinal use.

Marijuana research licenses were authorized creating a license to grow and possess marijuana for research purposes (SB 5121). An open container law was established for marijuana and motor vehicles, treating marijuana similarly to alcohol by trying to separate it from driving.

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Cannabis laws and regulations continued to multiply and evolve in 2015 & 2016. The Liquor Control Board was renamed the Liquor and Cannabis Board. The governor was enabled to enter into agreements with federally recognized Indian Tribes in the State of Washington concerning marijuana (HB 2000).

Marijuana cannot be consumed in any manner by drivers or passengers when the vehicle is upon the public highway. Open containers must be stored in the trunk or in some other area of the vehicle not normally occupied or directly accessible by the driver or passengers. (HB 1276).

The Cannabis Patient Protection Act (SB 5052) was passed

by Washington legislators in 2015. It added post-traumatic stress disorder and traumatic brain injuries to the list of qualifying conditions for medical marijuana authorizations. It merges the unregulated medical marijuana market with the highly regulated system established by I-502. The law replaces unregulated collective gardens & dispensaries with small patient cooperatives which are required to be registered with the Liquor and Cannabis Board, beginning July1, 2016.

Licensed marijuana retailers wanting to sell medical-grade marijuana to qualifying patients and designated providers are required to obtain a medical marijuana endorsement.

Beginning July 1, 2016, all marijuana retail stores with a medical endorsement are required to have a certified Medical Marijuana Consultant on staff. Medical Marijuana Consultants must first take and pass a state Department of Health approved training course. Training programs must include a minimum of 20 total instruction hours on designated topics.

Applications to become DOH certified trainer went online in March 2016. The Department of Health will review all applications and approve those training program providers that meet the criteria listed in statute and the rules. The Medical Marijuana consultant will enter patients into the patient authorization database and be able to assist with product selection, describe risks and benefits of administration methods, advise on safe handling and storage of products, and provide instruction on proper use .

The Cannabis Patient Protection Act (CPPA) mandates a voluntary patient database (medical patient registry). The Washington Department of Health is required to contract with a third party to create and administer a medical marijuana authorization database. Currently (4/2/16) the DOH is in the process of adopting rules relating to the operation of the database.

Effective July 1, 2016, patients who voluntarily enter into the authorization database are provided protection from arrest and prosecution and may obtain a recognition card. The recognition card authorizes possession by patients to 48 ounces of marijuana-infused solid product, 3 ounces of useable marijuana, 216 ounces of infused liquid product, 21 grams of marijuana concentrates, but only if they are registered with the database. Patients registered in the database can grow 6 plants and possess 8 ounces from those plants. Database enrolled patients are exempt from paying retail sales tax on cannabis and they are allowed to shop at medically endorsed retail stores.

Patients and designated providers who hold valid authorizations but aren't entered into the database will have an affirmative defense to criminal prosecution if they possess no more than four plants and six ounces of usable marijuana.

They may purchase only in accordance with the laws and rules for non-patients. (3) These patients are limited to 1 ounce of useable marijuana, 16 ounces of marijuana-infused solid product, 72 ounces of infused liquid product, and seven grams of marijuana concentrate.

The Department of Health began the rule-making process on the proposed medical marijuana rules during Fall 2015.

Stakeholders, members of the general public, and other interested parties were invited to participate in hearings and provide comments. The first medical marijuana rules package (medical marijuana consultant) went into effect March 18, 2016. Hearings on the final two rules packages (Marijuana Product Compliance and Medical Marijuana Authorization Database) were held on March 22 and 25 and are considered to be in progress at press time.

The Liquor and Cannabis Board adopted emergency rules on March 23rd to implement product recall procedures for those products deemed a risk to public health and safety. The rules also provide licensees with the ability to withdraw products for reasons that are not related to public health risks, such as faulty packaging or aesthetic purposes.

The Liquor and Cannabis Board made further rule recommendations on March 23rd, some of which include adding language that marijuana and marijuana products exposed to unauthorized soil amendments or fertilizers, or marijuana with detectable levels of unauthorized pesticides or plant growth regulators are subject to seizure and destruction.(4) Persons operating without a WSLCB approved marijuana licensed location will be discontinued, which effectively closes the last of the unregulated medical marijuana dispensaries. Inventory destruction as a penalty for producers and processors was removed, instead all penalties for producers and processors are monetary penalties. (4) The LCB will be asked to adopt proposed rules in May after this goes to print.

When you look at the recent history of medical and recreational (adult use) marijuana in Washington State it becomes very clear that the voters have been the primary drivers of change to more liberal marijuana laws.

Lawmakers and state agencies have been tasked to regulate and control marijuana per statutes. The state has been diligent in seeking input from the public on its draft rules.

Hearings were scheduled in multiple areas of the state to facilitate participation. Spoken and written comment by stakeholders was encouraged.

In the last year I have traveled to many hearings and meetings about marijuana policies and regulations. I’ve joined patients, family members, marijuana activists, business people, fellow nurses and healthcare providers in responding to the state’s request for stakeholder input.

The Department of Health’s document, Medical Marijuana Consultant Certification Concise Explanatory Statement: WAC Chapter 246-72, indicates that input from stakeholders compelled the Department of Health to add Registered Nurses with a bachelor’s degree in nursing, who have demonstrated knowledge of the subject matter they teach,

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and have an active license to practice as a registered nurse in WA to the list of approved Medical Marijuana Consultant Instructors (4). Initially ARNP’s were the only nursing category that were approved Medical Marijuana Consultant Instructors. What that tells me, is that we the people have the power to influence change at the local, state, and national level by rationally testifying to our elected officials.

Attempts to initiate home grow legislation for Washington state adults stalled during the most recent legislative session.

Washington activists have filed Initiative Measure No. 1419.

It’s Ballot Summary states: This measure would create a board to license and regulate medical-cannabis producers and dispenseries; create a board to govern the recreational use market; release offenders incarcerated for non-violent cannabis crimes; create tax exemptions and impose fees; allow unlicensed collective cannabis gardens; address medical-cannabis use by minors; limit use of THC bloodconcentration evidence; prohibit certain drug testing for marijuana byproducts; prohibit assistance with certain federal investigations; add criminal defenses; and adopt or repeal other cannabis-related laws.

I think that we can expect new regulations will impact the way marijuana testing labs operate. The LCB will continue to improve testing and labeling requirements for marijuana products available for purchase at medical and recreationally endorsed stores. The one thing that will stay constant in the marijuana industry is ongoing innovation and change.

(1) http://www.ncsl.org/documents/summit/summit2015/ onlineresources/wa_mj_law_history.pdf (2) http://app.leg.wa.gov/RCW/default.aspx? cite=69.51A.290 (3) http://www.doh.wa.gov/YouandYourFamily/Marijuana/ MedicalMarijuana/PossessionAmounts (4) http://lcb.wa.gov/publications/rules/2016-ProposedRules/MJ-Rules-2nd-Supp.docx (5) http://www.doh.wa.gov/Portals/1/ Documents/2300/2016/MMJCC-CES.pdf (6) http://sos.wa.gov/_assets/elections/initiatives/ FinalText_933.pdf

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Lisa Buchanan RN, OCN has been a licensed as a Registered Nurse in Washington since 1992 and has been involved in cannabis patient advocacy for the last 16 years. She holds certificates of completion for both the Core Curriculum for Cannabis Nursing and the Advanced Curriculum for Cannabis Nursing. She is a member of the Oncology Nurses Society and the American Cannabis Nurses Association. Lisa founded Paisley Nursing Group, LLC in 2015 which provides evidence-based education and consultation to patients, the public, and governmental agencies. Lisa is participating as a panelist at Seattle Hempfest, August 19th-21st, 2016 and is on the Cannabis Nurses Magazine Advisory Board.

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ALZHEIMER’S DISEASE and Medical Marijuana

Is it right for me or a loved one?

By: Dr. Gregory Smith

What is Dementia?

Signs of Alzheimer’s or Dementia: Poor decision making or judgement Unable to manage budget Difficulty having or keeping a conversation Losing track of date, day, or season Misplacing things and not being able to retrace steps

Normal Age-Related Changes:

Normal Age-Related Changes: Making a poor decision every once in awhile Missing a payment here and there Forgetting which word to use sometimes Forgetting the day but then remembering later Losing things every once in awhile

Alzheimer’s disease is one of the many causes of dementia. Dementia refers to any brain injury or disorder that affects thought, memory and language.

There are several common causes of dementia, other than Alzheimer's disease, including post-stroke dementia, repeated concussions, and genetic diseases like Huntington's disease, Parkinson's disease and Creutzfeldt-Jakob disease. There are also the normal, age-related brain changes that cause some minor memory issues and occasional poor judgement.

Many people who think that are getting Alzheimer’s disease, are actually just getting normal age-related changes. Here’s a comparison between Alzheimer’s disease and Normal Age-Related Changes:

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The

prevalence of Alzheimer’s disease is expected to

rise with the aging of the population, increasing the urgency to develop new therapies to

treat, delay, and, ultimately,

prevent the disease.

Alzheimer’s disease is common:

However, Alzheimer’s is a common condition, especially after age 65, and by 85 half of all people have it. Alzheimer's disease, is also called senile dementia, and represents 60-70% of all cases of dementia. Half of patients with Alzheimer’s have another cause of dementia as well. About 200,000 people under age 65 have Alzheimer’s disease, in these cases it is usually due to a genetic cause.

About 1% of Alzheimer’s cases are due to one of three abnormal genes.

An individual with a first degree relative (parent, sibling, child) who has Alzheimer’s, has a higher risk of getting the disease themselves, and this risk increases as the number of first degree relative with the disease increases.

Alzheimer’s is a degenerative brain disease: Alzheimer’s disease is caused by the buildup of a protein called amyloid in plaques outside of the cells, and inside the cells amyloid protein leads to tangles of tau protein. The untangled protein is a normal substance in the brain and functions to stabilized the structure of brain cells. The higher the amount of tangled up protein in and around brain cells the more rapid the rate of brain decline in Alzheimer’s. These plaques and tangles are toxic to brain cells via inflammation and adverse effects inside of the cell. These toxic effects are very slow and take decades to gradually kill brain cells and cause dementia and associated behavioral problems. A decreased number of brain cells in a center of the brain, leads to decreased messaging from that part of the brain to other parts of the brain, so communication between various centers that have to do with memory, organizing, and language become affected.

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The ways to halt the progression of the disease:

Any thing that decreases the amount of amyloid protein, and the number of tau tangles or decreases the inflammatory response around the brain cells will result in a delay in the progression of Alzheimer’s.

It starts with short-term memory loss: Patients with Alzheimer’s disease usually start out with short-term memory loss. Early on in the disease it may be difficult to differentiate normal aging changes from Alzheimer's disease. As the disease progresses symptoms include issues with language, mood swings, social withdrawal, disorientation to time, place or person, and other behaviors such as agitation. Late in the condition there is loss control of bodily functions.

Other medical conditions can increase the chance of getting Alzheimer’s including: depression, hypertension, and stroke or concussions. Ongoing mental and physical exercise and avoiding obesity may decrease the risk of getting Alzheimer's disease. Other medical conditions such as high blood pressure, heart disease, strokes, depression, concussions, and other neurodegenerative conditions can make the dementia worse. Also, using medications, recreational drugs or alcohol that affect memory, thinking, and concentration can temporarily make the dementia worse.

Early identification is the key halting the disease: It is agreed in the medical community that early identification of the onset of Alzheimer’s disease and newer means to halt the progression of the disease are likely to be the most effective treatment. This is because it is unlikely for a medication to help restore dead brain cells. So early diagnosis and halting the progression of the

disease is the goal of any treatment. The available prescription medications only treat some of the symptoms for 6-12 months, and then stop working. These medications do not prevent the disease, halt progression or cure the condition.

Early Warning Signs: The following is a list of the 10 most common early warning signs of Alzheimer's Disease. Do you recognize any of these signs?:

Memory loss that is disruptive to daily life Planning and problem solving becomes challenging Completing familiar tasks becomes difficult Confusion with place and time Difficulty understanding spatial relationships and images 

Caring for People with dementia is challenging. But Support for caregivers can help ease the Burden and may result in better outcome for Alzheimer's Patients.

Problems with words in speaking or writing that did not exist before Losing the ability to retrace steps and misplacing things Decreased or poor judgment around the plaques and damaged brain cells. Less Withdrawal from work and or social activities inflammation is good forhalting the progression of the Changes in mood and personality disease.

The ‘blood brain barrier’ stops most medications from getting to the brain: The hardest challenge to treating Alzheimer’s has been getting medication past the “blood brain barrier,” a natural protective barrier.

This stops most chemicals, drugs and microbes from getting out of the blood stream and to the brain cells. Only about 1% of the dose of a medication or nutraceutical used to treat Alzheimer’s gets through the blood brain barrier, the other 99% never gets to the brain and is useless in treating Alzheimer’s.

Medical marijuana gets past the ‘blood brain barrier.’

The two most medically active drugs in marijuana are THC and CBD. These drugs quickly get past the blood brain barrier in a matter of seconds. That is because they use specific receptors to quickly transport them across the blood brain barrier. This makes them very effective for treatment of certain brain conditions.

How does medical marijuana work:

In the past few years many studies in cell cultures and mice models of Alzheimer’s have shown that cannabis may be effective in reversing the accumulation of amyloid plaques in the brain by assisting in its transport across the blood brain barrier and out of the brain. In addition, and also very important, THC and CBD decrease the inflammation that is going on

Like the FDA approved prescription medications for the treatment of Alzheimer’s symptoms, THC decreases the action of the enzyme acetylcholinesterase. Since this enzyme speeds the formation of amyloid plaques, this should slow the progress of Alzheimer’s. THC was shown to work 5-15 times better than the available prescription medications. Studies of the prescription medications, show that they only improve the symptoms of Alzheimer’s for about 6-12 months, then stop working.

It is not known if this is true for THC. However, marijuana has many effects on halting Alzheimer’s disease, and this is only one of the effects.

THC, like melatonin, improves the function of mitochondria inside the cells. The mitochondria are the motors that drive the cellular functions.

Currently there are no high quality studies of marijuana and Alzheimer’s in humans, but these studies are underway and more are coming over next few years. But we can extrapolate what we learn in cell cultures and mice to humans.

Low doses of marijuana don’t get people “high”

Both THC and CBD provide different means of treating Alzheimer’s. Because THC and CBD cross the blood brain barrier so quickly and effectively, only very low doses of cannabis are needed on a daily basis to have a measurable impact. This means that the patients don’t get any appreciable “high” from the dose, but it is having a medical effect.

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This means that the patients don’t get any appreciable “high” from the dose, but it is having a medical effect.

It is rare to get addicted from once a day, low doses of marijuana: There are several studies that show that as many as 9% of regular recreational users of high THC cannabis can get physically dependent or ‘addicted’ to THC. This is especially true in adolescent users and in people that use cannabis several times a day. However, this is a mild addiction. People are able to withdraw from marijuana in one to two weeks with only mild side-effects.

Marijuana works on a system that is inside our brain and body: Both THC and CBD, stimulate receptors of the endocannabinoid system (ECS). This is a natural system in our bodies. It is present in parts of the brain and on immune cells all over the body. In the brain, receptors on brain cells are stimulated by the THC and this leads to more rapid removal of excess amyloid from the cell, so that the excess doesn’t turn into plaques, or result in tau tangles inside the cell. The end result is improved brain cell function, connection and communication with other brain cells. These natural receptors are most plentiful in the hippocampus part of the brain. That is the area of the brain most affected by Alzheimer’s and has to do with memory, and organization.

Marijuana also decreases cell destroying inflammation in the brain: CBD, and THC have another effect. They also attach to different cells, called microglial cells in the brain. These are the cells in charge of inflammation. When CBD or THC attaches to microglial cells, this turns down the inflammation that they cause around the plaques and damaged brain cells. This effect may be more important that decreasing the amount of amyloid. Because CBD can do this by itself, CBD-only oils that are legal and available in all 50 states, may be considered for halting the progression of Alzheimer’s right now.

Behavioral symptoms: mp The behavioral symptoms of the late stages of Alzheimer’s disease are the most devastating.

They significantly impact the patient and caregivers and are usually the cause for someone to be placed in a memory care facility. Marijuana has measurable effects on many of the behavioral symptoms of Alzheimer’s, such as anxiety,

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depression, insomnia, nausea and weight loss as well as on other medical conditions that are common in old age, such as arthritic pain and loss of appetite.

However, the low doses recommended to stop the progression of Alzheimer’s may not be high enough doses to have a measurable impact on these symptoms. However, THC and CBD often work hand-inhand with the regularly prescribed medications for these behavioral symptoms.

Alzheimer “Cocktails”:

Marijuana works in combination with the available prescription drugs, dietary modifications and the nutraceutical cures being touted such as vitamin C and E, frequent coffee consumption, aspirin, melatonin, magnesium and fatty acids. These nutraceuticals are often quite effective on their own accord. All of these safe, natural means of helping halt the Alzheimer’s disease process should be used, at the same time as cannabis-based medication.

Combinations of several of these ingredients along with THC and CBD, called Alzheimer’s “cocktails” are being developed by pharmaceutical companies. In addition newer techniques to get these “cocktails” past the blood brain barrier have been developed in nano-particles and specifically designed nasal sprayers.

Marijuana is safe and well tolerated by most patients:

Marijuana, and marijuana-related medications are very safe, and relatively inexpensive. The wide range of dosing of the medication, allows the patient to start at very low doses, and gradually titrate the dose up if necessary. Ultra-low to low doses of marijuana are all that have been shown to be necessary for Alzheimer’s treatment.

The potential side-effects from cannabis-medications are mild, self-limited and easy to monitor. However, cannabis has the ability to exacerbate some of the symptoms associated with later stages of Alzheimer’s such as paranoia, anxiety, and short term memory loss during intoxication with higher levels of THC. Therefore, focusing on the use of ultra-low and low doses of THC is important.

CBD alone does not cause a “high” and is not addictive: CBD is not associated with getting “high,” addiction or any of the adverse side-effects of THC. It has its biggest impact by reducing inflammation in the brain, which is an important factor in the progression of Alzheimer’s.

Always consult your doctor with any changes in treatment: Most doctors do not have any education or experience with medical marijuana. The lack of research makes it appear to doctors that marijuana is not a viable option for treatment. However, a little research should on the topic of marijuana and Alzheimer’s disease should help your doctor quickly understand the potential impact and cooperate. In addition a review of the safety of marijuana, especially in low, once daily bedtime doses, should help alleviate most of your doctor’s concerns about using medical marijuana for Alzheimer’s disease.

Contemplation of the use of marijuana, CBD oil, or over-the-counter nutraceuticals should be carefully considered with the guidance of a healthcare professional. If the decision in support of marijuana or nutraceutical treatment is made, treatment should be started slowly, and monitored by the patient and healthcare professional.

FDA approved medications for Alzheimer’s: The available FDA approved prescription medications for the treatment of Alzheimer’s are only effective at reducing some symptoms for 6-12 months. After that the effect wears off. They only work on one aspect of the disease, blocking acetylcholinesterase. Unlike THC and CBD, which affect many causes of the disease, these medications do not halt the progression of the disease, and they are expensive and associated with significant side-effects.

The right dose: The correct dosing of the medication is vital to success. Studies have shown that only a tiny amount of the THC and CBD need to get to the brain cells to have the desired medical effect. The disease smolders in the brain, and effects from cannabis will take weeks to months to become apparent. Given these facts, and considering it is probably desirable not to get “high” from the cannabis, or get behavioral side-effects such as anxiety, and temporary worsening of short term memory, the following are the doses that your medical professional will probably recommend.

First your medical professional will assess your baseline cognitive function with some simple screening tests. Once started the efficacy of the cannabis can be assessed by using the same tests.

The natural history for Alzheimer’s disease is for it to progress, sometimes quite rapidly. So, the outcome that you and your doctor are looking for is a halt in the progression of symptoms. Reversal of symptoms is not a goal although, it can happen. You and your doctor can not judge the efficacy of cannabis after a few doses, it needs to be given routinely for several weeks, before an assessment can be made of its efficacy.

Only a once a day dose is required initially. This is usually 2.5mg each of THC and CBD. This would be a 1:1 ratio of THC to CBD. This is best at bedtime, when any potential side effects would be less noticeable. If the initial dose doesn’t halt the progression of symptoms, the once-a-day dose can be gradually increased every 4-6 weeks, depending on the condition. The THC dose remains the same (2.5mg) while the CBD is increased by 2.5-5.0mg.

The THC and CBD dose should be increased to 2.5mg/10mg before considering adding a second or eventually a third dose, throughout the day.

It does not matter how the THC and CBD are taken.

For example oral delivery with edibles, tinctures, or mouth sprays are just as effective as vaporized or smoked cannabis, or dermal patches. The THC and CBD eventually all end up in the bloodstream, and are then quickly transported across the blood brain barrier where they can interact with brain cells. If only CBD is to be used, then the starting dose is 5mg at bedtime. This is increased to 10mg at bedtime, before considering adding second or third daily doses. The CBD only works on inflammation, and not on decreasing the amount of amyloid, so it may take longer or higher doses to get to the point where the progression of Alzheimer’s is halted.

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SPRING TIME Spring is a time when you’ll find some of the most tender and juicy fruits and vegetables in our markets. To celebrate, I have compiled some great spring recipes for all to enjoy!

To LeArn more AbouT

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go To www.cookwithherb.com

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Strawberry and Spinach Salad

herbed FiSh wrapped in lettuce

INgrEdIENtS 2 bunches spinach, rinsed and torn into bite-size pieces 4 cups sliced strawberries 1/2 cup THC olive oil 1/4 cup white wine vinegar 1/2 cup white sugar 1/4 teaspoon paprika 2 tablespoons sesame seeds 1 tablespoon poppy seeds

INgrEdIENtS: 3 tablespoons THC butter, softened 2 tablespoons chopped mixed fresh tarragon and/or parsley 1 tablespoon chopped shallots 4 6-ounce white fish fillets, such as flounder, sole or tilapia 4 large green or red leaf lettuce leaves, center rib discarded

dIrECtIoNS In a large bowl, toss together the spinach and strawberries.

In a medium bowl, whisk together the THC olive oil, vinegar, sugar, paprika, sesame seeds, and poppy seeds. Pour over the spinach and strawberries, and toss to coat.

Mixed GreenS with GrapeS & Feta INgrEdIENtS 1/4 cup THC olive oil 2 tablespoons red-wine vinegar 1/4 teaspoon salt, or to taste Freshly ground pepper to taste 8 cups mesclun salad greens (5 ounces) 1 head radicchio, thinly sliced 2 cups halved seedless grapes (about 1 pound), preferably red and green 3/4 cup crumbled feta or blue cheese dIrECtIoNS To prepare dressing: Whisk THC olive oil, vinegar, salt and pepper in a small bowl (or jar) until blended.

To prepare salad: Just before serving, toss greens and radicchio in a large bowl. Drizzle the dressing on top and toss to coat. Divide the salad among 8 plates. Scatter grapes and cheese over each salad; serve immediately.

dIrECtIoNS Preheat the oven to 375 degrees and lightly grease a baking sheet and set aside. In a large shallow bowl, mix together the cheese, herbs, and pepper. Dip each chicken wing into the THC butter and then dip into the cheese mixture and roll to coat. Place on the prepared baking sheet. Bake for 25 minutes, then flip over. Bake for an additional 1015 minutes, or until golden.

Garlic aSparaGuS with liMe INgrEdIENtS: 1 teaspoon THC butter 1 tablespoon THC olive oil 1 clove garlic, minced 1 medium shallot, minced 1 bunch fresh asparagus spears, trimmed 1/4 lime, juiced salt and pepper to taste dIrECtIoNS Melt THC butter with THC olive oil in a large skillet over medium heat. Stir in garlic and shallots, and cook for 1 to 2 minutes. Stir in asparagus spears; cook until tender, about 5 minutes. Squeeze lime over hot asparagus, and season with salt and pepper. Transfer to serving plate, and garnish with lime wedges.

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SprinG Garden SautĂŠ INgrEdIENtS 2 pound(s) asparagus, trimmed and cut into 1 1/2-inch pieces 8 ounce(s) sugar snap peas, strings removed 3 tablespoons THC butter 1 pound(s) radishes, each cut into quarters Salt and pepper 4 tablespoon(s) snipped fresh chives dIrECtIoNS Heat large covered saucepot of salted water to boiling on high. Fill large bowl with ice water; set aside. To saucepot, add asparagus and snap peas; cook 4 minutes. Drain vegetables; cool in bowl of ice water. Drain vegetables well.

Meanwhile, in 12-inch skillet, heat THC butter on medium until melted. Add radishes, 1/4 teaspoon salt, and 1/8 teaspoon freshly ground black pepper; cook 10 minutes or until tender-crisp.

Transfer to bowl; keep warm. To same skillet, add asparagus, snap peas, 1/4 teaspoon salt, and 1/2 teaspoon freshly ground black pepper; cook 5 minutes or until tender-crisp, stirring occasionally.

Stir in 2 tablespoons chives. Transfer to serving bowl; arrange radishes around edge. Sprinkle with remaining chives

walnut pot butter cookieS INgrEdIENtS 1 pound of THC butter, softened 4 cups of all purpose flour 3/4 cup of powdered sugar 2 tsps of vanilla 2 Tbls of water 1/2 tsp of salt 8 to 12oz of chopped walnuts Extra powdered sugar for dusting dIrECtIoNS Pre-heat the oven to 350 degrees. Using a wooden spoon, mix together the THC butter, flour, powdered sugar, vanilla, water and salt in a large mixing bowl. Mix together until the mixture forms a doughy consistency. If the dough if too sticky to handle just add a little more flour. Add the walnuts. Pinch the dough and roll it in a long shape about the size of your finger. Curve into a crescent shape and place on a buttered cookie sheet. Bake for 12 to 14 minutes. Let the cookies cool before dusting them with powdered sugar.

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diabetic peanut butter cookieS INgrEdIENtS 1/4 cup THC butter, softened 1 cup creamy style peanut butter 1/4 cup egg substitute 2 tablespoons honey 1/2 teaspoon vanilla extract 1 cup Splenda Granular 1-1/2 cups all-purpose flour 1/2 teaspoon baking soda 1/2 teaspoon salt dIrECtIoNS Heat oven to 350 degrees.

In a large bowl, beat THC butter and peanut butter with an electric mixer until creamy, approximately 1 minute. Add egg substitute, honey and vanilla extract. Beat on high speed for approximately 1 1/2 minutes. Add Splenda and beat on medium speed until well blended, approximately 30 seconds.

In small bowl, combine flour, baking soda and salt. Slowly add flour mixture to peanut butter mixture, beating on low speed until well blended, about 1 1/2 minutes. Mixture may be crumbly.

Roll level teaspoons of dough into balls and drop onto a lined sheet pan, about 2 inches apart. Flatten each ball with a fork, pressing a crisscross pattern into each cookie. Bake 7-9 minutes or until light brown around the edges. Cool on wire rack.

NV CANN LABS

6631 Schuster Street Las Vegas, NV 89118 Phone: (702) 826-2700 Email: Tara@nvcann.com

CANNABIS TESTING NV Cann Labs, Staff, Founder, Officers, Directors and Advisors are working together to create an environment to best serve our Clients Needs and The State Requirements State of Nevada Required tests charts

Product Usable marijuana

Tests Required

Flower * 12 grams or less Usable marijuana (dry flower, trim, kief as an endproduct or further processing prior to retail sale.

Note: marijuana that will be used to produce extracts does not require testing until after extractions and in its final state.

Extract of marijuana

7 grams or less (nonsolvent) like kief, hashish, bubble hash, infused dairy butter, or oil or fats derived from natural sources.

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Moisture content Potency analysis Terpene analysis Foreign matter inspection Microbial screening Mycotoxin screening Heavy metal screening Pesticide residue analysis Herbicide Growth regulators Residual Solvents

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Potency analysis Terpene analysis Foreign matter inspection Microbial screening Mycotoxin screening Heavy metal screening Pesticide residue analysis Herbicide Pesticide residue analysis Growth regulators

Product Extract of marijuana

4 grams or 1% of the production run, whichever is more. (solvent-based) - any approved solvent including concentrated cannabis.

Edible marijuana-infused product inclluding concentrated cannabis 1 unit or 1% of the production run, whichever is greater

Liquid marijuana-infused product

Tests Required 1.

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Potency analysis Terpene analysis Foreign matter inspection Microbial screening Mycotoxin screening Heavy metal screening Pesticide residue analysis Herbicide Pesticide residue analysis Growth regulators

1. Potency analysis 2. Terpene analysis 3. Foreign matter inspection

1.

Potency analysis Like Soda or Tonic including concentrated cannabis 1 2.

Terpene analysis unit or 1% of the 3. Foreign matter inspection productionrun. whichever is greater

We would appreciate the opporunity to meet withCyou to review what your testing needs will be

www.UnitedPatientsGroup.com/conference Pre-Conference Nurse's Workshop Friday, May 20th (4 CEU's)

'Myths about Marijuana' Harms have been proven scientifically.

Has no medicinal value.

The Therapeutic Role of Cannabis in Neurodegenerative Disorders: Alzheimer's Disease By: Sunil Kumar Aggarwal, MD, PhD, FAAPMR

Marijuana is highly addictive.

use during pregnancy damages the fetus.

Alzheimer’s Disease (AD) is also a progressive, neurodegenerative disorder of unknown etiology. However, beyond that, all similarity to Amyotrophic lateral sclerosis (ALS)/Lou Gehrig's disease, stops. AD is characterized by a progressive deterioration of memory and overall cognitive functioning. Other symptoms of AD include aggressive behavior and agitation, depression, appetite loss, and occasionally, in advanced cases, difficulty walking. The disease is estimated to affect about 5 million Americans. In 2006 the worldwide prevalence was 26.6 million. By 2050, prevalence is expected to quadruple, by which time one in eighty-five persons worldwide will be living with the disease (Brookmeyer et al. 2007).

Alzheimer’s usually begins after age sixty, though some younger people may very rarely have early-onset Alzheimer’s. The risk of developing Alzheimer’s goes up with age. Around 5 percent of men and women ages sixty-five to seventy-four have Alzheimer’s, and nearly half of those age eighty-five and older may have the disease, though Alzheimer’s is not a normal part of aging.

use impairs the immune system.

There are a number of physiological and anatomical changes that

is more damaging to the lungs than tobacco.

occur in the brains of AD patients. Nerve cells die in parts of the brain that are vital to memory and other functions, and connections (synapses) between nerve cells are broken. This

is a gateway drug. offenses are not severely punished. policy in the Netherlands in a failure. kills brain cells. causes an amotivational syndrome. impairs memory and cognition. cause permanent mental illness. causes crime.

Interferes with male and female sex hormones.

use is a major cause of highway accidents. active ingredient. THC, get trapped in body fat.

Marijuana-related hospital emergencies are increasing, particuarly among youth, is more potent today than in the past. use can be prevented.

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disruption in synaptic connections within the brain lead to impaired thinking and memory problems. Alzheimer’s starts with mild memory problems and can end with severe brain damage. How fast the disease works and the course the disease takes vary from person to person. Average Alzheimer’s patients live from eight to ten years after they are diagnosed, though they can live as long as twenty years. Biopsies of the brains of AD patients show numerous amyloid plaques- hardened protein deposits that are thought to directly cause most of the central nervous system dysfunction seen in AD.

Sometimes the term dementia is used to describe the symptoms caused by these changes in brain function.

Some symptoms may include asking the same questions repeatedly; becoming lost in familiar places; being unable to follow directions; getting disoriented about time, people, and places; and neglecting personal safety, hygiene, and nutrition.

There is no set schedule or rate at which people with dementia develop symptoms. While dementia is certainly part of AD, there are also many other conditions, reversible and permanent, that can cause dementia.

There are currently no Food and Drug Administration (FDA)- approved treatments or medications available that actually modify the disease course of AD. There are only a few drugs (Aricept [donepezil] and Namenda [memantine]) that have been FDA-approved to treat symptoms of the disease, but these drugs do not actually improve the long-term prognosis. None of these drugs halt the formation of plaques in the brains of AD patients.

There is now ample evidence in the medical literature to indicate that cannabis may provide not only symptomatic relief to patients afflicted with AD, but it also actually limits the formation of new plaques in the brain. Thus, it appears that cannabis may actually slow down the progression of the disease. In a study done at Scripps Research Institute in California, researchers reported that delta 9-THC, both in the test tube and in computer models, inhibited the enzyme responsible for the aggregation of amyloid plaque, which is the primary marker for AD, in a manner considerably superior to the FDA-approved AD drugs such as donepezil and tacrine (Cognex) (Eubanks et al. 2006).

This study identified a mechanism whereby cannabinoids can directly impact AD pathology.

The researchers concluded that cannabinoids, including delta 9-THC, may provide an improved therapeutic treatment for AD that simultaneously treats both the symptoms and the progression of the disease. Other studies, both in vitro and in vivo, have shown that cannabidiol (CBD) and the synthetic cannabinoid WIN-55,212-2 can help prevent brain cell death that results from exposure to the amyloid plaques and can also improve memory (Iuvone et al. 2004; Marchalant et al. 2008; Marchalant, Rosi, and Wenk 2007).

Other recent studies have shown that injecting the synthetic cannabinoid WIN 55,212-2 directly into the brain significantly decreased neurotoxicity and helped prevent cognitive impairment in rats injected with amyloid-beta peptide (a protein that induces AD in rats) (Ferraro et al. 2001; Ramirez et al. 2005). The cannabinoid appeared to reduce the neuroinflammation associated with AD. Pervious preclinical studies have demonstrated that cannabinoids can prevent cell death by antioxidation (Hampson et al. 1998). In addition to potentially modifying the progression of AD, recent clinical trials also indicate that cannabinoid therapy reduces agitation and improves appetite and weight gain in patients with AD. Daily administration of 2.5mg of synthetic THC over a two week period reduced nocturnal motor activity and agitation in AD patients in a open-label pilot study (Walther et al. 2006). Improved weight gain and mood state were also noted among AD patients administered cannabinoids in a separate study previously published (Volicer et al. 1997). Thus, far, at least two chemicals in cannabis, THC and CBD, have been shown to be effective against AD-related pathology. Additional studies using cannabis to treat AD are clearly warranted, as we face a looming global epidemic of Alzheimer’s disease as the population ages. Any advances in therapeutic and preventative strategies that lead to even small delays in Alzheimer’s onset and progression can significantly reduce the global burden of the disease (Brookmeyer et al. 2007).

Conclusion When cannabinoid receptors in the central nervous system are activated, this triggers signaling pathways in the brain that are lined to neuronal repair and cell maintenance, and the release of other compounds that further activate neuroprotective responses.

Additionally, it is clear that our own internal marijuana, the endocannabinoids, are released in response to pathogenic events, thus representing a potential compensatory repair mechanism. Enhancing this “on demand’ action of endocannabinoids is an important strategy the body uses to help prevent further brain injury as well as promote healing. The neuroprotective activities of both externally administered cannabinoids (i.e. transdermal patches, lotions, salves, etc.) and the internal endocannabinoids (sublingual, suppositories, edibles, oils, etc.) are novel processes that can be effectively exploited to help promote and protect the nervous system in the face of disease or physical and chemical trauma.

May/June 2016 CANNABISNURSESMAGAZINE.COM

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www.CannabisBusinessSummit.com

Resources

Recommended Books

Over the past decade, Truly global in scope and there have been major with contributions from advances in leading researchers understanding the around the world, The mechanisms whereby Handbook of Cannabis is marijuana interacts with the definitive resource on the brain in producing this fascinating drug. psychoactive and Combining scientific potentially therapeutic perspectives and clinical effects. The discovery of applications, it covers a specific gene coding for vast array of topics, from cannabinoid receptors why over the centuries activated by smoking cannabis has been used as marijuana, and the a medicine, through the finding of endogenous regulations facing those cannabinoids, which also wishing to self-administer activate the receptors, cannabis or provide cannabis-based medicines, to the have transformed cannabinoid research into mainstream chemical structure of its many constituents and the rapidly science with significant implications in human health growing group of synthetic cannabinoids that are currently and disease. being used for legal highs.

Cannabinoids and the Brain

Endocannabinoids control most of the body functions, and in the brain, they modulate neurotransmission, synaptic plasticity, confer neuroprotection, control metabolism, neuro- and neuritogenesis, survival, cognitive and motor functions as well as a plethora of other higher-order brain functions. Their fruitful therapeutic potential is recognized by cannabinoid researchers and pharmaceutical companies, respectively.

Genetics, Processing & Potency Describes the psychoactive constituents of cannabis and the effects on potency of growth conditions, genetics, harvesting techniques, and processing. Includes variations in THC and CBD content, species differentiation, seeds, grafting, cloning, bonsai marijuana, growing techniques, extraction of THC, preparation of hashish and hash oil, smoking vs eating, testing for THC and CBD, as well as legal concerns.

Illustrated.

May/June 2016 CANNABISNURSESMAGAZINE.COM

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Job Opportunities Perm & Travel

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If you are available for consideration, please reply to this email and a recruiting specialist will contact you as soon as possible.

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

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

01 NURSING CENTRAL

06 EPONYMS

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

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

02 LIPPINCOTT NURSING

07 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

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Nursing Conferences Come meet the National Cannabis Nurses at these future Events!

May Conferences

2016

Take Note

United Patients Group Conference Pre-Conference Nurse's Workshop Friday, May 20th Medical Cannabis: The Science. The Truth. <-- United Patients Group Conference (4 CEU's) May 21st & 22nd, 2016 | San Rafael, CA http://www.unitedpatientsgroup.com/conference

!

American Holistic Nurses Association (AHNA) May 31st- June 5th, 2016 | Bonita Springs, FL http://www.ahna.org/Conference/Sponsors-and-Exhibitors

June Conferences NCIA presents the 3rd Annual Cannabis Business Summit & Expo Pre-Summit Morning Workshop: Cannabis Nurses- The Role of Nursing in the Cannabis Industry June 20-22, 2016 | Oakland, CA http://www.cannabisbusinesssummit.com

August Conferences Southern California Cannabis Conference + Expo (SWCCE) August 6th & 7th, 2016 | San Diego Convention Center http://www.socalccexpo.com Seattle Hempfest- National Cannabis Nursing Panel August 19th - 21st, 2016 | Seattle, WA http://www.hempfest.org

September Conferences Association of Pediatric Hematology/Oncology Nurses (APHON) September 29-Oct 1, 2016 | Indianapolis, IN http://www.aphon.org/meetings/confindex.cfm

November Conferences Marijuana for Medical Professionals CME Certified Conference on Canabis Medicine November 14th - 16th, 2016 | Denver, CO http://www.marijuanaformedicalprofessionals.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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