LIFESTYLES
OPPORTUNITY
EDUCATION March/April 2016
SAFETY & TESTING MORE THAN "JUST A NURSE" MEDICAL
MARIJUANA KNOW WHAT YOUR PUTTING IN YOUR BODY THE
BIRTH OF ACNA MEET: MARY LYNN MATHRE
Safety First: What you Should Know about Cannabis, Products and your Health
Editor’s Letter Spring is upon us, time for sunshine and new life to blossom. Medical Cannabis and Recreational users alike will be in full bloom this season as they celebrate their right of freedom to use Cannabis. Well, at least that is what consumers hope to achieve at a national level as the freedom of the leaf is not truly free completely - yet. But for now, what is the 420 hype really all about and what does it mean when it comes to the safety of the plant? Medical Cannabis is taking a forefront in news and media in a positive light within medicine and gaining popularity in being a preferred treatment of choice. However, when it comes to recreational use, some still frown upon it and do not see or understand what the “High” is all about. I see both sides of the equation and see cannabis as preventative medicine. No matter how we choose to consume cannabis, for medical purposes or recreational, one thing is for sure, we need to make sure patients have safe access and that it is safe for the end user to consume. Thus, it is important to inform and educate patients on the safety of medical cannabis and to be responsible consumers as we approach this celebrated day. In this issue, Cannabis Nurses Magazine March/April 2016 focuses on: Cannabis Safety. Having a clear understanding of what to look for when it comes to safety standards in cannabis products is pertinent to a patient’s health and healing as they are being guided through the many tasks and challenges in learning that medical cannabis can bring. First, we hear from Chief Science Officer of DigiPath Labs, Dr. Cindy Orser, who was seen lecturing at The 2016 Emerald Lab Conference in Las Vegas, Nevada and she and her team are known for creating a replicable testing environment with validated protocols to ensure cannabis and cannabis-based products are safe for patients. Standardized testing is a viable and a necessary process to ensure patients and recreational users are kept safe from the multitude of factors and obstacles that can damage or destroy the integrity of medical cannabis and in even some cases create further issues to a sick and immune-compromised patient. Therefore, testing is pertinent to ensure safety of cannabis products and that national standards of testing are created across the nation- currently they are unequal. Nurse Heather Manus then leads us to a discussion about being “More than Just a Nurse” and how important it is for us to speak up for our patients. It is Nurses who are able to create change in medicine. We are the voice for patients. Patients who use Cannabinoid Therapeutics are more than “just a cannabis patient,” and nurses who care for these patients are more than “just a nurse”. We are Cannabis Nurses: Caring, Compassionate, and Intelligent Nurses. We deeply understand that EVERY Patient Deserves a Nurse. We also cover the importance of making sure you have your patients “Just Ask”. Teaching your patients to ask the dispensary and/or retail seller what is in their products- have them provide a list of ingredients- to examine prior to consumption, to assure proper dosing, proper strain selection, and that the products are tested properly and safe for consumption. It is your right to know what goes into your body and it is up to you to advocate for your patients and assure that products are safe to consume. When I look at cannabis production and testing across the nation - it being unequal- I wonder how we got into this mess. Many times when I am faced with adversity in nursing I look to my mentor, Florence Nightingale. I stop and examine and look closely at what she would do if she were here practicing nursing in today’s time in the world of cannabis prohibition. What lessons in nursing did she leave us to use as we walk the roadmap for our future generations? Nightingale’s experiences in nursing demonstrated to her the value of advocating for nurses and patients. She embraced an egalitarian value system and utilized leadership techniques to create change in nursing. She believed all nurses are leaders by virtue of assuming the role of a nurse. Nursing has never been simple, nor is serving as a patient advocate. However, nursing has embraced advocacy as a professional construct. Advocacy includes a complex interaction between nurses, patients, professional colleagues, and the public. It is our duty to assure that ALL patient’s needs are met even if it goes against societal stigmas, rules and regulations that prohibit us from its use. It is our duty as medical providers – especially nurses- to get involved and be the voice for patients to create true change for whole healing. And, by doing so we will ultimately keep them safe. We must Grow.
Julie Monteiro RN, BSK “Ask Nurse Juhlzie” Editor@Cannabis Nurses Magazine
When we engage with our patients, instead of asking “What’s the matter?” we can ask instead “What matters to you?” By asking this, we will be able to hear the patient’s voice even when that voice is a whisper.” De Silva DM (2013) Measuring Patient Experience. Evidence Scan. London: the Health Foundation
Contributors January / February 2016
Publisher
Robert Herman
Managing Editor
Julie Monteiro RN, BSK
Creative Director
Tiffany Watson
Contributors Heather Manus, RN Leslie Reyes, RN Marcie Cooper, RN, MSN, AHN-BC Lisa Buchanan, RN ,OCN Mary Lynn Mathre, RN, MSN, CARN Jessica Aragona MS, RD, LDN Eloise Theisen MSN, RN, AGPCNP-BC Carey S. Clark, PhD, RN, AHN-BC, RYT 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.
Leslie Reyes, RN Leslie Reyes, RN is a Board Member and the Secretary for the American Cannabis Nurses Association (ACNA). Leslie has worked as a Registered Nurse in Urgent Care, Psychiatric and Behavioral Health, and has been involved in cannabis patient advocacy for over nine years. She is a co-creator and co-author of the Core Curriculum in Cannabis Nursing owned by the ACNA, and is also on the committees for Communications and Media, Conference Planning, Certification, Events, Membership, Nominations, and the Executive Committee.
Marcie Cooper, RN, MSN, AHN-BC
Marcie Cooper is Board Certified as an Advanced Holistic Nurse and licensed as a Registered Nurse in Colorado. Originally from Memphis, Tennessee, she started her nursing career on a general med-surg hospital floor in 2004 and began a focus specializing in Oncology.
Lisa Buchanan, RN, OCN
Lisa Buchanan is an Oncology Certified Nurse (OCN) who has worked with the seriously ill and dying for more than 20 years. She a member of the Oncology Nurses Society (ONS), American Cannabis Nurses Association (ACNA), and the Washington State Nurses Association. (WSNA). She has earned certificates in the Core Curriculum for Cannabis Nursing and the Advanced Curriculum for Cannabis Nursing.
Mary Lynn Mathre, RN, MSN, CARN Mary Lynn (ML) Mathre, RN, MSN, CARN is the President and Co-founder of Patients Out of Time, a national non-profit organization dedicated to educating health care professionals and the public about the therapeutic use of cannabis, and the founding member of American Cannabis Nurses Association (ACNA).
Contributors Cindy S. Orser, PhD As Chief Science Officer of DigiPath Labs, Dr. Cindy Orser is creating a replicable testing environment with validated protocols to ensure cannabis and cannabis-based products are safe. She is also developing standards and biomarkers to clearly distinguish products derived from specific cannabis strains concomitant with determining the bioavailability of the cannabinoids found in the product. Dr. Orser draws from over 20 years of experience innovating in both academia and private industry. She holds 18 issued patents and has authored 41 peer-reviewed publications. She received her BS in Botany from Montana State University in Bozeman, and was awarded a PhD from the University of California, Berkeley, in Plant Pathology and Genetics. Dr. Orser is the founder of five biotech companies including Adlyfe, Cellphire, Big Sky Biosystems, ASDx Biosystems, and iPDx Biosciences. She has consulted for the molecular and medical diagnostics industry as well as the federal government. For five years, Dr. Orser served as Corporate Senior Scientist and Head of the Biodefense/ Biotechnology Initiative at Areté Associates in Washington, DC, and she was also a tenured professor of Biochemistry and Bacteriology at the University of Idaho.
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.
Contact Information Publisher ND1Media Editorial Robert Herman
Art&Graphic Design To submit artwork/ad creation Email: ads@cannabisnursesmagazine.com
Advertising & Marketing For advertising opportunities Email: ads@cannabisnursesmagazine.com Sales/Product Director Email: sales@cannabisnursesmagazine.com
Writers To submit articles for publication Email: editor@cannabisnursesmagazine.com
Reach Us By Post Cannabis Nurses Magazine 4780 W. Ann Rd., Suite 5 #420 N. Las Vegas, NV 89031 info@cannabisnursesmagazine.com www.cannabisnursesmagazine.com
Julie Monteiro RN, BSK Julie Monteiro (Nurse Juhlzie) is a Registered Nurse in the state of Nevada and a UNLV Alumni from the Department of Kinesiology. She has worked well over twenty years in medicine specializing in Internal Medicine, Orthopedics, Pediatric ER/Trauma (PALS) and Adult ER (ACLS/TNCC), Outpatient Surgery and Pain Management, and a Nurse Educator in many of these specialties. She is on multiple committees with the American Cannabis Nurses Association (ACNA) and a member of the American Nurses Association (ANA) and Nevada State Nurses Association (NSNA). Through ACNA she has earned certificates in The Basic Core Curriculum for Cannabis Therapeutics and the Advanced Curriculum for Cannabis Nursing. She is known in the Las Vegas Community as “Ask Nurse Juhlzie” of fame and educates professionals, patients, caregivers, corporations, organizations and legislation on Cannabis Therapeutics in numerous platforms. She owns Medical Cannalyst Consulting Group LLC., “Ask Nurse Juhlzie”, Canna-Aid Foundation, and Cannabis Nurses Magazine which are local and national platforms to promote cannabis information and education. She is a voice for the patients and believes Every Patient Deserves a Nurse.
The Story Behind 420
The historic term of 420 all started at 4:20PM on 4/20 for 420-ing in San Rafael, California where a group of five San Rafael Hight School friens known as The Waldos, by virtue of their chosen hangout spot a wall outside the school, coined the term in 1971. And so, the term 420 was created and is now used and celebrated across the nation on April 20th ever since.
Table of
March/April
Contents WHAT'S INSIDE P.2
EDITORIAL PAGE
P.6
SAFETY OF CANNABIS PRODUCTS
P.14
CANNABINOIDS AND CHRONIC INFLAMMATORY CONDITION
P.18
Do you actually know what you're putting in your body?
P.23
THE BIRTH OF ACNA
P.26
MORE THAN JUST A NURSE
2016
FEATURES SAFETY OF MEDICAL CANNABIS PRODUCTS
PAGE. 06 CANNABINOIDS AND CHRONIC INFLAMMATORY CONDITIONS PAGE. 14
P.28
A Dietitian's Perspective on Cannabis
P.30
Nursing Humor
P.31
Resources
P.32
Nurse Job Opportunities: Perm & Travel
P.33
Helpful Apps for Health Care Professionals
P.34
Nursing Conferences for 2016
Do you actually know what you're putting in your body?
PAGE. 18 THE BIRTH OF ACNA
PAGE. 23 MORE THAN JUST A NURSE
PAGE. 26
SAFETY OF MEDICAL CANNABIS PRODUCTS: What Every Patient Should Know By: Cindy S. Orser PhD
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As medical marijuana legalization creeps across the country, state-by-state, in defiance of marijuana’s schedule 1 status at the Federal level, so does the mandatory quality assurance testing of medical cannabis products. It has happened in Nevada, Washington, Massachusetts, and Oregon; and, it is slated for Colorado in 2016, and even California is now talking about mandatory testing. What is missing is standardization of medical marijuana testing, no doubt the direct consequence of the gradual legalization process across the country combined with the lack of Federal oversight by the FDA, EPA and Department of Agriculture. Standardization of Cannabis Testing Standardization of cannabis testing would ensure consumer confidence; allow product comparison, and evaluation of efficacy. In addition, standards add credibility to new products and the entire cannabis market, fueling the development and implementation of new technologies. The standards that Federal regulations would specify for the cannabis industry in lieu of each state figuring it out on their own include: uniform batch and sample size for testing, testing frequency, sample preparation, the use of certified reference standards and standard operating procedures (SOPs), instrumentation, proficiency testing and accreditation, acceptable levels of contaminants, mycotoxins and agricultural by-products and the Food Safety and Modernization Act (FSMA). Standardization of cannabis testing requires quality assurance testing. The menu of potential quality assurance tests from which each medical marijuana compliant state has picked and chosen from includes determining residual moisture, potency, residual pesticides, heavy metals, microbial screening for human pathogenic bacteria, enterobacteriaceae, total aerobic bacteria, total yeast and mold, mycotoxins and residual solvents for those products where a solvent was used. Quality Assurance Testing of Cannabis in Nevada Medical cannabis patients living in Nevada have access to the most thoroughly tested cannabis products available anywhere in the country as the State of Nevada has adopted quality assurance tests for the most robust safety testing of any state to ensure patient safety. In the State of Nevada all medicinal cannabis products undergo a potency analysis that includes both cannabinoids and terpenes. Potency analysis at DigiPath Labs includes identification and quantitation of the complete set of eleven cannabinoids for which certified reference standards are currently available as listed in Table 2 below as well as 22 terpenes. Quality Assurance Challenges Pesticide Residues. While cannabis is unique in many ways, its Schedule 1 drug status presents nearly insurmountable challenges to the adoption of standardized quality assurance testing in particular for pesticide residue analysis.1 States generally rely on the federal government to set pesticide policy. The Feds register thousands of pesticides for use on crops and sets limits of how much pesticide can remain on hundreds of other crops once they've been harvested. The government bases those limits on factors such as how much of those foods Americans consume over a period of time. When it comes to pesticides, the label on the container is the law. No pesticides list marijuana on their labels, leaving it to states to craft their own policies. March/April 2016
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The Cannabis Safety Institute in collaboration with agricultural pesticide experts from around the country have published a set of recommendations to allow states to effectively address this need until the federal government is willing to bring the EPA into the picture.2 The only clear path for states to avoid noncompliance on pesticide use on cannabis is to adopt exempt pesticide products that have no oversight for use on any commodity. Nonetheless, several states, including Nevada, are boldly creating pesticidemonitoring lists with accompanying tolerance limits for synthetic pesticides commonly used and found on cannabis flower. Microbial Screening. There are literally hundreds of different bacteria and fungi associated with cannabis grown indoors, which has triggered almost universal adoption of quality assurance testing of cannabis for a select group of pathogenic bacteria that are highly infectious and fungi known to produce potent toxins. While the FDA oversees and endorses validated assays for the enumeration of microbial contaminants in food and drug products as published in the Bacteriological Analytical Manual (BAM)3 , you will find no chapter attributed to microbial analysis of cannabis, one more consequence from cannabis’ Schedule 1 status. In addition, an often unaddressed and very real potential complication for evaluating microbial contaminants on cannabis is the unknown inhibitory impact of the chemical profile of the plant matrix on the viability or culturability of fungal spores and bacteria. The inhibition or possible growth promotion may not be uniform across all fungal and microbial species. Potency Testing The potency or chemoprofile of a cannabis flower sample is made up of the specific cannabinoid and terpene content. Only the State of Nevada requires testing for terpenes. It is important to realize that there are three sources of cannabinoids: those made by your own body through what is called the Endocannabinoid System, those from plants which is the subject of this article, and the scourge of synthetic cannabinoids or cannabimimetics, which are manufactured in 100s of variants and dumped onto the black market in the US, giving cannabinoids a black eye in large metro areas. The Endocannabinoid System The human Endocannabinoid System (ECS) consists of at least two types of cannabinoid receptors, those located in the brain, called CB1 receptors; and, those throughout the central and peripheral nervous system, called CB2 receptors and the endocannabinoid that bind to the CB receptors. The ECS utilizes both the endocannabinoids that your own body produces and also those from plants to balance many physiological processes in the body including appetite, pain-sensation, mood and memory and the psychoactive effects of cannabis. They help to control inflammation caused by many chronic diseases through stimulating the anti-inflammatory response as well as the imbalances of multiple sclerosis and seizure disorders. It prevents osteoporosis by restraining the body’s hyperactive bone re-adsorption mechanisms.
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The Major Plant Cannabinoids Tetrahydrocannabinol (THC) is a powerful psychoactive agent, analgesic, muscle relaxant, antispasmodic, neuroprotective antioxidant that delivers 20 times the anti-inflammatory power of aspirin and twice the power of hydrocortisone. Cannabinol (CBD) helps us fight microbial infections, such as methicillin-resistant Staphylococcus aureus (MRSA), while helping our bodies moderate some of the adverse effects of THC like anxiety, tachycardia, sedation, and hunger pangs. Cannabigerol (CBG) is a non-psychoactive substance working as a counterpoint to THC by interacting with the same receptors. It decreases anxiety and muscular tension, and is a strong anti-inflammatory, making it effective in treating inflammation in the GI tract and glaucoma. It is also an effective antidepressant and decreases tumor size in animal models. Terpenes In addition to cannabinoids, cannabis as well as other plants, also produce many terpenes, a large and diverse class of organic compounds that give a particular cannabis strain its unique aroma and taste. Various plant terpenes are believed to possess antibacterial, antineoplastic, and other medicinal functions, and are an important ingredient in many pharmaceutical and herbal remedies. In fact, vitamin A is a terpenoid. Terpenes are thought to work synergistically with cannabinoids to exert the full potential medicinal benefit of a given cannabis strain. Important Message about Dosages Cannabis contains hundreds of chemical compounds that interact with each other. The potency of these compounds varies by strain, how and when the plant is harvested, and how it is processed, making dosing complicated. Until recently, the focus on potency has been on THC levels, but emphasis is moving to other cannabinoids, as ongoing research proves their therapeutic significance in treating specific medication conditions. Table 1. Edibles THC Dosage Rules of Thumb
Dose
Patient‐Reported Psychoactivity
Tolerance Level
Notes
2 mg
Mild
Beginner
Slight impairment
2.5‐5 mg
Moderate
Beginner
6‐10 mg
Strong
Some Experience
15+ mg
Extremely Strong/Excessive
Very Experienced
11‐15 mg
Very Strong
Experienced
May reduce anxiety, stimulate appetite, and increase focus.* Significant distraction from pain.** Uncomfortable for many patients
* Although CBDs are known to reduce anxiety, many people experience increased anxiety and paranoia when they first ingest an edible, mostly because they are not used to the effect on their bodies and mood. Anxiety is typically reduced with repeated use.
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The Irony It is curious to think that so many chronic pain diseases from fibromyalgia and migraines to arthritis and irritable bowel syndrome could be caused by a deficiency in our own Endocannabinoid System. Medical Marijuana Products Today, medical marijuana patients can purchase cannabis-based products in a variety of formats. This is good news for medical marijuana patients, as it allows customization of patient treatment plans to facilitate therapeutic goals. It also presents a challenge. So many choices can confuse or overwhelm patients, especially those new to cannabis. We understand it is difficult for anyone to embrace something they do not understand, so we have described the most popular dispensary products in this section to help increase medical marijuana patient comfort levels. Cannabis flower – dried and cured, packaged and sold by weight. Cannabis Concentrates - available in an increasing number of formats, such as cannabis oil, hashish, tinctures, live resin and topicals. To make concentrates, cannabinoids and terpenoids are isolated by extraction, either by physical means or with the use of alcohol, fats, oils or solvents. Kief - also known as “dry sift” or “pollen,” is the bulbous, crystal formation on the tip of a gland that contains a high concentration of terpenes and cannabinoids. Kief is used to make hashish and edibles, or it can be eaten raw, smoked, or vaporized. Hashish - produced for thousands of years using heat and force to mechanically compress kief and varying amounts of cannabis flowers and leaf fragments into blocks. Today, hashish can be solid or resinous, depending upon the way it was produced. Hash Oil - made by employing solvent or non-solvent extraction methods. The oil is a tacky liquid that retains a robust terpenoid-rich flavor profile and moderate THC levels. Marijuana Wax - concentrate that contains high levels of THC. It is also called "ear wax," because of its color or just "wax." Tinctures - herbal extracts usually made using alcohol or glycerin. Sometimes flavored to improve their taste, cannabis tinctures are most effectively administered sublingually, but they can be added to food and beverages. Compared to other concentrates, cannabis tinctures are inexpensive and easy to make. Edibles - ingestible products infused with cannabis extracts. Producers of edibles often make their own extract by slow-cooking cannabis plant material in a fat, like oil or butter. Edibles are available in a variety of formats that range from brownies and granola bars to beverages like sodas and teas. Suppositories - administered rectally, usually about an inch in length and made with either cannabisinfused coconut oil or a blend of solid propane hash oil and coconut oil. 1 Stone D (2014) Cannabis, pesticides and conflicting laws: The dilemma for legalized States and implications for public health. Regulatory Toxicology and Pharmacology 69:284-88. 2 Voelker R & Holmes M (2015) Pesticide Use on Cannabis. Cannabis Safety Institute. 3 www.fda.gov/Food/FoodScienceResearch/LaboratoryMethods/ucm2006949.htm
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Topicals - Salves, creams, lotions, and other topically administered cannabis products are typically made with alcohol or by slowly heating cannabis in olive oil, coconut oil, or beeswax to extract the cannabinoids and terpenoids. Topicals can also be formulated as transdermal patches applied to the skin to deliver medication locally and over time.
Table 2. Cannabinoid Abbreviations and their Potential Medicinal Value4 Abbreviation
Cannabinoid
CBC
Cannabichromene
CBDA
Cannabidiolic acid
CBD
CBDV CBG
CBGA CBN
Cannabidiol
Cannabidivarin Cannabigerol
Cannabigerolic acid Cannabinol
Δ9THC
Delta‐9‐tetrahydrocannabinol
Δ8THC
Delta‐8‐tetrahydrocannabinol
THCV
THCA
Tetrahydrocannabivarin
Tetrahydrocannabinolic acid
Medicinal Synopsis Analgesic, antimicrobial, anti‐ inflammatory, sleep aid Analgesic, antidepressant, antiproliferative, anticonvulsive Anti‐inflammatory, antiproliferative Anti‐convulsive, bone growth stimulant Analgesic, antidepressant, anti‐ inflammatory, antimicrobial Analgesic, anti‐inflammatory
Analgesic, anticonvulsive, anti‐ inflammatory, antimicrobial, mildly psychoactive Analgesic, antiproliferative, anti‐ inflammatory, antispasmodic, psychoactive, neuroprotective Antidepressant, antispasmodic, anxiolytic Anorectic, anti‐convulsive, bone growth stimulant Anti‐inflammatory
Cannabis Product Labeling Medical cannabis products sold in Nevada are required to have a label that at a minimum contains the following cannabinoid test results presented as a % of the weight: THC, CBD, THCA, CBN. On occasion, some products will state they have a 1:1 ratio of THC to CBD. This ratio simply means that there are equal amounts of both THC and CBD in the product. An important point to understand is that when someone or something says THC, they almost always mean Δ9THC. Furthermore, THCA is the acidic form of THC or Δ9THC and that when the plant material is heated as in smoking, the THCA is converted to Δ9THC through a process called decarboxylation and that this chemical conversion results in a small loss of mass and is usually presented as “potential” Δ9THC following decarboxylation; but of course not everyone combusts flower through smoking. 4
DigiPath Labs 2015 Guide to Medicinal Use of Cannabis. www.digipathlabs.com March/April 2016
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Medical Cannabis WHAT CLINICIANS NEED TO KNOW AND WHY Gregory L. Smith, MD, MPH
NEW! Available Winter 2016 Exclusively from Aylesbury Press
A Convenient New Resource…
Practical and Up-To-Date…
Up to now there has been no serious textbook for training clinicians and medical students about the use, efficacy, and monitoring of medical cannabis. Medical Cannabis is the first, single source for concise, up-todate information about which conditions respond to cannabis, dosing guidance, and the safe use of cannabis by your patients.
Medical Cannabis is an indispensable resource for primary care physicians, family practice physicians, internists, pain specialists, oncologists, geriatricians, medical students, nurse practitioners, physician assistants, and others who are involved with recommending medical cannabis to their patients.
This invaluable reference will answer your questions about – • What type of cannabis to use? • With what conditions? • What is THC versus CBD? • What are the side effects? • Is it addictive? • How is it prescribed?
Instant Access to Vital Information… The goal of this book is to provide the basic science and clinical information necessary to make the practicing physician feel comfortable answering questions about cannabis as well as recommending it as a medication. Topics covered include – • History of the human use of cannabis • The endocannabinoid system • Cannabis pharmaceuticals • Conditions and symptoms that respond to medical cannabis • Monitoring cannabis medication • Cannabis dependence and psychological adverse effects • Writing recommendation letters for cannabis use
Highly focused and relevant, this book clarifies the history, utility, and efficacy of medical cannabis and the burgeoning new horizons for its use as a legitimate, effective, and safe medication.
AVAILABLE WINTER 2016 Exclusively from Aylesbury Press 8 West Street, Beverly Farms, MA 01915
HEALTH
Cannabinoids Cannabinoids and and Chronic Inflammatory Conditions
By Gregory L. Smith, MD, MPH Cannabis has been used to treat inflammatory conditions for millennia. Salves and ointments made from cannabis are discussed in Chinese medical texts from 2700 B.C.E. At the turn of the 20th century, there were hundreds of patent medicine elixirs made from cannabis used to treat a wide variety of conditions, but were known especially for inflammation and spasms. The Underlying Cause of Many Diseases Today, we know the process called inflammation is the underlying cause of many significant diseases, including all types of arthritis, autoimmune diseases, and many neurodegenerative conditions. It is also estimated that 15%-20% of cancer is caused by chronic inflammation.
Table I: Conditions Due to Chronic Inflammation:
Brain ->ALS ->Alzheimer's Disease ->Dementia from Recurrent Concussions ->Parkinson's Disease
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Body ->Allergic Conditions/Asthma -> Athersclerosis ->Autoimmune Diseases ->Bowel and Breast Cancer ->Eczema/Psoriasis ->Inflammatory Bowel Disease
Chronic Inflammation is Slow Unlike acute inflammation, such as an ankle sprain, chronic inflammation is a slow, smoldering process that often takes years to cause symptoms. In addition, chronic inflammation tends to be localized to one organ system or specific tissues or parts of the brain. For example, Alzheimer's disease is due to decades of smoldering inflammation in the cerebral cortices at the sites where abnormal proteins collect, inside and outside neurons, gradually resulting in neuron cell death. Inflammation is a Protective System Inflammation is a protective system of the body that is used to heal tissues and wounds, and targets injured cells, allergens, infections, and "foreign" cells or materials. There are several components to the inflammatory response. First, there is the humoral response, several types of cells in the brain and body release inflammatory chemicals called cytokines. In addition, there is also the cellular response, with T-cells and macrophages. When the inflammatory response is too robust or persists longer than necessary, it causes more damage than good. In the case of autoimmune conditions, the body is making antibodies against normal healthy cells (i.e. the synovial cells in rheumatoid arthritis). These antibodies attach to the healthy cells and start the whole cascade of inflammatory cytokines and cellular immunity. FDA-Approved Medications There is a wide array of FDA-approved medications for chronic inflammation, including NSAIDs, oral or topical steroids, and disease-modifying "biologic" medications, that suppress the immune and inflammatory response. However, all of the available drugs are associated with serious adverse effects, and sometime fatal reactions, and the newer drugs can be prohibitively expensive. Cannabis is an Adjunct Medication Cannabis should be considered an adjunct medication to the available FDA-approved medications. As I will explain in detail, cannabis works through different mechanisms of action than the available FDA-approved medications, and adding cannabis can not only help the condition but also may result in the need for less FDA-approved medications and, thus, result in fewer adverse effects. Understanding the Endocannabinoid System (ECS) An understanding of the ECS is fundamental to understanding how cannabis works. The ECS is a retrograde feedback system, that provides chemical modulators, called endocannabinoids, that turn down the effects of other neurotransmitters, such as dopamine, serotonin, norepinephrine, and histamine. So, in the case of inflammation, the ECS will make on-demand endocannabinoids that decrease immune and inflammatory responses promoted through histamine and acetylcholine. The inflammatory cells have cannabinoid receptors (CB1 and CB2) on them. The body makes endocannabinoids that, when released, bind to these receptors and decrease the inflammatory processes. Both THC and CBD, when ingested, bind to these same receptors and decrease both humoral and cellular inflammation. There are also special T-cells, called Treg cells, that regulate the cellular response by promoting programmed cell suicide, called apoptosis, of the activated immune cells, decreasing the inflammatory response. THC is particularly effective in increasing the number of Treg cells. Cannabis also decreases the mobilization of macrophages, thus decreasing the damaging component of phagocytic cells. March/April 2016
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Cannabis-Dosing Strategies The dosing strategy for cannabis is different from cannabis dosing for other conditions. The chronic inflammatory conditions are very slow, and the primary goal of cannabis is to stop the progression of the disease. Since these diseases progress very slowly, it may take many months or over a year to know if the patient is using the correct dose. Because most of the damage caused by chronic inflammation is permanent, reversal of symptoms is a secondary goal, after halting progression of the disease. A huge issue with all cannabis-dosing regimens is the dearth of high-quality studies in humans. Many studies we do have were done with synthetic THC (Marinol) or are older, and it is not clear exactly how much THC and CBD the patients were getting in the studies. The end result is that the medical community has little hard science to back up recommendations for dosing and ratios of THC to CBD. However, because of the inherent safety of cannabis and the hundreds of years of anecdotal observation of cannabis on diseases, we can make initial dosing recommendations and modify the dose in response to effects and side-effects in each individual patient. The Sweet Spot Both CBD and, especially, THC have a dose amount that is known as "the sweet spot." This will vary from patient to patient. This is the dose range where cannabis has a therapeutic effect. If the dose is too low, there will be no measurable effects. If the dose is too high, not only do the therapeutic effects disappear, but it may actually aggravate the condition that is being treated. Doses that are too high will change the number and efficiency of the cannabinoid receptors. This causes tolerance and the need to keep escalating the dose. In addition, high and frequent doses of cannabis are associated with anxiety, temporary psychosis, and the development of dependency syndromes. Almost without exception, the best dose for the therapeutic effects of cannabis will be less than that which causes psychoactive effects, such as getting "high". Start Low And Go Slow The second strategy for dosing cannabis, no matter what condition is being treated, is to "start low and go slow." In the case of a chronic inflammatory condition, start with one daily dose of 2.5 mg each of THC and CBD. This can gradually be increased at several-month intervals to 5 mg each, then 10 mg, all once daily. From there, the same dose can be given twice or three times a day. Again, this all depends on the effects and side-effects in each individual patient. 1:1 Ratio CBD and THC each have different effects on the inflammatory processes. In addition, a balanced 1:1 ratio of CBD to THC will tend to decrease the psychoactive effects and most bad side-effects of the THC. After a maximum dose of 10 mg of THC, only the dose of CBD should be increased. CBD has a bigger impact on inflammation than THC. Also, CBD is very safe, with minimal side-effects, unless it is in very high doses. So, while THC is maximized at 10 mg per dose, the CBD dose can go well over 100 mgs per dose.
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Doubled-Edged Sword Cannabis can also be a double-edged sword. In proper "sweet spot" doses there are many beneficial effects on inflammation and autoimmune conditions. However, larger doses can have immunosuppressive effects that may worsen HIV infection, liver fibrosis, and allergies. A well-trained and experienced medical professional in cannabis therapeutics should be involved when cannabis is being considered as an adjunct treatment for chronic inflammatory conditions. Preventive Cannabis Chronic inflammatory conditions are often silent until they have produced enough damage to cause irreversible symptoms. Considering how safe and well tolerated low-dose cannabis can be, it is likely that a daily preventive dose of 2.5 mg each of THC and CBD will be recommended in the future to ward off a variety of hidden inflammatory processes in our brains and bodies. Chronic Inflammatory Conditions CNS
BODY
->ALS ->MS ->AD ->Bowel Cancer ->Breast Cancer ->Dementia from Recurrent Concussions
->Allergy ->Autoimmune Conditions ->Eczema/Psoriasis ->Inflammatory Bowel Disease
Gregory L. Smith, MD, MPH Author of Basic Science & Clinical Applications: Medical Cannabis What Clinicians Need to Know and Why
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Do you actually know what you’re putting in your body? By Nurse Juhlzie Monteiro RN, BSK
What you are putting in your body has been a mainstream
completely illegal to research. And it has been kept this way for
concern by consumers over the last decades with the
over 75 plus years through prohibition. Thus, federal agencies are
development of science and research informing us of the many
not governing nor setting national standards for medical cannabis
dangers we can encounter within our world. What we consume,
despite the majority of the states legalizing it.
inhale, or use as treatments in the medical cannabis industry lacks national attention and does not guide us as to which governing bodies to use as an official source of reliable information. In fact, it has become clear as mud when one is trying to research this topic. And for medical providers this can be extremely frustrating when it comes to the safety of our patients.
Why is this?
In the absence of this federal guidance, regulators in each state have turned to different sources for information, and each state has produced a unique set of rules and regulations (if they have produced any at all). Many of these are in outright conflict with each other, and the majority of laboratory testing facilities are largely
not
grounded
on
scientific
research. http://
cannabissafetyinstitute.org/wp-content/uploads/2015/06/ Microbiological-Safety-Testing-of-Cannabis.pdf
However, many
Safety recommendations are normally outlined and provided by
states around the nation such as Nevada, Washington, Oregon, and
federal agencies such as the EPA, FDA, or USDA who set
Massachusetts are leading the way by example for national
national standards. That is not the case with Medical Cannabis.
standards to be modeled after. The Annual Emerald Conference
Federally, cannabis is illegal and a Schedule 1 Drug stating it
held in Las Vegas, Nevada at The Monte Carlo Hotel this year in
“has no currently accepted medical use” and since it has remained
January 2016 was a perfect example of states coming together to
in the Schedule 1 Drug category, despite numerous efforts and
create a master plan for national standards. Ultimately, the Cannabis
current efforts to reclassify (CARERS Act of 2015 S.683 -
Industry, whether medicinal or recreational, has its work cut out in
Compassionate Access, Research Expansion, and Respect States
future years as regulations will be demanded by healthcare providers
Act of 2015) the federal government considers it taboo-
and patients to ensure patient safety as a whole.
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As a reminder, it is important that patients know, despite its schedule 1 classification, Cannabinoids possess a remarkable safety record, particularly when compared to other therapeutically active substances, particularly prescription drugs. Most significantly, the consumption of marijuana -regardless of quantity or potency -- cannot induce a fatal overdose.
Guidelines for Testing and Screening of Products should include
According to a 1995 review prepared for the World Health Organization, "There are no recorded cases of overdose fatalities attributed to cannabis, and the estimated lethal dose for humans extrapolated from animal studies is so high that it cannot be achieved by ... users." http://www.druglibrary.org/schaffer/hemp/general/whoindex.htm As more states legalize medical or recreational marijuana, they’re tasked with defining the kind of tests and quality controls that must be done, if any, on the edibles, flower bud, concentrates and medical cannabis infused products sold at dispensaries and storefronts across the country. Standardization of testing at a national level is necessary for consistency and safety of medical cannabis. It is our duty as medical providers to advocate for patients that they not only have safe access but also safe products to consume. Assuring your state is setting up quality lab standards is vital to the safety of your states medical cannabis program and recreational products alike.
So what do we do now? One thing for sure, the Cannabis Industry needs science. And, we need to be able to conduct cannabis research
but not limited to: 1.
Foreign Matter Inspection
2.
Moisture Content Analysis
3.
Microbial Screening
4.
Heavy Metal Screening
5.
Solvent Residue Analysis
6.
Pesticide Residue Analysis
7.
Mycotoxin Screening
8.
Potency: Cannabinoid and Terpene Analysis
9.
Cannabinoid Ratios (THC:CBD)
10..
Final Review
Here is a list of ingredients you should avoid in your Medical Cannabis product lines: • Derived Products consisting of: Butane-BHO (Butane Hash Oil), Benzene, Methylbutane, Neopentane, Hexane, Pentane and Heavy Metals. Residual solvents can remain in the product(s) and testing is necessary to detect if these residual solvents remain. Extraction solvents only become a health concern when residual solvents remain after processing the plant material. The health risks of consuming cannabis concentrates with residual solvents are not specifically known at this time and this is an area of study open for research. However, when medical cannabis is manufactured correctly and tested properly the finished product is quality and potency tested assured. • PEG (Polyethylene Glycol): PEG Compounds often contain small amounts of ethylene oxide. According to experimental results reported on in the National Toxicology program’s Eighth Annual Report on Carcinogens, ethylene oxide increases the incidences of uterine and breast cancers and of leukemia and brain cancer. According to http://www.ncbi.nlm.nih.gov/ pubmed/16011869 all PEGs and PEG derivatives, must not be applied to damaged skin as they do not readily penetrate intact skin, and in view of the wide use of preparations containing PEG and PEG derivatives, only few case reports on sensitization reactions have been published, mainly involving patients with exposure to PEGs in medicines or following exposure to injured or
legally. One state after another has had to struggle with
chronically inflamed skin.
building a safe and regulated new agricultural industry. Until
• DEA (Diethanolamine), MEA (Monoethanolamine), TEA
the research is allowed and conducted, we as medical
(Triethanolamine) – These are hormone disrupting chemicals that
providers need to assure our patients have safe access and
can form cancer causing agents. In fact, these chemicals have
advocate for national standards to be developed. Above is a
been linked to liver and kidney cancer. They are most commonly
list of guidelines that should be examined while testing and
found in shampoos, soaps, bubble baths and facial cleansers.
screening cannabis and cannabis products.
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• Phthalates and Parabens – You may have heard of these before, particularly parabens. There’s been a paraben free
• Sugars- The average American downs nearly 150 pounds of sugar and high-fructose corn syrup a year, according to the
movement going around in fact Europe banned these chemicals
United States Department of Agriculture. And if patients are
in 2003. Phthalates and parabens are a group of chemicals
eating and consuming anywhere near that much sugar, they may
commonly used as preservatives in cosmetics and
have more than just a sweet tooth — their body may be hosting
pharmaceuticals. They are commonly found in cosmetics,
an unhealthy overgrowth of Candida albicans. A small amount
hairspray and nail polishes and have been shown to be
of this common, yeastlike fungus living in the gut is normal
carcinogenic. In particular, they have been linked to breast
when its numbers are kept in check by healthy flora. But when
cancer.
an intestinal imbalance and immune suppressed patient
• Propylene Glycol – Propylene glycol is a related chemical
consumes sugary edibles, it acts like kudzu, colonizing
that, like PEGs, functions as a penetration enhancer and can
everything in its path. Sugars in medibles need to be avoided
allow harmful ingredients to be absorbed more readily through
when it comes to diabetics or cancer patients and their nutrition
the skin. It can also cause allergic reactions. Health Canada
needs to be evaluated.
categorized propylene glycol as a "moderate human health priority" and flagged it future assessment under the government's Chemicals Management Plan. Propylene Glycol is the active ingredient in antifreeze. It is also used in makeup, toothpaste and deodorant. Stick deodorants have a higher concentration of PG than is allowed for most industrial use. Direct contact can cause brain, liver and kidney abnormalities. The EPA requires workers to wear protective gloves, clothing and goggles when working with it. And yet, the FDA says we can put it in our mouths. • Talc – This is a surprising one, huh? Talc can be found in makeup, baby and adult powders and foundation but has been linked to ovarian and testicular cancer. • Sodium Lauryl Sulfate and Sodium Laureth Sulfate – These two chemicals are two of the most toxic around. You may be familiar with the names because they are commonly used in toothpaste as well as makeup, shampoos and conditioners. But guess what else they’re commonly used for? They are used to clean engines, garage floors and at car washes. Not really something you want to put on or in your body, right?
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In review, it is important as a patient and consumer of cannabis products to know what the products are made of. Make sure to educate your patients to ask for a list of ingredients and methods of production and testing of the medical cannabis from seed to sale that they are about to purchase. This will assure and guarantee the products they are consuming are safe. Ultimately, it is your right to know what goes into your body and it is important to make sure you know and if you don't know, Just Ask. It’s the vital step that should never be ignored. Your safety and the safety of your patients depends upon it. Terms/Resources: "GRAS" is an acronym for the phrase Generally Recognized As Safe. Under sections 201(s) and 409 of the Federal Food, Drug, and Cosmetic Act (the Act), any substance that is intentionally added to food is a food additive, that is subject to premarket review and approval by FDA, unless the substance is generally recognized, among qualified experts, as having been adequately shown to be safe under the conditions of its intended use, or unless the use of the substance is otherwise excluded from the definition of a food additive. http://www.fda.gov/food/ingredientspackaginglabeling/ gras/default.htm
http://cannabis-med.org/index.php?tpl=journal&id=228&lng= en&fid=:&red=journallist
www.UnitedPatientsGroup.com/conference
The Birth of ACNA
"American Cannabis Nurses Association" Est. 2010
Mission: To advance excellence in cannabis nursing practice through advocacy, collaboration, education, research and policy development. In the mid 1980s I had returned to school at Case Western Reserve University to get my masters degree in nursing and I conducted my thesis on Marijuana Disclosure to Health Care Professionals. At that time, marijuana was the most used illicit drug in the US and I wondered if health care professionals were asking patients about their use of it and whether or not the Patients would admit to use.
surprising because at the time I had only heard that marijuana could help with chemoinduced nausea and vomiting and glaucoma. I did more research on the plant and learned that the “marijuana” prohibition was based on lies, racism and greed and that the proper name for the plant was cannabis. Following graduation, I did volunteer work for NORML as their Director of the Council on Marijuana and Health and later as a member of the Board of Directors. I learned about the Compassionate Investigational New Drug (IND), the Federal Government’s medical cannabis program and gathered the 1st five patients together to meet and support each other. These are the patients who received marijuana from the federal government each month. I was astounded by the hypocrisy. At this time in the US, the War on Drugs was raging--and talk about marijuana or cannabis as a medicine, was largely avoided by health care professionals (HCPs). My husband and I realized that legalizing the plant for adult use was too great a leap for many HCPs and so in 1995, we created Patients Out of Time, a non-profit educational charity that would focus on the medical value of cannabis and we enlisted some of the federal (IND) patients and other noted health experts on the subject as our board members.
American Cannabis Nurses Assocation Founding Board Members Cirque 2010 (From left: Mary Lynn Mathre RN, MSN, CARN,Ed Gerlick RNs, KenWolski RN, MPA, Bryan Krumm CNP
I developed a survey and contacted the National Organization for the Reform of Marijuana Laws (NORML) to see if I could distribute this survey to their membership and in return, I would share my results with them. The leadership at NORML thought it was a great idea and I ended up with more than 900 respondents. In short, I learned that most marijuana users were not asked about their use of marijuana, but that over half would admit to use if asked. But my last question was an eye-opener for me. I asked about their health concerns related to their use of marijuana and gave them several choices from which they could check as many as they wanted. The last choice was “other” and 25 persons checked that box and wrote in that they used it as medicine: for nausea and vomiting, for migraines, for MS, for spasms related to a spinal cord injury and other uses. Wow – that was
We began by getting health care organizations to pass resolutions in support of medical cannabis, starting with the Virginia Nurses Association and the Virginia Nurses Society on Addictions and the American Public Health Association. We wanted to hold medical cannabis conferences that were accredited for continuing education for physicians and nurses, but couldn’t find an institution that would work with us. Finally, Melanie Dreher, PN, PhD who was Dean at the University of Iowa’s College of Nursing convinced both the Colleges of Nursing and
Medicine to accredit our first conference in 2000. The First National Clinical Conference on Cannabis Therapeutics began our biennial conference series and we were able to get continuing education credits from other sources. The conferences were set up as multi-disciplinary events. The faculty included cannabis researchers from around the world, cannabis clinicians, patients and sometimes policy experts or family members. Our goal was to present the science and real case studies. To our dismay, the attendance of physicians and nurses was limited. Most were so intimidated by the federal prohibition that being associated with anything positive about cannabis was still seen as a risk to their professional status. However, over time a core group of nurses attended these conferences and as we learned about the Endocannabinoid System and the safety and efficacy of cannabis it became clear to us that this was a new and important specialty area of nursing. Ed Glick RNs and I began by getting our organization incorporated as a non-profit entity. Finally at The Sixth National Clinical Conference on Cannabis Therapeutics, that was held in Warwick, RI in 2010, a handful of nurses along with a few supporters came together to form the American Cannabis Nurses Association. The founding nurses include: Ed Glick RNs, Ken Wolski RN, MPA, Bryan Krumm CNP, and Sharon Palmer RN along with me. The process moving forward was slow, but steady, as we had no financial support and our specialty clearly wasn’t (and still isn’t) recognized as a legitimate area of practice – after all our organization was centered on a Schedule I “forbidden” medicine.
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Times were changing as various states passed initiatives or legislators passed laws to support patient access to cannabis. We gradually recruited new nurses who were attending the Patients Out of Time conferences and they brought new skills and energy to create a more viable website, develop our basic structure, and begin to create educational courses specifically for nurses. Just this past year we became a 501(c)(3) educational charity and moved our headquarters to New Jersey. Our mission statement is: To advance excellence in cannabis nursing practice through advocacy, collaboration, education, research and policy development. Today our total membership is 350 and is steadily growing. Cannabis is becoming more and more accepted by the public and because of their demand, more and more nurses are responding to their needs. We are first and foremost patient advocates. We have practicing nurses, retired nurses, disabled nurses, and encourage our growth in student membership. Struggles and roadblocks remain, but we continue to breakdown the barriers. We have nurses who join the ACNA, but request that their membership remain confidential due to the potential repercussions in their work environment. In some institutions, simply speaking in favor of patient access to cannabis or an end to the cannabis prohibition is enough to be singled out for drug testing to determine if that open-minded nurse may be consuming cannabis. We have nurses who have a medical condition and discover that cannabis is the safest and most effective medicine for them, yet if their institution learns of their use, they could lose their job and possibly their license to practice nursing. In states where cannabis remains illegal, some nurses have actually grown cannabis for patients or actively worked to find a safe source of this medicine solely on their understanding and compassion for the needs of the patients. Yes, some nurses have broken the law, but it is not a careless breech in practice. Rather it comes from a clear understanding that the prohibition of this natural plant, a safe and effective botanical medicine, is baseless and a crime to humanity. It is very difficult for nurses to stand by and watch patients suffer without access to this medicine once we understand the physiology of the
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Endocannabinoid System and how cannabis actually works to help patients attain, maintain or regain health and homeostasis. A few years after my book on cannabis Cannabis in Medical Practice: A Legal, Historical, and Pharmacological Overview of the Therapeutic Use of Marijuana was published in 1997, the head of the hospital actually called the Chief Nurse into his office to question her as to how he should “deal with this nurse” – but my boss was close to retiring, she had seen its value to cancer patients decades ago when she was working on an oncology unit, and she knew about my work. She simply asked,“Have you read the book?” When he said he hadn’t, she suggested that he read it first and left his office. I can say that while some key leaders “had my back” there were others who felt I needed to go.
Ken Wolski RN, MPA & Mary Lynn Mathre RN, MSN, CARN
Throughout my years of nursing practice I was careful about speaking out against the marijuana prohibition. But, the more I learned the more confident I became because I could see the greater harm caused by the prohibition. While working as the Addictions Consult Nurse at the University of Virginia Health System, if a patient admitted to using cannabis, I would teach them about the risks and benefits. I always began with the warning that their use of it was illegal, but wanted them to know that I understood it was good medicine and they should not have to feel ashamed about using it. Often times I would need to have a discussion with the patient’s physician to advocate for the patient and to discourage any drug testing for cannabis and I am happy to say that many physicians actually followed my advice. Needless to say, not everyone felt this way, especially the hospital administrators. I think the greatest contribution I have and can make for the ACNA and the cannabis nursing specialty is to use my decades of
experience and my knowledge base that grew exponentially with the conference series by Patients Out of Time to speak out publically to leaders in health care, politicians and government officials, law enforcement, and the public at large about the harms caused by the cannabis prohibition, the amazing science of the newly discovered Endocannabinoid System (ECS) and the remarkable safety of natural cannabis. I will continue to speak out until the cannabis plant is removed from the controlled substances classification and it is finally fully accepted as a first line medicine that can be used for health maintenance and wellness as well as a firstline medication due to its safety and efficacy. Patients deserve to have cannabis as an option for them and health care clinicians need to recognize its potential value and understand how to use it effectively for their patients. The ACNA board and active members have been working hard to continue to develop the organization. We recognize that it takes years to be accepted as a new nursing specialty, but with the added burden of the cannabis prohibition, our path will probably take a few years longer than usual. Eileen Konieczney RN, is a powerful patient advocate who brings incredible administrative leadership to the organization and I feel she will take the ACNA to a new level as our new President. Our core curriculum will soon be available as an online course so nurses can learn about the ECS and cannabis from the comfort of their homes. Once educated, most nurses recognize the incredible importance of the ECS and we can teach our patients about this system and how they can keep it healthy which in turn will help keep them healthy. I will certainly stay involved with the ACNA, but will also devote my time and effort to sustaining Patients Out of Time. Years ago I had a conversation with Melanie Dreher, RN, PhD (Melanie has been my mentor and hero as she did groundbreaking research on the use of “ganja” in Jamaica by pregnant women and followed the children for several years.) about whether or not to let Patients Out of Time fade away as the health care professionals took the lead with cannabis as a specialty area. Melanie reaffirmed the importance of the multidisciplinary nature of the Patients Out of Time conference series, which serves to bring together
the various disciplines for a more holistic understanding of the medical use of cannabis. Nurses always put the patients in the center of care and these conferences bring together the cannabis researchers to share their new discoveries, the clinicians to share their clinical experiences with patients, and patients to share their experiences with standard medical treatment compared to their use of cannabis. It is an incredibly synergistic conference with each discipline learning from others and networking with colleagues throughout the US and beyond. I see nurses, physicians, pharmacists, herbalists, social workers, physical therapists, etc. learning about this field through the conference series (also available online) and then using this knowledge to continue to develop themselves as leaders in their chosen profession to develop this specialty practice. We are all in this together for the benefit of the patient and it will take all of our voices working in our own areas and coming together as needed to end the cannabis prohibition. We do, as Mahatamas Ghandi said, we need to “Become the change you wish to see.” For all nurses working in this area and for those willing to open their minds to the science and open their hearts to the needs of the patients, my advice is to continue to learn and to speak the truth. The truth is on our side. Prohibiting the cannabis plant is literally a crime and we need to educate our peers, the legislators, law enforcement, and the general public about this incredible plant. At this time we need nurses to join the ACNA with an attitude of “how can I help end the prohibition; how can I help patients gain safe access to this medicine; and how can I educate others?” rather than “what can the ACNA do for me?” ACNA nurses are first and foremost patient advocates and when it comes to cannabis we need to be the change makers. Nurses are the most trusted professionals and our patients are counting on us to stand up for them and to stand with them.
As a closing thought I encourage nurses to recognize the full value of the cannabis plant to all citizens and to our planet. Cannabis not only provides medicine for the sick, but nourishment for our bodies (and for all animals) and the hemp plant offers wonderful strong, safe, useful health and industrial products that are good for the environment. This is a plant that gives back to the earth and it needs to be grown outdoors to help sustain our planet. Don’t ever give up.
BIO Mary Lynn Mathre RN, MSN, CARN
Lecture: The Remarkable Safety of Cannabis Speaker at: Green Flower Conference Sunday | January 24th, 2016 By: Mary Lynn Mathre RN, MSN, CARN
Overview
Know what cannabis you’re consuming. Ideally, you’ll know how and where your cannabis was grown. When buying cannabis from a dispensary, for example, you want to make sure that it’s a reputable establishment. And you want to ask plenty of questions about their lab testing practices. Cannabis that has been grown and sold irresponsibly can potentially contain any number of contaminants such as mold, mildew, insects, pesticides, or dirt – none of these things are part of holistic health! Different states have different regulations for lab-testing, some better than others. The important thing, again, is to ask questions. And if you’re stuck with the traditional black-market mystery bag of cannabis thanks to prohibition, better to get out there and rock the vote. In fact, all cannabis advocates need to Vote, Vote, Vote. http://greenflowermedia.com/article/howto-use-cannabis-for-holistichealth-2016-2/
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 four 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 Ms. Mathre has studied the medical use of cannabis. She is the co-founder 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 regarding medical cannabis and served as an expert witness on the topic. March/April 2016
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Miss Colorado Kelley Johnson
More Than "Just a Nurse" By Nurse Heather Manus, RN
On September 13, 2015, during the Miss America pageant, the Country watched while Miss Colorado, Kelley Johnson, defied stereotypes when she donned her scrubs and stethoscope during the talent portion of the competition to deliver a powerful and insightful monologue about being “Just a nurse.” She spoke of her patient, Joe, who had Alzheimer’s and suffered from night terrors. He often asked Nurse Kelley if she could adjust his medications, but she replied that she couldn’t because she was “just a nurse.” Kelley revealed that one evening Joe was having a particularly difficult time dealing with his symptoms, diagnosis and slipping memories. Kelley encouraged comfort for Joe by telling him he wasn’t just Alzheimer’s. She reminded him that he was a person with a family, and that he shouldn’t define himself by his condition. Surprisingly, Joe flipped the script on Kelley by reminding her that she also wasn’t “just a nurse.” While appearing on the Ellen DeGeneres show, Kelley explained, “My talent is taking care of people and caring about other people. And so I wanted to give the nurses that don’t have that voice, that voice, and that recognition of just somebody going up there and just being a little different and unique.” Every day, more nurses across the world are learning about the Endocannabinoid System and the benefits and safety profile of Cannabinoid Therapeutics. Nurses are standing up, using their voice, and are “just being a little bit different and unique.” As Cannabis Nursing gains momentum and credibility, nurses are recognizing from a new perspective what the American Nurses Association (ANA) meant in 1995 when the organization launched the campaign “Every Patient Deserves a Nurse.”
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At the writing of this article, Medical Cannabis laws exists in 41 US States, Districts, or Territories (23 States, District of Columbia, 2 Territories, 15 States- CBD Only). Over the Counter (OTC) access is available to adults 21 or older in 4 States, with even more on the ballot for 2016. The role of Nurses is very important during this fast moving Revolution in HealTHCare. With more than 75% of States allowing certain patients to choose and safely access cannabis medicine, nurses are sure to encounter “Cannabis Patients” within our nursing practice. What should Nurses know about Cannabis Patients? First of all, remember these patients aren’t “just a cannabis patient.” Cannabis patients can be pediatric, geriatric, psychiatric, oncology, neurology patients, or anyone in between. Many patients have been suffering from chronic debilitating conditions, and have tried nearly everything that conventional medicine had to offer. These patients have turned to Cannabinoid therapy as an alternative, complementary, or last resort option. If a patient has the courage to disclose that they are using cannabis as an option, Nurses need to have the courage and knowledge to provide appropriate care, support, and documentation.
During Assessment of the Patient: 1. Is the patient a legal patient on a State program? a. Ask to review legal State issued Medical Cannabis Program card or paperwork. 2. Does the patient have availability to safely access medicinal-grade cannabis products? a. Ask which local dispensary the patient uses. Recognize that “dispensaries” are the functional equivalent to “pharmacies,” and it’s important to know that patients are able to legally and safely access cannabis medicine from one of these legal sources. 3. Which Methods of Administration (MOA) are being used to support the patient’s Endocannabinoid System? a. Dispensaries provide multiple products that can be administered by various methods. Inhaled, Oral, Sublingual, Topical, Transdermal, and Rectal methods are currently available to most medical cannabis patients. Understanding the mechanism of action regarding each method of administration is important for nurses to understand. 4. What benefits are being experienced by the patient as a result of Cannabinoid therapy? a. Patients and caregivers provide valuable assessment information regarding cannabinoid therapeutics for nurses and physicians. It is not uncommon for cannabis patients to request assistance from their medical provider to safely reduce or discontinue certain pharmaceutical medications. It’s important to always encourage patients to work with their physician while titrating down or off of medications.
If you learn nothing else from this article, please remember this… Patients who use Cannabinoid Therapeutics are more than “just a cannabis patient,” and nurses who care for these patients are more than “just a nurse.” We are Cannabis Nurses; Caring, Compassionate, and Intelligent Nurses who deeply understand that EVERY patient deserves a Nurse.
ALZHEIMER’S:
Facts: Alzheimer’s disease is a progressive,
degenerative disorder that attacks the brain's nerve cells, or neurons, resulting in loss of memory, thinking, and language skills; and behavioral changes. These damaged neurons, which produce the brain chemical, or neurotransmitter, acetylcholine, break connections with other nerve cells and ultimately die. For example, short-term memory fails when Alzheimer’s disease first destroys nerve cells in the hippocampus, and language skills and judgment decline when neurons die in the cerebral cortex. Two types of abnormal lesions clog the brains of individuals with Alzheimer’s disease: beta-amyloid plaques- sticky clumps of protein fragments and cellular material that form outside and around neurons; and neurofibrillary tangles- insoluble twisted fibers composed largely of the tau proteins that build up inside nerve cells. Although these structures are hallmarks of the disease, scientists are unclear as to whether they cause it or are a byproduct of it. Alzheimer’s disease is the most common cause of dementia, or loss of intellectual function, among people aged 65 and older. Alzheimer’s disease is not a normal part of aging. Source: Alzheimer’s Foundation of America
Findings: Researchers from the University of
South Florida’s Health Byrd Alzheimer’s Institute report, in an article published in the Journal of Alzheimer’s Disease, that extremely low doses of THC reduce the production of amyloid beta and prevent abnormal accumulation of this sticky protein. Low concentrations of THC have also been shown to selectively enhance mitochondrial function, aid in supplying energy, transmitting signals, and maintain a healthy brain. “THC is known to be a potent antioxidant with neuroprotective properties, but this is the first report that the compound directly affects Alzheimer’s pathology by decreasing amyloid beta levels, inhibiting its aggregation, and enhancing mitochondrial function”, said study lead author Chuanhai Cao, Ph.D., a neuroscientist at the Byrd Alzheimer’s Institute and the USF College of Pharmacy. “Decreased levels of amyloid beta means less aggregaation, which may protect against the progression of Alzheimer’s disease. Since THC is a natural and relatively safe amyloid inhibitor, THC or its analogs may help us develop an effective treatment in the future.”
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CANNABIS CAN SAVE THE WORLD
A Dietitian’s Perspective on Cannabis By Jessica Aragona, MS, RD, LDN
“Cannabis can save the World” a bold statement perhaps, but potentially true none the less. As a Dietitian, when I look at the cannabis plant, I first see its nutritional value as a vegetable, loaded with vitamins, minerals, and antioxidants. I also know that, essentially, cannabis is hemp and “hemp hits a home-run every time” when it comes to nutritional value - among its other thousands of industrial uses. A quick nutritional summary of hemp: Great source of complete protein 100% vegan, dairy free, gluten free Easy to digest High in healthy Omega-3 and Omega-6 fatty acids Wow- what a power house!
Tips and recommendations for incorporating more “Green” into your daily diet -> Raw cannabis can be used every day, multiple times a day by anyone of any age. ->Raw cannabis is NOT psychoactive unless it is heated- meaning there are no worries of mental or physical impairment after consuming -> Raw cannabis can be added to smoothies, juices, salads -> Like any other herb or seasoning, ground up raw buds can be sprinkled on top of soups, stews, oatmeal, yogurt or pudding -> Juicing specifically takes a lot of material, Dr. Courtney suggests 20-30 big shade leaves or 2-3 raw buds (2-3 inches in length) per day for therapeutic benefits -> Having your own garden at home is helpful as access to this quantity of raw product may be difficult or illegal in your state.
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As a holistic healthcare professional, I recognize and highly respect the diversity of cannabis in its uses as a medicine to heal and repair both the body and the mind. It is my opinion that, cannabis may, not only be the best medicine but also the most nutritious plant known to humankind thus far.
Nutritional Benefits of Raw Cannabis
While the exact nutritional profile of cannabis has yet to be determined, it seems safe to presume that the cannabis plant including the seeds, is most likely just as nutritious as hemp, if not more so. What’s being discovered now is the nutritional power and overall beneficial health effects of raw cannabis. Raw cannabis is not psychoactive unless heated and it contains powerful disease-fighting compounds known as cannabinoids. Of these compounds the most frequently studied are, Tetrahydrocannabinol (THC) and Cannabidiol (CBD).
When used just as you would any other vegetable (in a smoothie, salad, sauté, juiced), cannabis appears to provide some pretty awesome health benefits. You may have heard of Kristen Peskuski-Courtney? A woman who struggled with multiple chronic illnesses which left her all but debilitated. After years of pharmaceutical intervention to no avail, she was finally cured through the power of raw cannabis juicing. The man behind this method of ingestion is Dr. William Courtney, a medical doctor and huge promoter of the “raw greens” cannabis movement.
A direct quote from Dr. Courtney’s website www.rawhemp.tk “Whether Sativa, Indica, Ruderalis, male, female, hermaphrodite, native, feral, bred for fiber, seeds or medicinal resin, Cannabis is the best source for [beneficial cannabinoids]... Over 50 patients have used only [cannabinoids] to put their cancer in remission; and over 150 have found symptomatic relief.”
What does that tell you?
What it says to me is that there is some powerful research being done and treatment methods being delivered out there to very sick patients and they are all based on raw cannabis.
HERBAL HEADACHE RELIEF (Remedies) 2 tbsp valerian (dried) 2 tbsp skullcap (dried) 2 tbsp cannabis (chopped) 2 tbsp chamomile (dried)
2 tbsp rosemary (dried) 2 tbsp peppermint (dried) 1 tbsp hempseed 2 tbsp honey
Grind all herbs in a coffee grinder or food processor until powdered. Blend with enough honey to bind. Break off small, pill-sized pieces. Roll into a ball, then flatten slightly. Dry. Store in a tightly sealed container in a cool dark place. Use 1 or 2 doses (pill-sized pieces) to help relieve a tension headache. Wait one hour before next dosage. Note: The shelf life of this herbal remedy is only a few weeks as it breaks down rapidly. Therefore, you should use within two weeks of grinding. PEACEFUL & LOVING LIFE
Dr. Courtney has determined that:
• Smoking cannabis doesn’t treat the disease, only the symptoms • Therapeutic levels of cannabinoids can only be achieved through ingestion (not smoking) • When cannabis is heated or burned, the chemical structure of the plant compounds are changed- specifically the acidity of THC which alters its ability to be therapeutic. • Raw cannabis activates the brain’s Endocannabinoid System which triggers an antioxidant release • These antioxidants act as a “cleaner” and remove damaged cells from the body • Raw cannabis improves the efficiency of the cells in our body • Creating oils, butters or eating the raw plant is the only way to get the necessary beneficial compounds
2 heaping ounces compassion 2 large quarts of understanding 2 whole lbs. love & true caring 1 packed bag selfless giving 1 whole lb. patience 1 rounded cup kindness
3 dozen lbs. peace 1 large bottle gracious listening 3 heaping bags forgiveness 2 bunches true understanding 2 packed lbs. caring insight 2 ounces complete passion
2 large jars real sharing Mix all ingredients well together. Toss in lots of laughter and liberal smiles. Serve generously to all those around you with true love and peace in your heart. Note: Please share with others and practice peace and random acts of kindness each and every day.
SCALLOP VEGGIE VORTEX STIR-FRY (Seafood) 2 tbsp cannaoil 1 medium white onion 2 tbsp garlic (chopped) 1 bunch broccoli 8-oz mushrooms (sliced) 2 medium carrots 1 cup peas 4 small scallions (chopped)
*Shellfish Allergy Warning
2 tbsp cannabis (finely chopped) 1 lb. scallops 1 cup sprouts 1 cup rice 1 (4-oz.) jar artichokes (diced) 4 tbsp Stir-Fry sauce 1 bunch cilantro (fresh, chopped) 1 bunch chives (fresh, chopped)
Dice vegetables into small pieces. Cook rice and set aside. In a large frying pan or wok heat cannaoil. Slowly add garlic, broccoli, mushrooms, carrots and onions. Stir-fry several minutes, until onions are slightly brown and broccoli is a deep green. Add scallions, cannabis and scallops, mix well. Add artichokes and sprouts, continue stirring. Mix in 2 tablespoons stir-fry sauce until all veggies are evenly coated. Add rice and stir. Finally add 2 more tablespoons stir-fry sauce and mix until rice is brown. Serve. Makes 4 to 6 servings.
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Nursing Humor
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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.
Shelly Johnson-Ochoa always new that she
would write a book but she never imagined it would be about marijuana. Shelly has created something truly unique and necessary for every medical marijuana patient. Shelly has created a detailed Medical Marijuana Journal for patients to document the products they are and the results they are achieving daily. With thousands of strains of medical marijuana to choose from and hundreds of products available to try, it is difficult for patients to keep track of what they are using. My MMJ Journal allows patients to track their progress and guide them to successful results.
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Job Opportunities Perm & Travel
Cannabis Nurse Job Board has over 2,000 job opportunities in all nursing specialties.
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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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If you are available for consideration, please reply to this email and a recruiting specialist will contact you as soon as possible. Call us immediately: 800-591-7860 or scan the QR code To complete a full application, please scan the QR code
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
2016
Come meet the Nurses of ACNA at these future Events!
March Conferences American Academy of Hospice and Palliative Medicine & the Hospice and Palliative Nurses Association (AAHPM) March 9th-11th, 2016 | Chicago, IL http://aahpm.org/uploads/footer/AAHPM16_EXPR_Application_Form_a_fillable_locked.pdf
April Conferences The Tenth Clinical Conference on Cannabis Therapeutics: "Cannabis: A Botanical Medicine" Patient’s Out of Time Conference ACNA's Workshops for Nurses: Future CEU's Available Online. April 14th-16th, 2016 | Baltimore, Maryland Look for ACNA Workshops in your area in the near future by visiting: http://www.medicalcannabis.com http://americancanabisnursesassociation.org/Events
May Conferences
Take Note
United Patients Group Conference Medical Cannabis: The Science. The Truth. May 21st & 22nd, 2016 | San Rafael, CA http://www.unitedpatientsgroup.com/conference
!
ACNA Advanced Core Curriculum will be offered at <-- United Patients Group Conference
American Holistic Nurses Association (AHNA) May 31st- June 5th, 2016 | Bonita Springs, FL http://www.ahna.org/Conference/Sponsors-and-Exhibitors
September Conferences Marijuana for Medical Professionals CME Certified Conference on Canabis Medicine September 27th & 28th, 2016 | Denver, CO At: Sherman Street Event Center Association of Pediatric Hematology/Oncology Nurses (APHON) September 29-Oct 1, 2016 | Indianapolis, IN http://www.aphon.org/meetings/confindex.cfm
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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