Cannabis and the nurse: What's new?

Talk Tuesday - September 22, 2020

Presenter

Lynda G. Balneaves RN PhD

Dr. Balneaves is an Associate Professor in the College of Nursing, Rady Faculty of Health Sciences at the University of Manitoba. Previously, she has held academic positions at the University of Toronto and the University of British Columbia. Her research program has focused on the use of complementary therapies by individuals living with cancer and supporting informed treatment decisions. She also engages in health policy and access research related to medical and non-medical cannabis. Currently, Lynda is the Intermediate Past-President of the Society for Integrative Oncology (SIO) and is Deputy Director of the Canadian Consortium for the Investigations of Cannabinoids (CCIC).  

Summary

We heard from Dr. Lynda Balneaves tonight for an update about medical and non-medical cannabis. Lynda first spoke with Association members two years ago around the time of legalization. 

She shared how rates of medical and non-medical cannabis use have changed since legalization, how the rates of those who use cannabis daily compare and described how people are using cannabis now and what’s changed. Lynda also noted a drop in individuals holding active registrations with licensed producers of medical cannabis suggesting they may be obtaining it through other routes though they still may use it for therapeutic purposes. 

The Cannabis Act is a federal law though things like age of consumption, number of plants allowed per home, distribution and access are regulated provincially. Lynda shared the framework of the federal act and what changes have been made since 2018. Notably, cannabis edible and extracts are allowable now with limits on per package amounts of THC to minimize risk of overdose. 

In Quebec, the age of consumption was raised to 21 and they do not allow sale of cannabis candies and desserts to avoid appealing to a youth market. In Manitoba, there have been court challenges to the provincial regulation that limits personal growing to four plants per home. There is a provision in the Cannabis Act that requires it to be re-examined in 2021 so we can expect more changes as the situation evolves. 

Lynda recalled the potential harms that were discussed pre-legalization including impaired driving, increased access for youth, and increased use of emergency services and though there is some preliminary data it really hasn’t been long enough to show a clear answer. 

Authorizing, prescribing and administering medical cannabis is another area of interest for nurses. Manitoba, like most provinces, allows nurse practitioners to authorize/prescribe medical cannabis if the patient is under their care and cannabis is required for the condition that the client is receiving treatment for. Federal and provincial law allows nurses to distribute and administer medical cannabis though the policies of individual facilities vary and there are additional considerations outlined by the Canadian Nurses Protective Society and the College of Registered Nurses of Manitoba. 

Lynda finished up by reviewing barriers to including medical cannabis in the curricula of nursing education programs and a roundup of current and upcoming resources nurses can access to support us as we counsel patients.

Question and answer

1. Can nurses in long term care facilities give seniors cannabis if there is a medical license?

According to federal and provincial law yes. But some facilities don’t allow it so make sure you’re familiar with the CNPS amd CRNM regulations as well as the policy of your facility.

2. Can you talk about cannabis and mental illness?

  • That’s a big topic. Here’s a bit of a summary. There is a link between high THC, high potency strains and episodes of psychosis. People that use high THC cannabis are more likely to experience a psychotic episode and earlier onset of schizophrenia. This doesn’t necessarily mean that the risk of schizophrenia is higher, just that the onset may be earlier in some individuals.
  • In some individuals anxiety can be exacerbated if they use high THC strains, but there is also some very early evidence that CBD may be beneficial.
  • There is an urgent need for research into cannabis and opioid use disorder. In surveys we are seeing that people are using cannabis as an “exit drug” rather than an “entryway drug.”
  • We are starting to see some sex differences as well. It may be that girls and women are more likely to develop cannabis use disorder but again, more research is needed.
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3. Do you know if there are specific physicians and clinics in Manitoba who prescribe cannabis? And if so, what do they prescribe it to treat?

Yes. I don’t want to name names but there are definitely individuals who have focused their practice on cannabis. I’d be happy to discuss more offline. There are individuals in Manitoba who have done the training and research and treat a whole host of conditions, though primarily pain. Especially from arthritis, peripheral neuropathy or other kinds of neuropathic pain, sleep disorders. There is even some really preliminary evidence that cannabis can be used to treat metabolic disorders.

4. How would the general public know how to access medical cannabis? Is this a barrier to access?

The reason I’m hesitant to name names is because some clinics are directly affiliated with licensed producers so recommendations and relationships get more complicated then. It’s important for nurses to counsel patients that they can access any licensed producer, they aren’t restricted...If you google medical cannabis Winnipeg or Manitoba you will see some clinics come up and you can call them - ask if they’re connected with a licensed producer, ask what kinds of health conditions they treat in that clinic…

5. Have you heard about cannabis being used to treat ankylosing spondylitis or multiple sclerosis?

I haven’t heard anything about ankylosing spondylitis specifically. I know of some survey data about cannabis use in multiple sclerosis where people answered that cannabis was associated with some improvement in pain, spasticity and quality of life. This is why we need clinical trials, so we can have some clear answers.

6. What is the future of cannabis use in hospitals? Are administrators exploring the topic or changing policies? Who is going to drive this?

  • Patients will drive it, I think we’re going to see patient advocacy groups really pushing for it, parents pushing for it in pediatric settings...That or we’re going to need a physician or nurse leader really pushing that agenda.
  • The biggest barrier in prescribing is a lack of Phase III Trial data which is what would help prescribers feel confident prescribing cannabis at certain doses for certain conditions… This is a real barrier because how cannabis is used now is so far outside the paradigm of how health care professionals prescribe.
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7. How can I help my patient quit daily cannabis use? 1-2 grams per day, gets quite symptomatic when she cuts back, non-medical, likely high THC…

  • Yes this is hard, there is a tonne of research just coming out about how to treat cannabis use disorder. Lots of it is focused on pharmaceuticals, we’re just starting to summarize and synthesize this so I don't know it off the top of my head - I would invite people to contact me after and I can direct them to the studies.
  • Lots of focus on cognitive behavioural therapy dealing with the cognitive issues that surround daily use of cannabis. We know that the side effects of stopping cannabis are not as severe as those associated with alcohol or opioid withdrawal but I don’t say that to discount or minimize an individual's experience of that. They may need supportive therapy and medical therapy, there are support groups out there…
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8. What was the name of the CBD pharmaceutical you mentioned earlier?

It’s Eidiolex in Canada, quite expensive…

9. Is there any guidance re: use of oils in palliative care or for wound care?

Yes, if you google my name and palliative care there is an article that addresses some of the challenges and includes recommendations.