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How to Effectively Apply the Nursing Process to the Cannabis Patient Copyright, June 4, 2016: Leslie Reyes Waddington, RN How to Effectively Apply the Nursing Process to the Cannabis Patient › The nursing process can be effectively applied to a patient using cannabis therapeutics, if the nurse understands a few basic things about the cannabis plant and the human endocannabinoid system. › By the end of this workshop, the Nurse will be able to effectively apply the nursing process to the cannabis patient. › The following topics will be discussed in this lecture… 1. What is the Endocannabinoid System? 2. What are Cannabinoids? 3. What are Phytocannabinoids vs. Endocannabinoids? 4. What effects does THC have on the body? 5. What effects does CBD have on the body? 6. What is the difference between cannabis Indica and cannabis Sativa? 7. What is the “Entourage Effect”? 8. What are the benefits versus drawbacks of inhaled cannabis? 9. What are the benefits versus drawbacks of ingested cannabis? 10. What do I need to assess in order to determine if my patient is a good candidate for the legal program in their area? Why is this education needed As of the date of this article lecture, some form of medical cannabis is legal in twenty-four states, and Washington D.C., and is legal for recreational purposes in at least two states (National Conference of State Legislature, 2016). However, cannabis is still classified on a federal level as an illegal schedule I drug, along with heroin. (Drug Enforcement Agency, 2016) The DEA defines cannabis as a highly addictive, toxic substance with no medicinal value (DEA, 2016) Why is this education needed? › More and more people, particularly those who have not found relief from standard western health care protocols, are looking for alternatives, such as acupuncture, Ayurveda (traditional Indian medicine), Chinese herbal medicine and cannabis therapies. Currently, there are a lack of professional healthcare staff who understand the application of cannabis as medicine. › In 2013, high profile physician and CNN’s Chief Medical Correspondent, Sanjay Gupta, published an editorial titled “Why I Changed My Mind on Weed”, followed by documentaries which showcased the potential healing properties of cannabis. This brought knowledge of medical cannabis into the mainstream. Why is this education needed? › Currently, there are no standard treatment protocols or formal training on the endocannabinoid system in American Medical Schools or in Canada (Allen, Stewart, Colombe, & Mullins, 2013). › Without standard protocols in place, our current healthcare institution is unable to care for the cannabis patient in a responsible manner (Ziemianski, Capler, Tekanoff, Lacasse, Luconi, & Ware, 2015). › Furthermore, the health care providers’ current inability to answer patients’ questions about delivery methods and dosing options leaves the patient feeling distrustful of the health care provider, as well as the health care institution in general. › The more patients turn to people outside of the health care field for answers about cannabis, the less they trust the traditional, western health care institution. Why is this education needed? › David Allen, M.D., a retired cardiovascular surgeon from Sacramento, California, held a survey to study the state of education on ECS science in American medical schools. › Dr. Allen’s team contacted 157 accredited Medical Schools across all 50 states, by phone and then followed up by e-mail. › The researchers asked these learning institutions three questions: – If they had a department of endocannabinoid science with a director, – If they taught endocannabinoid science as an organized course, and – If they mentioned the endocannabinoid system in any ancillary classes. › Out of the 157 surveyed accredited medical schools in the United States, not one of them had a department of endocannabinoid science or an ECS director. › None of the schools surveyed are teaching endocannabinoid science as an organized course. › Only 13.3% (21 of the 157 schools surveyed) mention the endocannabinoid system in an ancillary course (such as neurology, pathophysiology, pharmacology, etc.) Why is this education needed? › This means, less than 14% of accredited medical schools in the United States of America are teaching our future physicians and healthcare professionals about the endocannabinoid system. (Allen et al., 2013) › The education on ECS in Canada is not much better. Cannabis has been legal in Canada since 1999, and yet, in an article published by BioMed Central of a nationwide survey of Canadian physicians, there was a lack of knowledge regarding dosage, delivery options, creating treatment plans, and a misunderstanding of the difference between cannabis as an herbal medicine and using prescription synthetic cannabinoids. (Ziemianski et al., 2015). › A Lack of Education on ECS Science Affects Patients’ Attitudes and Trust. Patients who live in one of the twenty-four states where cannabis is legal may have safe access to a variety of medicinal products made from cannabis. › Unfortunately, product availability, as well as legality of different forms, varies from state to state (NCSL, 2016). In addition, the patients in these states still do not have easy access to reliable information from true healthcare professionals, and are often left to come up with their treatment protocols based on a dispensary worker or “budtender’s” recommendations. (Allen et al., 2013) Cannabis Basics: What Every Nurse Needs to Know Before Working with the Cannabis Patient. What is the Human Endocannabinoid System? (Sulak, 2015) › The endocannabinoid system (ECS) is a major system of neurotransmitters and receptor sites which exists in the human body and all living vertebrae (Sulak, 2016). › Also known as the endogenous cannabinoid system, the ECS was discovered over twenty years ago in July of 1990 by a group of scientists working for the National Institute of Mental Health. (Grotenherman & Müller-Vahl, 2012). › The entire human body contains receptor sites for cannabinoids, including major organs, such as the brain, immune cells, and glands. Cannabinoids are chemical compounds which interact with those receptor sites and help the body maintain homeostasis (Sulak, 2016). › CB1 and CB2 receptors are the most prominent cannabinoid receptors. – CB1 receptors are involved in our sleep cycles, hunger and metabolism, memory, mood, and pain sensory. – CB2 receptor sites exist in our immune cells, and when activated, have the ability to fight inflammatory disease responses, including the apoptotic cell death of cancer cells (Chakravarti, Ravi, & Ganju, 2014). Cannabis Basics: What Every Nurse Needs to Know Before Working with the Cannabis Patient. › Cannabinoids can be created by our own bodies (endocannabinoids), created by plants (phytocannabinoids) such as those found in the cannabis plant and other plants (Gertsch, Pertwee, & Di Marzo, 2010), or those created in a lab (synthetic cannabinoids), such as dronabinol, a synthetic form of tetrahydrocannabidiol (THC) which is found in both the cannabis plant (D9-THC) and made by the human body in the form of “anandamide” (Grotenherman et al., 2012). › The endocannabinoid system is believed to be responsible for promoting homeostasis in the body, which would make it one of the most important physiological systems involved in maintaining human health. (Sulak, 2016) Cannabis Basics: What Every Nurse Needs to Know Before Working with the Cannabis Patient. › What are Cannabinoids? › Cannabinoids, the active compounds found in the cannabis plant, promote homeostasis at every level of biological life, from the sub-cellular, to the entire organism. › These are the compounds which bind to the cannabinoid receptors in the human cannabinoid system. › There are over 130 compounds in the cannabis plant. The two cannabinoids every health care professional should know about are: “Delta-9 Tetrahydrocannabidiol” (THC) and “Cannabidiol” (CBD) Some of the Effects of THC: Analgesic Anti-emetic appetite stimulant anti-depressant anti-proliferative Some of the Effects of CBD: Analgesic Antibacterial Anti-diabetic Anti-ischemic (reduces risk of artery blockage) Treats psoriasis Anti-anxiety Neuroprotectant What is the “Entourage Effect”? o Cannabinoids do not work as well when synthesized and isolated. o For instance, CBD is not as effective without some THC, and THC is not as effective without some CBD. o Full plant extractions or full plant based medicines are the most effective o When the cannabinoids of the cannabis plant work together, this is known as “The Entourage Effect”. (Sanjay Gupta, 2013) What are Cannabinoid Receptors? Cannabinoid receptors are present throughout the body, and are believed to be more numerous than any other receptor system. Researchers have identified two main cannabinoid receptors: o CB1, predominantly present in the nervous system, connective tissues, gonads, glands, and organs; and o CB2, predominantly found in the immune system and its associated structures. o Many tissues contain both CB1 and CB2 receptors, each linked to a different action. Researchers speculate there may be a third cannabinoid receptor waiting to be discovered. What are Endocannabinoids? › Endocannabinoids are the substances our bodies naturally make to stimulate these receptors. › The two most well understood of these molecules are called: • Anandamide (from the Indian word “Ananda=Bliss”) and • 2-arachidonoylglycerol (2-AG). Delivery systems: In what forms can a patient take cannabis? o Inhaled: Vaporized, Smoked o Dried Flowers: “Joint” cigarettes, Water pipes “bongs”, pipes, vaporization machines, vaporizer pens o Oils and extractions (hash, trichromes) can be inhaled: E-cigarettes, oilvaporizers o Ingested: Edibles, pills, oils o Absorbed: Suppositories, topicals (lotions and oils on the skin), tinctures (under the tongue) o Cannabis cannot be injected or administered via IV. What are the benefits of inhaled vs. edible cannabis? Inhaled (vaporized or smoked): › Benefits: Easy for the patient to self-titrate the dose, Use minimum dosage for maximum effects, Difficult to overdose, no evidence of permanent lung damage, no risk of lung cancer › Drawbacks: Bronchial irritation and infection, odor from smoke/vapor, dry cough, shorter duration of action Edible or ingested: › Benefits: No irritation to lungs or respiratory tract, longer duration of action › Drawbacks: Hard to titrate, easy to “overdose”, unpleasant side effects if taken too much, expensive (need more plant material when ingesting than if inhaling) Reviewing the Nursing Process: A.D.P.I.E. › Or: Assess, Diagnose (Nursing Diagnosis vs. Medical Diagnosis), Plan, Implement, Evaluate NURSING CARE PLANS › For patients who may benefit cannabis therapeutics Applying the Nursing Process and Treatment Plan for Patient #1 “MJ” › Client’s Primary Medical Diagnosis › Secondary Medical Diagnosis › Acute Renal Injury › Microlytic Anemia These are the Nursing Diagnoses related to this patient’s disease process: #1 Nursing Diagnosis: Less Than Body Requirements: Weight Loss, Nausea, Vomiting. Related to: Acute Renal Failure NSAID use (10x 200 mg tablets per day x 2 weeks). As evidenced by: Increased BUN and serum creatinine, decreased intake and output, weight loss of 10 lbs in two weeks. #2 Nursing Diagnosis: Chronic Pain Related to: History of neck injury, car accident____ As evidenced by: Patient stating pain above 5 on a 0-10 scale, patient grimaces. Nursing Care Plans for the Cannabis Patient: Goals, Objective and Subjective Data Patient #1 “MJ” (continued) Goal(s): › Patient will report an increase in appetite, and evidence of increased intake and output levels. › Patient will report a decrease in nausea and vomiting and an increase in appetite › Patient will achieve optimal urinary elimination as evidenced by: urine output greater than 30 mL/hr, electrolytes and BUN within or near normal limits, and normal specific gravity. › Patient will report pain less than 5 on a 0-10 pain. Objective Data: › Labwork: BUN levels, serum creatinine levels, electrolyte levels, urine specific gravity levels, decreased input and output, kidney stones 2 years ago, vomiting. Loss of 10 pounds in two weeks. Subjective Data: › Patient states that she was taking 10 tablets of OTC ibuprofen (equivalent to 2,000 mg) per day for two weeks. › Patient states she suffered a neck injury during a car accident 1 year ago. › Patient complains of chronic pain (5 or greater, usually an 8 on a scale of 0-10), vomiting, weight loss and nausea. Patient states, and records show, that she has lost approximately 10 pounds in two weeks. The Physician would like to offer a recommendation to the patient for medical cannabis: The Nurse Must Assess the following: › Is there a legal cannabis program in your State? › Is chronic pain a legal qualifying condition? › Is the patient a good candidate for the medical cannabis program? › Has patient used in the past and if yes, was the experience negative or positive? › How much does the patient already know about cannabis and how to use it? › Can the patient inhale vaporized cannabis or smoke? Or can the patient ingest or use a sublingual tincture? Are these legal and available in your State? › Is the patient capable of caring for themselves, or will they need a caregiver involved? › Will the patient be able to afford the medicine needed under their State’s current medical cannabis laws? › Does the patient have a caregiver willing to help with the process of becoming a medical cannabis patient? Applying the Nursing Process to the Patient: “Assess” Assess the needs of the patient: The patient is suffering from Acute Renal Injury from taking 30% or more over the recommended dosage of OTC NSAIDs. Patient is suffering from chronic pain and misuse of NSAIDs. The doctor has ordered that the patient refrain from using NSAIDs. Applying the Nursing Process to the Patient: Diagnose What are the Nursing Diagnoses? The medical diagnosis is acute renal injury, but the nursing diagnoses are the symptoms related to the medical diagnoses which the nurse must help the patient manage. The patient is suffering from weight loss, lack of appetite, nausea, vomiting, and chronic pain. The Nursing diagnoses are: Less than body requirements, nausea and vomiting, anorexia, and chronic pain. How will the nurse help the patient manage her chronic pain? • Cannabis is a good option because it does not cause to renal injury, even when used above recommended dosages (citation needed). How will the nurse help the patient manage her nausea, vomiting and weight loss? • Not only is cannabis good for pain management, it also helps with nausea, vomiting and weight loss (citation needed). Applying the Nursing Process to the Patient: “Plan” › Once the nurse assesses the patient and has determined that she is a good candidate for the State’s Medical cannabis program, the nurse, and patient if possible, need to come up with a treatment plan. a. Is the patient’s current attending physician qualified under the State’s program to write a recommendation for cannabis? › If Yes, the physician writes a Letter of Recommendation. At the time of this publication (June, 2015), Cannabis is still listed as a Schedule I drug, and it is therefore still illegal to write a PRESCRIPTION for cannabis. It can only be recommended, not prescribed. (In some States, Physicians Assistants and Nurse Practitioners may write a letter recommending cannabis. ) › If No, then a qualifying physician must be sought: In some States, physicians and patients may be required to register onto a physician or patient registry and pay a registration fee. b. Is the patient comfortable with using medical cannabis? Social Stigma? Negative past experiences? Problem inhaling or ingesting medicines (cannabis based medicine cannot be given via IV or injection)? Once it has been determined that the patient is a good candidate for the cannabis program, the patient has obtained a letter recommending the use of cannabis from their physician, and has legally registered into the State’s Medical Cannabis Program (if applicable), a source for medicine must be identified. This patient in this scenario lives in the State of Colorado, where cannabis is legal in all forms for medical use and recreational use. The patient has the option of becoming a medical patient, or obtaining medicine in a dispensary and paying sales tax. *Please note, in most States, Nurses and Physicians cannot identify or recommend a specific facility to a patient, as it is considered “aiding and abetting”. Doctors and Nurses can educate the patient on where the resources are so they can find a facility themselves. PLEASE note the local medical cannabis laws in your area. Applying the Nursing Process to the Patient: “Plan” (continued) How will the patient obtain medicine? Caregivers/Private growers Collectives Dispensaries Applying the Nursing Process to the Patient: “Plan” (continued) What products are available legally in your State? Tinctures Edibles Inhaled Full Plant Dried Flowers (smoked or vaporized) Tablets/Pills Oils What products can the patient Tolerate? Can the patient eat? Can the patient inhale vapor or smoke? Does the patient have, or can they obtain, the appropriate delivery system tools? Does the patient have a caregiver who can help them obtain and use these, if the patient needs help? Applying the Nursing Process to the Patient: “Plan” (continued) If Smoking has been chosen: Will they use rolled “joints”? Does the patient know how to roll a “joint?” Glass pipes, water pipes, bubblers “bongs”**: Does the patient know how to properly use these? If so, can the nurse educate the patient? If not, can the nurse provide the appropriate person to educate the patient? **Please Note: In some states it is still illegal to refer to water pipes as “bongs” when shopping for delivery devices. Please advise your patient accordingly. If Vaporization is chosen: o Will the patient use an e-cigarette? o Will the appropriate oils for this system be available? o Will the patient need a vaporizing machine which vaporizes dried plant material? o Can the patient afford the necessary “paraphernalia” o Vaporizers can range in price from $200-$600 and health insurance does NOT cover these. If Edibles are chosen: o Is the patient diabetic, suffering from high cholesterol, or on any special diets which might forbid them to eat pastries or edibles high in fat, sugar or carbohydrates? o Does the patient have a digestive issue which might make eating difficult? o Does the patient understand the importance of “titration” The nurse must educate the patient that ingesting cannabis can be difficult, because the medicine must go through the entire digestive system before effects are achieved. It is important that a patient who is new to edibles starts out slowly eating a very small amount, and waiting at least a half-hour/30 minutes, before taking another dose Additionally, there is now a focus on using the lowest possible dosage to treat the problem. Lowest dose is equivalent to 2.5 mg-10mg THC. “Start low and go slow”. Applying the Nursing Process to the Patient: “Plan” (continued) Which cannabinoids/stains will be most effective in treating the patient’s particular nursing diagnoses? It’s important for the nurse to at least have a basic understanding of Indica vs. Sativa Strains, or CBD-dominant vs. THC-dominant Strains. High CBD strains, or “Indicas” generally work on physical pain, and help the patient to relax. High THC strains or “Sativas” generally work as a stimulant, and help to elevate mood. They are also used as appetite stimulants. Applying the Nursing Process to the Patient: “Implement” Patient #1: › The patient has been given a letter from her qualifying physician recommending the use of cannabis and is legally registered in her State’s medical cannabis program. › Once all the above variables have been assessed and considered, the treatment plan can be implemented. Applying the Nursing Process to the Patient: “Implement” In Patient #1’s Scenario: The patient is familiar with smoking and vaporization methods, has no contraindications to this method, and is comfortable with it, as it will allow the patient to titrate the dose. The patient has obtained dried plant material for vaporization. The patient has also acquired the appropriate equipment to vaporize the medicine. The patient will be using both Indica (CBD dominant) and sativa (THC dominant) strains to treat her pain (Indica/CBD) and her loss of appetite and nausea/vomiting (Sativa/THC). The patient has been instructed on the proper use of the vaporizer, and has effectively demonstrated back to the health care staff how to operate the vaporizer Patient has been instructed to vaporize approximately 1-1.5 grams of dried cannabis per day, prn (as needed) when symptoms occur. Applying the Nursing Process to the Patient: “Evaluate” Evaluate: After treatment has been implemented, the nurse and the healthcare team evaluates the effectiveness of the treatment. Patient #1: Two weeks after utilizing cannabinoid medicine, the patient follows up with her primary care physician and reports that her pain levels remain below a 5 on 0-10 scale 75-90% of the time. Patient also reports that her appetite has returned. Patient has gained 3 lbs in two weeks. Patient is no longer using NSAIDS and feels the cannabis effectively controls her pain. Treatment plan is determined to be successful Problem: Recommendation Recommendation Recommendation The patient reports feeling a dry throat and cough immediately following vaporization. Advise the patient to turn the heat down on the vaporization machine and to drink plenty of water while medicating Advise the patient to try a sublingual tincture, or supplement inhalation with an oral preparation to cut down on amount of vaporizing or smoking. The patient using edible forms of cannabis complains of feeling too “high”. Advise the patient eat smaller amounts and leave more time between dosages Assess the patient for inhaled forms, explaining that it is easier to titrate, harder to overdose, and smoking and vaporization are not linked to permanent lung disease or cancer. Patient may want to try a sublingual tincture The patient states she become paranoid even when only inhaling small amounts of medicine. Assess if this happens after patient uses Indica or Sativa, suggest alternative strain Sativas may cause paranoia, advise patient to stick with Indica or Indica hybrids if Sativa is the cause Remind patient that negative side effects (both physical and psychoactive) of cannabis are temporary and will eventually wear off. Continued use of cannabis lessons the psychoactive effects as patients become adjusted. Applying the Nursing Process and Treatment Plan for Patient #2 “TC” Client’s Primary Medical Diagnosis Intraductal Breast Carcinoma, right breast, ER+ Client’s Secondary Medical Diagnoses Anxiey, Depression, Pain These are the Nursing Diagnoses related to this patient’s disease process: #1 Nursing Diagnosis: Body Image Disturbance __ Related to: Positive breast cancer diagnosis, scheduled mastectomy As evidenced by: Positive Biopsy, Positive Scan for Intraductal Breast Ca, ER+ #2 Nursing Diagnosis: Anxiety, Depression, Insomia, Pain Related to: Cancer diagnosis As evidenced by: Patient stating that she is depressed and having trouble sleeping at night. Patient anxious about diagnosis, non-compliant, looking for other options before undergoing surgery. Nursing Care Plans for the Cannabis Patient: Goals, Objective and Subjective Data Patient #2 “TC” (continued) Goal(s): Patient will verbalize understanding of disease process. Patient will be involved in creating treatment plan, and verbalize understanding of the pros and cons of treatment plan, and verbalize the importance of treatment compliance Patient will report feeling less anxious about treatment plan. Patient will report pain less than 5 on a 0-10 pain. Patient will report sleeping through the night. Objective Data: Biopsy and labwork, pathology report: positive for stage 1 breast carcinoma in right breast, intraductal, ER+. Patient’s speech is rapid. Patient becomes tearful easily. Patient has cancelled and rescheduled surgery for her mastectomy once and Is stating that she wants to cancel her surgery again. Subjective Data: Patient states that she has met some people who say they effectively treated their cancers with “cannabis oil”. Patient states she has been unable to sleep through the night, and had suffered suicidal ideations. Patient is concerned about being “disfigured” by the surgery. Applying the Nursing Process and Treatment Plan for Patient #2 “TC Physician Orders: Patient should follow through with surgery. Physician has asked that the nurse assess the patient to see if she is a good candidate for the State’s Medical Cannabis program. The Physician would like to offer a recommendation to the patient for medical cannabis: The Nurse Must Assess the following: › Is there a legal cannabis program in your State? › Is chronic pain a legal qualifying condition? › Is the patient a good candidate for the medical cannabis program? › Has patient used in the past and if yes, was the experience negative or positive? › How much does the patient already know about cannabis and how to use it? › Can the patient inhale vaporized cannabis or smoke? Or can the patient ingest or use a sublingual tincture? Are these legal and available in your State? › Is the patient capable of caring for themselves, or will they need a caregiver involved? › Will the patient be able to afford the medicine needed under their State’s current medical cannabis laws? › Does the patient have a caregiver willing to help with the process of becoming a medical cannabis patient? Applying the Nursing Process to Patient #2: “Assess” Patient #2 “TC”, is suffering right intraductal breast carcinoma, stage I, ER+, as well as anxiety, insomnia, and depression a. Assess if the physician could offer the patient medical cannabis : Is there a legal cannabis program in your State? – In this Scenario, the patient lives in Pennsylvania, a State where medical cannabis has not yet been legalized. – The patient lives near the New Jersey state border, and stated that she would be willing to move to New Jersey, where medical cannabis is legal. › Is breast cancer a legal qualifying condition in the State of New Jersey? Yes › Are behavioral health issues a qualifying condition in the State of New Jersey? No Applying the Nursing Process to Patient #2: “Assess” Is the patient a good candidate for the medical cannabis program? In patient #2 “TC”’s scenario: – Has patient used in the past and if yes, was the experience negative or positive? › Patient states she has never used recreational drugs in her entire life, and rarely uses prescription or over the counter medications. › Patient has tried legal herbal remedies in the past (i.e. chamomile, St. John’s Wort, Echinacea) – How much does the patient already know about cannabis and how to use it? › Patient states she “doesn’t know anything about it, except a few people I know had tried using cannabis oils illegally and their doctors have told them they are cancer free now.” – Can the patient inhale vaporized cannabis or smoke? › The patient reports that she does not suffer from any chronic respiratory issues. › Inhaled cannabis could treat symptoms related to the patient’s primary diagnosis (pain, depression, insomnia), however, anecdotal evidence shows that cannabis oils with a 1:1 THC to CBD to 4:1 THC to CBD ratio oils are preferred. In ER+ cancers (estrogen receptor positive cancers), anecdotal evidence shows that a cannabis oil with at least a 1:1 CBD to THC (OR HIGHER CBD to THC ratio) is preferred. Applying the Nursing Process to Patient #2: “Assess” › In this patient’s Scenario: › THE PATIENT’S BREAST CANCER IS ER+, AND THEREFORE, SHE NEEDS A HIGHER PERCENTAGE OF CBD TO THC. THIS IS NOT LEGAL IN PA OR NJ AT THE TIME OF THE PATIENT’S DIAGNOSIS. – Or can the patient ingest or use a sublingual tincture? Are these legal and available in your State? › Oils, tinctures, edibles, extractions, etc. are all illegal under NJ’s medical cannabis program. › Only dried plant material is available › THE PATIENT’S TYPE OF CANCER IS BEST TREATED WITH A FULL PLANT CANNABIS OIL WITH A 1:1 CBD:THC RATIO. THIS IS NOT LEGAL IN PA OR NJ AT THE TIME OF THIS PATIENT’S DIAGNOSIS Applying the Nursing Process to Patient #2: “Assess” › The nurse concludes that “TC”, patient #2, will not benefit from the current medical cannabis programs which are available to her at the time of diagnosis. › The nurse reports to the physician that the patient will not be able to obtain the correct medicine legally under the medical cannabis programs currently available to the patient at the time of the diagnosis. › The physician asks the nurse if Marinol would be a viable legal alternative for the patient: – Patient has a history of anxiety and insomnia. Some of Marinol’s potential side effects include racing thoughts, anxiety and paranoia. – The patient has ER+ carcinoma. Because ER+ cancers do not respond well to higher doses of THC than CBD, Marinol is not favored. › The nurse and physician determine they cannot offer any medically effective, legal options to the patient which involve cannabinoid medicines. › Under the current laws at the time of the patient’s diagnosis, patient would be unable to legally obtain the proper medication. Conclusion: How To Effectively Apply The Nurisng Process to the Cannabis Patient Conclusion: There is a need for physicians, nurses, and other healthcare professionals to understand the complexity of the needs of the patient who qualifies for, or is already using, cannabis therapeutics. Delivery systems and titration methods when dealing with herbal medications is so different from what most people in Western society are comfortable with. Health care professionals need to understand the proper way to assess and implement a treatment plan so that the patient will be comfortable with their treatment options, and for their treatment be most effective. It’s important that the health care provider understand why certain delivery systems may be favored over others, as well as effectively communicate risks and benefits of using cannabinoid medicine. References Aggarwal, S. K., Carter, G. T., Sullivan, M. D., ZumBrunnen, C., Morril, R., & Mayer, J. A. (2009). Medicinal use of cannabis in the United States: historical perspectives, current trends, and future directions. Journal of Opioid Management, 5(3), 153-168. American Herbal Pharmacopoeia (2013). Cannabis Inflorescence: Standards of Identity, Analysis, and Quality Control. Scotts Valley, CA: American Herbal Pharmacopoeia. Grotenhermen, F. & Russo, E. (Eds.) (2002). Cannabis and Cannabinoids: Pharmacology, Toxicology, and Therapeutic Potential. NY: The Haworth Integrative Healing Press, Inc. Izzo AA, Borrelli F, Capasso R, Di Marzo V & Mechoulam R. (2009). Non-psychotropic plant cannabinoids: new therapeutic opportunities from an ancient herb. Trends in Pharmacological Sciences. 30(10):515-27. Joy, J.E., Watson, S.J. & Benson, J.A. (1999). Marijuana and Medicine: Assessing the Science Base. Washington, DC: National Academy Press (Institute of Medicine). ISBN 0309-07155-0 Mathre, ML (1997). Cannabis in Medical Practice: A Legal, Historical and Pharmacological Overview Dreher, M., PhD. et al. (1997), “Prenatal Marijuana Exposure and Neonatal Outcomes in Jamaica: An Ethnographic Study” Pediatrics, February 1994, Volume 93, Number 2, pp. 254-260. American Academy of Pediatrics. Tashkin, D., et al. (2006), "Marijuana use and the risk of lung and upper aerodigestive tract cancers: results of a population-based case-control study." Cancer Epidemiology Biomarkers & Prevention 15.10 (2006): 1829-1834 Fine PG, Rosenfeld MJ. The Endocannabinoid System, Cannabinoids, and Pain. Eisenberg E, Vulfsons S, eds. Rambam Maimonides Medical Journal. 2013;4(4):e0022. doi:10.5041/RMMJ.10129. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3820295/#!po=2.00000 Russo EB. Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. British Journal of Pharmacology. 2011;163(7):1344-1364. doi:10.1111/j.1476-5381.2011.01238.x. Caffarel MM, Andradas C, Mira E, et al. Cannabinoids reduce ErbB2-driven breast cancer progression through Akt inhibition. Molecular Cancer. 2010;9:196. doi:10.1186/1476-4598-9-196. Robert J. McKallip, et.al. Δ-9-Tetrahydrocannabinol Enhances Breast Cancer Growth and Metastasis by Suppression of the Antitumor Immune Response 10.4049/jimmunol.174.6.3281 The Journal of Immunology March 15, 2005 vol. 174 no. 6 3281-3289 P McAllister, et. al Pathways mediating the effects of cannabidiol on the reduction of breast cancer cell proliferation, invasion, and metastasis. 2011 Aug;129(1):37-47. doi: 10.1007/s10549-010-1177-4. Epub 2010 Sep 22. More on Breast Cancer: http://unitedpatientsgroup.com/PatientsRoom-Breast-Cancer