Nurses are always looking for ways to expand their knowledge and skills. Today, more patients have access to cannabis than ever before, and they have questions about using it properly. With federal decriminalization likely to happen within the next few years, nurses must be prepared to meet the needs of their patients.
Whether you’re looking to incorporate cannabis knowledge into your current practice or start your own consulting, you must start with foundational knowledge in the cannabinoid sciences. In our recent event, we asked Eloise Theisen, AGPCNP-BC—and President of the American Cannabis Nurses Association—for her advice on where to begin, and how cannabis nursing can support the needs of your patients.
Watch the full event below!
What Is Cannabis Nursing?
According to the American Cannabis Nurses Association’s (ACNA) scope and standards, the cannabis nurse aims to not only support and educate patients but also to work toward supporting wellness and healing through a caring presence, which supports the patient’s needs.
Cannabis nursing requires that the nurse be educated in multiple areas above and beyond all registered nurse competencies, including knowledge of:
- The endocannabinoid system
- Cannabis therapeutics
- Cannabinoids
- Terpenoids
- Cannabis laboratory testing requirements
- Potential medication interactions
- Advocacy
- Ethics
- Law
Moreover, the cannabis nurse’s role expands as he or she acts as an advocate, coach, and navigator to guide patients through a sea of cannabis information and misinformation. The cannabis nurse is a leader in guiding patients toward a maximal state of homeostasis through the upregulation of the endocannabinoid system.
The cannabis nurse practices self-care to maintain a professional and caring presence with patients.
The NCSBN Guidelines for Cannabis Nursing
The National Council of State Boards of Nursing (NCSBN) asserts that nurses need practical information to care for the increasing number of patients who utilize cannabis, and who self-administer cannabis as a treatment for various symptomatology or for recreational purposes.
Individuals are using cannabis and nurses will care for these patients.
The NCSBN Guidelines entail the following Six Principles of Essential Knowledge:
- The nurse shall have a working knowledge of the current state of legalization of medical and adult-use cannabis.
- The nurse shall have a working knowledge of the jurisdiction’s medical cannabis program.
- The nurse shall have an understanding of the endocannabinoid system, the receptors, ligands, enzymes, and the interactions among them.
- The nurse shall have an understanding of cannabis pharmacology and the research associated with the medical use of cannabis.
- The nurse shall be able to identify the safety considerations for patient use of cannabis.
- The nurse shall approach the patient without judgment regarding the patient’s choice of treatment or preferences in managing pain and other distressing symptoms.
Let’s Get Clinical — Cannabis 101
The endocannabinoid system (ECS) is found in all vertebrate animals and some invertebrate animals, and it is responsible for maintaining homeostasis by regulating mood, appetite, pain-sensation, memory, and sleep.
Medicinal cannabinoid use affects two main areas physiologically.
Cannabinoid Receptor CB1
The homeostatic effects produced by Cannabinoid Receptor CB1 stimulation include an increased drive to sleep and eat, a reduction of perceived pain, fear and anxiety, maintenance of well-being, and the promotion of recovery during stress.
There are very few CB1 receptors in the brainstem or in the cardiorespiratory centers, which accounts for the absence of a lethal dose when using cannabis.
Cannabinoid Receptor CB2
CB2 receptors, on the other hand, are primarily found in the immune system. The homeostatic effects produced by CB2 stimulation include a reduction of the release of inflammatory mediators and a reduction of immune cell migration into the brain.
FDA-Approved Cannabinoids
Dronabinol (Marinol)
- Approved for N/V and for appetite stimulation
- The average dose is between 2.5-20mg per day
Nabilone (Cesamet)
- Approved for N/V
- The average dose is between 1-2mg BID
Cannabidiol (Epidiolex)
- Approved LGS and Dravet’s Syndrome
- The average dose is between 5mg/kg-20mg/kg
Let’s Take a Closer Look at Phytocannabinoids
More than 113 cannabinoids can be found in plants. The two most common are THC and CBD.
Tetrahydrocannabinol (THC)
- Can produce euphoric effects
- Can alter behavior
- Can alter consciousness
- Can alter mood
- Can alter perception
Cannabidiol (CBD)
- Mood-altering substance
- Antipsychotic
- Anxiolytic
- Antidepressant
- Relieves anxiety, depression, and psychosis
Cannabis Legalization in the United States
So far, cannabis legalization in the US is as follows:
- 37 states, plus D.C allow medical cannabis
- 15 states, plus D.C allow adult use
- 12 states have cannabis legalization on the ballot for 2021
Cannabis Terminology
Drug Scheduling
Drugs can be categorized into distinct categories or schedules depending on the drug's accepted medical use as well as its abuse or dependence potential.
Federally, marijuana is a schedule 1 drug, while hemp was descheduled in 2018, and CBD is a schedule 1 drug (per DEA and FDA regulations).
Marijuana vs. Hemp
High THC (marijuana): States with medical and adult use programs sell high THC products through licensed dispensaries. Products are tested and regulated.
High CBD (hemp): CBD can be found online, in some health food stores and is legal in 47 states (ID, NE, KS). Not regulated, may be tested. THC content must be 0.3% or less.
Note that CBD from hemp and CBD from marijuana are the same molecule.
Hemp-Derived Products
Hemp plants can flower, but hemp is mostly grown for its industrial uses; stalks and stems are used for rope, textiles, concrete, paper, and a variety of other uses. Flowers are best for producing medicine.
Farmers are growing cannabis that is defined as legal hemp (with <0.3% THC) but using techniques to emphasize the promotion of CBD from flowers. Look for companies who advertise their hemp-derived products as “flower-derived CBD.”
CBD Products on the Market
Currently, there are more than 3,000 CBD products available on the market.
When choosing products, look for those that:
- Use independent 3rd party testing facilities
- Display the amount of each cannabinoid, terpenes, molds, etc.
- Use safe extraction methods that leave no residual solvents in the final product
- Are derived from high-resin cannabis grown sustainably and organically
And avoid products that:
- Have toxic additives, corn syrup, or artificial colors
- Make explicit health claims
- Have cannabinoids derived from the seed and stalk of the hemp plant
- Don’t provide a COA within the last year
Cannabis and Its Clinical Implications
Insomnia and Sleep Issues
There is moderate evidence in the medical literature that cannabis and cannabinoids are effective at improving short-term sleep outcomes with sleep disturbances associated with obstructive sleep apnea, fibromyalgia, chronic pain, and multiple sclerosis.
Chronic Pain
There is also conclusive evidence that cannabis or cannabinoids are effective for treatment of chronic pain in adults. CBD has been shown to be effective at reducing inflammation, modulating pain, boosting opioid analgesic effects, and shifting the dysphoria associated with pain.
Anxiety and Depression
Many patients self-medicate with high-THC cannabis for depression. A 2016 survey found that 50% of cannabis users were seeking relief from depressive symptoms.
Additionally, a 2018 study demonstrated that the ECS plays a significant role in regulating mood and a dysfunctional ECS can contribute to depression.
Getting into Cannabis Consulting
- Work within your license SOP (Be sure to understand and work within your license scope of practice)
- Adhere to NCSBN guidelines (NCSBN Guidelines provides information prelicensure, RNs and APRNs)
- Focus on serving size (Avoid giving medical advice by recommending specific dosages; instead, focus on serving size)
Cannabis Consulting Appointments
Below, the following sections outline what you should do before, during, and after a cannabis consulting appointment with a patient.
Prior to the Appointment
Before meeting with the patient, ensure that you review the patient’s:
- Medical records
- Results of related tests and exams
- List of medications
- List of allergies
- Health history
- Treatment history
- Comorbidities
- Cannabis use
- Substance-use disorder (if applicable)
During the Appointment
During the appointment, make sure you discuss the patient’s:
- Primary health concerns
- Goals of cannabis therapy
- Hours of sleep each night
- Daily water and alcohol consumed
- Daily exercise
- Stress management techniques
- Life changes in the last year
- Cannabis experience and use
- Employment status
- Education level
Following the Appointment
Make sure you prepare the patient to begin a cannabis regime. Here are some steps you can follow:
- Work with the patient to identify priorities
- Have the patient share in the decision making process
- Begin with the “low-and-slow” approach
- Prepare them for possible side effects
- Have them use a journal to record their experiences
- Make sure that the products are tested for safety and efficacy
- Consider any drug-drug interactions
- Consider focusing on one primary cannabinoid at a time
Cannabis Nursing Education
The following are legitimate educational resources you can use to pursue further education in cannabis nursing:
- Radicle Health Training: Self-Paced Modules
- Pacific College Health and Sciences: Medical Cannabis Certificate
(with 8 college credits) - University of Maryland: Master’s in Cannabis Therapeutics
Additional resources for getting involved:
- American Cannabis Nurses Association (ACNA)
- Cannabis Nurses of Color (CNOC)
- Cannabis Nurses Network (CNN)
Cannabis Challenges and Opportunities
Challenges you may face when preparing to become a cannabis nurse:
- Cannabis remains a Schedule I substance, so it can be difficult to set up your business when you work with cannabis-banking and insurance
- There are no formal trainings or standards of practice
- State’s Boards of Nursing have not officially adopted the NCSBN guidelines
Opportunities, or what you can do:
- Start a coaching practice to work with patients
- Provide education to your community and place of work
- Teach cannabis at college level
- Sell CBD products
- Work in dispensaries and/or with CBD companies
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