Medical Marijuana What does the Advance Practice Nurse Need to Know

Transcription

1 Medical Marijuana What does the Advance Practice Nurse Need to Know Presented by Caroline Coussens, APRN-CNS Stephanie Moore, DNP, APRN, ACNS-BC Objectives Define cannabinoids for medical use Describe the short and long term effects of medical marijuana Review evidence for the benefits and adverse events of medical marijuana Describe the current legislative initiatives in Oklahoma related to medical marijuana 1

2 Definition of Medical Marijuana Medical Marijuana refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions. National Institute on Drug Abuse (NIDA), 2017 Historical Significance Cannabis widely used in the U.S. as a patent medicine in the 19 th and 20 th century Described in United States Pharmacopoeia Federal restriction of cannabis use and sale with the passage of the Marihuana Tax Act Dropped from United States Pharmacopoeia 1951 & Legal penalties for possession Boggs & Narcotic Control Acts Bridgeman & Abazia,

3 Historical Significance Cont. Controlled Substance Act of 1970 U.S. drug policy under which the manufacture, importation, possession, use and distribution of certain narcotics, stimulants, depressants, hallucinogens, anabolic steroids and other chemicals is regulated These actions created limitations on research by restricting procurement for academic purposes only Proposition 215, Compassionate Use Act California allowed the use of medical cannabis Bridgeman & Abazia, 2017 Controversies Legal, Ethical & Societal Implications Safe administration, packaging, and dispensing Adverse health consequences and deaths attributed to intoxication Therapeutic indications based on limited clinical data Bridgeman & Abazia,

4 Hemp (Cannabis Satvia) From the Plant family Cannibaceae Cultivated for its fiber or edible seeds Contains THC very small amounts compared to the plants grown for the production of marijuana or hashish Edible Hemp seeds: contain 30% oil and are a source of protein, fiber and magnesium Shelled hemp hearts sold as health food; sprinkled on salads; fruit smoothies Hemp seed milk Oil from hemp seed used to make paints, varnishes, soaps, lotions Caged bird feed 4

5 Marijuana Definition & Description Marijuana refers to the dried leaves, flowers, stems, and seeds from the Cannabis sativa, Cannabis indica, or Cannabis ruderalis plant (a species of the Cannabinaceae family of plants) (sativa and indica are the predominant strains in the U.S.) Most commonly used illicit drug in the United States and world Other names for marijuana or Cannabis are: ganja, grass, hashish, hemp, Indian hemp, marijuana, pot, reefer, weed, herb, bud, Mary Jane FDA - Schedule 1 Drug NIDA, 2017 & Bridgeman & Abazia,

6 Definition & Description Cont. Cannabis contains the chemical compound THC (delta-9 tetrahydrocannabinol) believed to be responsible for most of the characteristic psychoactive effects of cannabis The plant also contains more than 500 other chemicals, including more than 100 compounds, chemically related to THC, called cannabinoids The plant produces resinous secretions (known as hashish) The fiber of the cannabis plant is cultivated as industrial hemp - used in textile manufacturing NIDA, (2018) Cannabinoids Organic substances present in Cannabis sativa, having a variety of pharmacologic properties Cannabinoids are chemicals related to delta-9- tetrahydrocannabinol (THC) Two main cannabinoids that are of interest for medical treatment: Cannabidiol (CBD) THC NIDA,

7 Cannabidiol (CBD) Increasing interest in CBD Cannabis indica strain higher CBD content Mainly physical effects: Helping with pain, muscle spasms, and inflammation Treat Childhood Epilepsy Oil form for treatment purposes Not intoxicating Doesn t cause the high Possibly useful in treating mental illness and addictions NIDA, (2018) tetrahydrocannabinol (THC) [tet rah-hi dro-kah-nab ĭ-nol] Cannabis sativa strain higher THC-to-CBD ratio Marijuana s main mind-altering ingredient high Increases appetite and reduces nausea May also decrease pain, inflammation (swelling and redness) Useful in muscle control problems May alleviate depression, headaches, including migraines NIDA,

8 THC acts on numerous areas of the brain NIDA, 2018 Pharmacokinetics Pharmacokinetic research challenging Cannabinoid components vary greatly Absorption and onset of action vary Depending on route of administration Ratio of THC-to-CBD in a product Smoking: Rapidly transferred from lungs to blood Highly lipophilic Bridgeman & Abazia,

9 Short Term Adverse Effects of Marijuana on Brain Altered senses (for example, seeing brighter colors) Altered sense of time Changes in mood Impaired body movement Difficulty with thinking and problem-solving Impaired short-term memory Hallucinations (when taken in high doses) Whiting et al, 2015 Short Term Adverse Effects of Marijuana on Brain Cont. Delusions and paranoia (when taken in high doses of THC) Psychosis (when taken in high doses of THC) Dry mouth Fatigue Somnolence Confusion Dizziness Whiting, et al.,

10 Cannabinoid Hyperemesis Syndrome Cause chronic marijuana use Three phases: prodromal hyperemetic (usually 48 hours) recovery (days, weeks, months) Signs/Symptoms: nausea/vomiting abdominal pain Galli, Sawaya, & Friedenberg, 2011 Cannabinoid Hyperemesis Syndrome Cont. Treatment: May require hospitalization due to abdominal pain, volume depletion, and severe nausea and vomiting Treatment mainly supportive therapy fluid resuscitation anti-emetic medications hot showers/baths Galli, Sawaya, & Friedenberg,

11 Long Term Adverse Effects It has been linked to mental illness in some Worsening symptoms in patients with schizophrenia Addiction occurs in 10% of users who start smoking marijuana before age 25 Altered brain development; cognitive impairment; poor educational outcomes Chronic bronchitis Depression Vascular conditions (MI, stroke, TIA s) Bridgeman & Abazia, 2017 Whiting, et al., 2015 Other Health Effects Breathing problems (in those who smoke marijuana) Tachycardia Child development during and after pregnancy Slower reaction times Negative drug-to-drug interactions Bridgeman & Abazia, 2017; Whiting et al.,

12 ? Link Between Marijuana Use, Schizophrenia Gene identification AKT1 gene (Previous research has found a link between the AKT1 gene and people who have gone on to develop psychosis) When under the influence of cannabis, young people with variation in the AKT1 gene experienced visual distortions, paranoia and other psychoticlike symptoms more strongly than young people without this variation. Family history of schizophrenia Risk of psychotic episodes Decrease the age of schizophrenia onset Morgan, Freeman, Powell, & Curran, 2016 Methods of Administration Inhalation via smoking currently most common Inhalation via vaporization becoming increasingly more common Reduces exposure to the byproducts of combustion & possible carcinogens; decreasing adverse respiratory symptoms Ingestion of edible products Eaten (brownies, cookies, candy) Drank (brewed as a tea) NIDA,

13 Marijuana Extracts THC resins are extracted from the plant (known as dabbing) These extracts come in different forms and deliver a larger amount of THC: hash oil or honey oil a gooey liquid wax or budder & mash; a soft solid with a texture like lip balm shatter a hard, amber-colored solid Dangers in preparing these extracts *The amount of THC in marijuana has been increasing steadily in recent decades, creating more harmful effects in some people* NIDA, 2018 The Human Endocannabinoid System Largest receptor system in the body Human body makes Cannabis-like substances (endogenous cannabinoids) Created on demand; not stored A-AG and anandamide These interact with ECS receptors CB1 and CB2 Cannabinoid receptors react to and are activated by exogenous cannabinoids Helps maintain homeostasis throughout the entire body eat, sleep, relax, forget, and protect Cannabinoids are involved in immune function If endocannabinoid deficient more likely to become sick ECS still not well understood Pettinato, 2017; Pirschel,

14 Endocannabinoids (ecbs) Endocannabinoids and their receptors found throughout body. Nervous system Internal organs, Connective tissues Glands Immune cells Play a role in the pathology of many disorders Also serve a protective function Bridgeman & Abazia, 2017 Optimal Functioning of ECS Exercising Reducing stress Manipulating our diets Omega-3 fatty acids in balance with omega-6 fatty acids Caryophyllene (an essential oil) Flavonoids Yoga or meditation Acupuncture or osteopathic treatments Bridgeman & Abazia,

15 Drug Schedules: A Review Classified into five (5) distinct categories or schedules Classification is dependent on: The drug s acceptable medical use The drug s abuse or dependency potential Abuse rate is a determinate factor in the scheduling of the drug Schedule 1 Drugs, Chemicals, Substances High potential for abuse Potential to create severe psychological and/or physical dependence A substance does not need to be listed as a controlled substance to be treated as a Schedule I substance for criminal prosecution Drugs with no currently accepted medical use Drug Enforcement Administration (DEA),

16 Examples of Schedule 1 Drugs Heroin Lysergic acid diethylamide (LSD) Marijuana (cannabis) 3,4-methylenedioxymethamphetamine (ecstasy) Methaqualone Peyote DEA, 2016 Federal Law Marijuana is a Schedule 1 substance Marijuana is illegal to use, possess, cultivate, or distribute State marijuana laws cannot preempt (overrule) federal law Federal marijuana laws: Laws that the federal government enacts to criminalize marijuana possession, sale, and cultivation DEA,

17 Recent News 01/05/2018, Attorney General Jeff Sessions revoked an Obama administration policy that was a Hands off approach to marijuana enforcement In The Obama administration policy recommended that enforcement of federal marijuana laws not be a priority in states that have legalized marijuana. Attorney General Sessions will leave it up to federal prosecutors to decide what to do Recent News Cont. Trent Shores, U.S. attorney, Tulsa-based Northern District of Oklahoma Attorney General Sessions memo makes it clear the Justice department will enforce the laws of the United States. Shores committed to turning the tide of the drug crisis, reducing violent crime and dismantling criminal gangs. Tulsa World January 5. pp. A4. Law has not changed, only federal enforcement 17

18 U.S. Food & Drug Administration (FDA) Steps for approval Investigator submits investigational new drug application Application includes protocols for studies, qualifications of investigators, assurances of informed consent & protection of rights, safety, and welfare of subjects Review of applications to market drugs determining safety and efficacy for intended indications. Lack of FDA approval and oversight means purity and potency may vary FDA Cont. FDA has not found any product with botanical marijuana to be safe and effective for any indication Study of marijuana in clinical settings is needed to assess the safety and effectiveness of marijuana for medical use To date, FDA has not approved a marketing application for a drug product containing or derived from botanical marijuana Collaboration with other agencies involved in marijuana research 18

19 FDA Approved Drugs Synthetic Version of Marijuana Marinol (dronabinol), Syndros (dronabinol) Schedule III Dronabinol is a synthetic delta-9-thc Indications: anorexia/weight loss related to AIDS: 2.5mg -10mg BID; Max 20mg/day Chemo-related nausea/vomiting: Adverse Reactions: dizziness, confusion, somnolence, feeling high, exacerbation of mania, depression or schizophrenia Avoid using in patients with a psychiatric history FDA, 2015 FDA Approved Drugs Cont. Cesamet (nabilone) Schedule II Synthetic Chemical structure similar to THC Indications: Nausea/vomiting r/t chemotherapy Dosage: 1-2mg BID; Max dosage 2mg TID Adverse Reactions: drowsiness, a spinning sensation, dry mouth, a "high" feeling, lack of coordination, headache, and difficulties in concentrating; tachycardia, hallucinations, hypotension FDA, 2015; Cesamet, UpToDate,

20 Individual states: Legalized Medical Marijuana Regulate who may use it Regulate how the product is distributed within its borders Processes in place for certifying and registering eligible people Designated dispensaries (medical marijuana centers) May vary in the list of conditions that qualify people for treatment with medical marijuana Qualifying Conditions (may vary between states) ALS Anorexia due to HIV/AIDS Chronic Pain Crohn s disease Epilepsy or seizures Glaucoma (not recommended by the American Academy of Ophthalmology) MS or severe muscle spasms Nausea, vomiting or severe wasting associated with cancer treatment Terminal illness Tourette syndrome 20

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22 Colorado An example November, 2012 Colorado Department of Revenue & Department of Health Work together to regulate Colorado s Marijuana s policy Website: Tax revenue Motor vehicle accidents Hospitalizations Current Data pacific/enforcement/statistics-and-resources 22

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24 Medical Marijuana License 24

25 Use of Medical Marijuana in Cancer Chemotherapy-Induced nausea and vomiting Appetite stimulant Chronic pain Whiting, et al., 2016 Medical Use of Marijuana Appetite Stimulation in HIV/AIDS Spasticity due to multiple sclerosis or paraplegia Depression Anxiety disorder Sleep Disorder Whiting, et al.,

26 Oklahoma State Question 788 A Yes Vote Legalizes the licensed use, sale, and growth of marijuana for medicinal purposes License required for use and possession of marijuana for medicinal purposes Must be approved by an Oklahoma Board Certified Physician. The State Department of Health will issue medical marijuana licenses: Applicant must be eighteen years or older and an Oklahoma resident. Special exception will be granted to an applicant under the age of eighteen Applications must be signed by two physicians and a parent or legal guardian Oklahoma State Election Board,

27 State Question 788 continued The State Department of Health will: Create a new division, hire an administrator and staff (according to Tony Sellars Director, Office of Communications, Oklahoma State Department of Health) Create an office to review applications and issue licenses to patients, growers and people involved in processing or selling cannabis Issue seller, grower, packaging, transportation, research and caregiver licenses. Required to inspect marijuana processing facilities Individual and retail businesses must meet minimal requirements to be licensed to sell marijuana to licensees. Oklahoma State Election Board, 2018 State Question 788 Cont. The punishment for unlicensed possession of permitted amounts of marijuana for individuals who can state a medical condition is a fine not exceeding four hundred dollars. Fees and zoning restrictions are established. 7% state tax is imposed on medical marijuana sales. The license holder allowed to possess up to 3 ounces of the drug, 6 mature plants and six seedlings These limits can be increased by individual counties or cities Oklahoma State Election Board,

28 House Bill 3468 If SQ 788 is passed News Update March 18, 2018 Independent commission will be formed to regulate medical cannabis This will assist in protecting the state from losing federal funds if federal marijuana laws are enforced Tulsa World by Randy Krehbiel News Update April 9, 2018 Green the Vote organization (Isaac Caviness, President) Seeking signatures to get 2 issues on Nov. 6 ballot (total of 123,725 required) State question 796 medical marijuana use State question 797 recreational marijuana use Organization states that these State questions have a list of qualifying conditions unlike SQ 788 These would be constitutional initiatives not statutory initiatives Tulsa World April 11, 2018 by Barbara Hoberock. Medical, recreational marijuana advocates seek votes, volunteers 28

29 ANA Position on use of Medicinal Cannabis It is the shared responsibility of professional nursing organizations to speak for nurses collectively in shaping health care and to promulgate change for the improvement of health and health care (ANA, 2015, p. 36). Therefore, the ANA strongly supports: Scientific review of marijuana s status as a federal Schedule I controlled substance and relisting marijuana as a federal Schedule II controlled substance for purposes of facilitating research Development of prescribing standards that includes indications for use, specific dose, route, expected effect and possible side effects, as well as indications for stopping a medication ANA, 2016 ANA Position Cont. Establishing evidence-based standards for the use of marijuana and related cannabinoids Protection from criminal or civil penalties for patients using therapeutic marijuana and related cannabinoids as permitted under state laws Exemption from criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for health care practitioners who discuss treatment alternatives concerning marijuana or who prescribe, dispense or administer marijuana in accordance with professional standards and state laws American Nurses Association (ANA),

30 Questions? FDA.gov Drugabuse.gov Resources American Cannabis Nurses Association Society of Cannabis Clinicians - American Academy of Cannabinoid Medicine

31 References American Nurses Association (ANA) Position Statement, Therapeutic Use of Marijuana and Related Cannabinoids, ANA Center of Ethics and Human Rights. Retrieved at Bridgeman, M. & Abazia, D. Medicinal Cannabis: History, pharmacology, and implications for the acute care setting. P&T 2017; 42(3), pp Cesamet, Retrieved from: nces Colorado Department of Revenue, Retrieved at pacific/enforcement/statistics-and-resources Drug Enforcement Administration, Diversion Control Division, Controlled Substances Act, Title 21 United States Code (USC), Food and Drugs, Chapter 13 Drug Abuse Prevention and Control. U.S. Government Printing office. Galli, J., Sawaya, R., & Friedenberg, F. (2011). Cannabinoid Hyperemesis syndrome, Current Drug Abuse Reviews, 4(4), Galli, J., Sawaya, R., & Friedenberg, F. (2011). Cannabinoid Hyperemesis syndrome, Current Drug Abuse Reviews, 4(4), Morgan, C., Freeman, T., Powell, J., & Curran (2016). AK1 genotype moderates the acute psychotomimetic effects of naturalistically smoked cannabis in young cannabis smokers. Translational Psychiatry, 6, e738. NIH National Institute on Drug Abuse. Drug Facts. Marijuana as medicine. References Cont. Oklahoma State Election Board, State Question 788. Retrieved at Oklahoma Health Department: We can t afford to regulate medical marijuana. Pettinato, M. (2017). Medicinal cannabis: a primer for nurses. Nursing, 47(8), pp Pirschel,C. (2018). Understanding Medicinal Cannabis is Cancer Care. ONS Voice, January, State Marijuana Laws in 2018 Map, Tulsa World Friday January 5, 2018 A1, A4 by Barbara Hoberock. Medical cannabis vote set for June. Tulsa World Saturday January 6, 2018 A11, A13 by Justin Wingerter The Oklahoman. U.S. Attorneys voice views on marijuana prosecution 31

32 References Cont. U.S. Food & Drug Administration, How Drugs are Developed and Approved, Development & Approval Process. Retrieved at ult.htm U.S. Food & Drug Administration, FDA and Marijuana: Questions and Answers. Retrieved at Whiting, P. et al. Cannabinoids for Medical Use: A systematic review and meta-analysis. JAMA. 2015:313(24): HEMP Plant The editors of Encyclopedia Britannica Small, E. and D. Marcus Hemp: A new crop with new uses for North America. p In: J. Janick and A. Whipkey (eds.), Trends in new crops and new uses. ASHS Press, Alexandria, VA. 32