Analysis

Medicinal cannabis: how the change in the law could herald a new nursing specialty



Nurses can play a vital role in helping to support and educate the public about the use of cannabis as a medicine

Nurses can play a vital role in helping to support and educate the public about the use of cannabis as a medicine 


Picture: Alamy

The government is finalising details of its decision to allow medicinal cannabis to be available on prescription for those with ‘exceptional clinical needs’. The law is expected to change this autumn, and it's a decision that is welcomed by the RCN.  In May, the college's congress voted in favour of decriminalising cannabis for medical use in the UK.

New rules mean cannabis-derived medicinal products will become schedule 2 controlled drugs, with guidance expected soon on the medical conditions that might be covered.

Government heeded advice

The reform of the law follows a series of high-profile cases involving children with epilepsy, whose condition appears to be helped by cannabis oil.

After considering expert advice, home secretary Sajid Javid highlighted the cases of Alfie Dingley and Billy Caldwell, who have severe forms of epilepsy. 

1971

The year cannabis became
illegal in the UK

Mr Javid said: ‘Recent cases involving sick children made it clear to me that our position on cannabis-related medicinal products was not satisfactory.

‘Following advice from two sets of independent advisers, I have taken the decision to reschedule cannabis-derived medicinal products – meaning they will be available on prescription.

‘This will help patients with an exceptional clinical need, but is in no way a step to the legalisation of cannabis for recreational use.’

Restrictions on prescription 

In places where it is legal, medicinal cannabis is used to treat and support patients with conditions, including multiple sclerosis, epilepsy, migraines, chronic pain, anxiety, arthritis, cancer, nausea and Crohn’s disease. It is also used to ease pain and improve quality of life for people who are terminally ill.

It is unclear what type of medicinal cannabis products will be available in the UK, which patients will receive it and how widespread its prescription will be. The Home Office said only ‘specialist clinicians’ will be able to prescribe cannabis-derived medication. It is unlikely nurse prescribers will be required to do so.

The Department of Health and Social Care and the Medicines and Health products Regulatory Agency are working to define what constitutes a cannabis-derived medicinal product so these can be rescheduled and prescribed.

RCN professional lead for long-term conditions and end of life care Amanda Cheesley says she feels the nursing role for cannabis medicine will be ‘to advise and support, rather than prescribe.'

‘My understanding is that these medications are often a last resort and therefore, would almost always be prescribed by a consultant doctor.’

Ms Cheesley says it is likely the RCN would produce guidance for nurses once the guidelines and details about medicinal cannabis prescribing has been established.

Need to reflect on potential bias                   

In countries including the Netherlands, Canada, Australia, Chile, Israel and some states in the US, cannabis is already legally in use as a medicine.

Canadian Nurses Association programme lead Karey Shuhendler says medicinal cannabis care should be no different to any other type of care.

‘A nurse should practise reflectively, examining their own potential bias and knowledge gaps and look for good quality evidence to develop their knowledge base around cannabis for medical purposes.

‘The nurse needs to understand their scope of practice, the law and the perspective of their nursing regulator, as all of these have implications for practice.

‘Nurses have an obligation to advocate for policy changes to promote access, equity and healthy public policy.’

Cannabis on the curriculum

Cannabis is legal either medicinally or recreationally in 30 US states, despite the drug still being illegal under federal law, and some nurses have set themselves up as ‘cannabis nurses’.

The American Cannabis Nurses Association (ACNA), which has 700 members, has developed three continuing professional development curriculum courses for the drug's use as a medicine, as well as scope and standards of practice for cannabis nurses.

‘We want to educate people and end stigma'

Carey Clark, president of the American Cannabis Nurses Association 

Although not yet recognised as a speciality, the ACNA hopes cannabis nursing might become an advanced practice discipline certified by the American Nurses Credentialing Center.


Dr Carey Clark

ACNA president Carey Clark says she welcomes the UK’s decision to decriminalise cannabis for medical use, but hopes the scope of its use is not too narrow.

100

active drugs are found in grown cannabis with a variety of concentrations and ratios including tetrahydrocannabinol (THC) and cannabidiol

‘I am excited for the UK, but it will depend on whether patients have access to cannabinoid medicines that work best in their conditions.'

Dr Clark, professor of nursing at the University of Maine at Augusta, says it is crucial UK nurses educate themselves about the health benefits of cannabis as a medicine and how the body responds to it.

‘We are ethically obligated to learn about it, because our patients are using cannabis, whether medicinally or recreationally.

‘Our focus is on educating nurses so they understand the endocannabinoid system (ECS) which is the largest receptor system in the body.

‘We make our own cannabis-like systems and when we don’t make enough of this, we fall out of homeostasis and become ill.’

'Cannabis has a fairly safe profile – there has never been a case of anyone dying from using it'

Carey Clark

Dr Clark wants the ECS to become standard content in nursing curricula.

‘I think nurses should know that cannabis has a fairly safe profile – there has never been a case of anyone dying from using it, unlike opiates.’

Dr Clark urges the UK’s nurses to remain open-minded and learn about the health benefits of medicinal cannabis and believes that, in the future, cannabis will be ‘far less prohibited’ than it currently is.

‘We want to educate people and end stigma – that is the challenge.’

Unsupervised use makes drug interactions likely

Eloise Theisen, an advanced practice nurse in older people's care, is co-founder of Radicle Health – a company that provides access to medicinal and educational cannabis resources.

In California, where the company is based, cannabis medication cannot be prescribed and clinicians can only make so-called ‘recommendations’ about dosage.

But, with or without a recommendation, anyone over the age of 21 can purchase cannabis from authorised dispensaries found in shops and office buildings. 

'This has its own set of challenges', says Ms Theisen.

‘It can be life-changing for some people – it can be their magic bullet'

Eloise Theisen, older people's nurse and co-founder of Radicle Health

‘Most of the people I work with in adult geriatric medicine are too intimidated to walk into a dispensary and get cannabis, or if they do, they get poor advice.

'The retail staff who work at these dispensaries have no idea about the specialist needs of a geriatric patient.’

As people aged over 60 take an average of five medications a day, drug interactions are likely but a shop assistant would not have the appropriate knowledge to advise about these.

Benefits end of life care

Ms Theisen has helped care for more than 4,500 patients over the five years she has been working with cannabis – which equates to around 25 patients a week.


Eloise Theisen

The average age of her patients is 76 and most come for help with pain, sleep, anxiety or depression. ‘We also see people for neurological conditions such as Parkinson’s or dementia and multiple sclerosis,' Ms Theisen says.

1

The only cannabis-derived drug registered for use by the UK is Sativex, which is for people with multiple sclerosis

‘We see some pretty sick people with long-term conditions and usually cannabis is a last resort.

‘They might have tried unsuccessful treatments. When people come to us, they are looking for guidance and we navigate them through the complexities of cannabis as a medicine.'  She advises on what to take, possible interactions, side effects, and what to expect from the treatment.

Ms Theisen says the best part of cannabis nursing has been the realisation that she is really helping people.

‘If nurses are interested in this [area of practice] they can see patients getting better, often for the first time.

‘It can be life-changing for some people – it can be their magic bullet.

‘It helps with pain, sleep, anxiety, depression, arthritis and minimises agitation in patients with dementia.

'Cannabis nurses need to have tough skin as they may be ridiculed by their peers'

Eloise Theisen

‘Some people can eliminate their entire pharmaceutical [intake] or reduce their opiate intake and we see a lot of benefit in palliative care.

‘Patients can often manage their symptoms without other pharmaceuticals, are more engaged with their loved ones and feel better than they do with opiates.’

Establishment is cautious

Ms Theisen advises the UK’s nurses to learn as much as they can about medicinal cannabis and to work with public officials to help educate them and start increasing access for patients.

‘There is a lot of stigma that needs to be undone – cannabis nurses need to have tough skin and be willing to be ridiculed by their peers because there is a lot of old thinking around cannabis.’

Despite many positive endorsements for medicinal cannabis, the UK's medical establishment is cautious about the drug's potential for harm.

In a review of recent evidence on the medicinal and therapeutic effects of cannabis, the UK's chief medical adviser Dame Sally Davies said: 'There are well known harms from cannabis and some of its derivatives including addiction and mental health disorders.

'As with all medicines, doctors must balance the potential for harm against the potential for benefit for individual patients.'

While the future is uncertain, nurses have an opportunity to play an educational and supportive role while official frameworks and guidelines are being made clear.

The UK is the largest producer of legal cannabis 

Cannabis has been illegal in the UK since 1971 and until now has been classed as a schedule 1 drug. This means it was thought to have no therapeutic value, although it can be used for the purposes of research with a Home Office licence.

Despite the scheduling, the UK is the world’s largest producer of legal cannabis, according to a recent report by the International Narcotics Control Board.

The UK produced 95 tonnes of marijuana in the UK in 2016 for medicinal and scientific use, accounting for 44.9% of the world total.

It was also the main exporter of legal cannabis – providing 67.7% (2.1 tonnes) of the world total followed by the Netherlands, which exported 16.4% (0.5 tonnes).

Source: International Narcotics Control Board

Nurses in Canada are concerned over plans to decriminalise drug

When cannabis becomes legal beyond medical use in Canada on 17 October, it will pose new challenges for the profession, say nurses there.

Medicinal cannabis has been legal in the country since 2001 and nurse practitioners have been legally able to authorise, as distinct from prescribe, its use since 2014. In Canada, 300,000 people are registered to use it.

The Canadian Nurses Association (CNA) has concerns about continued access to medical cannabis strains that have been developed to treat specific conditions.

CNA programme lead public policy Karey Shuhendler says: ‘It is foreseeable that without protection of a separate stream for medical cannabis, production will be based on consumer demand, which will be largely for recreational purposes.'

Another concern is the continuing need for care and clinical oversight for people using medical cannabis, rather than leaving patients to self-medicate.

‘This clinical oversight allows for therapeutic interaction with healthcare providers, including nurses, to help assess for therapeutic effect, side effects and drug interactions,’ says Ms Shuhendler.

She says nurses need to prepare themselves to discuss the risks and harms of non-medicinal cannabis. ‘Nurses need to be able to have these evidence-informed conversations with patients in a way that promotes open, honest discussion and reduces stigma.’


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