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HomeMy WebLinkAbout2017/08/03 Agenda Packet - Workshop I declare under penalty of perjury that I am employed by the City of Chula Vista in the office of the City Clerk and that I posted the document according to Brown Act requirements. Dated: "1 Z'1 (� Signed• CRY OF CHULA VISTA Mary Casillas Salas, Mayor Patricia Aguilar, Councilmember Gary Halbert, City Manager Mike Diaz, Councilmember Glen R. Googins, City Attorney John McCann, Councilmember Kerry K. Bigelow, Acting City Clerk Stephen C. Padilla. Councilmember Thursday, August 3, 2017 4:00 PM Council Chambers 276 4th Avenue, Building A Chula Vista, CA 91910 REGULAR CITY COUNCIL WORKSHOP CALL TO ORDER ROLL CALL: Councilmembers Aguilar. Diaz, McCann. Padilla and Mayor Casillas Salas PLEDGE OF ALLEGIANCE TO THE FLAG AND MOMENT OF SILENCE PUBLIC COMMENTS Persons speaking during Public Comments may address the Council on any subject matter within the Council's jurisdiction that is not listed as an item on the agenda. State law generally prohibits the Council from discussing or taking action on any issue not included on the agenda, but, if appropriate. the Council may schedule the topic for future discussion or refer the matter to staff. Comments are limited to three minutes. WORKSHOP Council Workshops are for the purpose of discussing matters that require extensive deliberation or are of such length, duration or complexity that the Regular Tuesday Council Meetings would not be conducive to hearing these matters. Unless otherwise noticed on this agenda. final Council actions shall be limited to referring matters to staff. If you wish to speak on any item, please fill out a "Request to Speak" form and submit it to the City Clerk prior to the meeting. Comments are limited to five minutes. City of Chula Vista Page 1 Printed on 7/2712017 City Council Agenda August 3, 2017 17-0306 CANNABIS WORKSHOP Presentation and discussion of current state cannabis laws and the future of local regulations regarding cannabis ADJOURNMENT to the Regular City Council Meeting on August 8. 2017, at 5.00 p.m., in the Council Chambers. Materials provided to the City Council related to any open-session item on this agenda are available for public review at the City Clerk's Office, located in City Hall at 276 Fourth Avenue, Building A, during normal business hours. In compliance with the AMERICANS WITH DISABILITIES ACT The City of Chula Vista requests individuals who require special accommodations to access, attend, and/or participate in a City meeting, activity, or service, contact the City Clerk's Office at(619) 691-5041(Califomia Relay Service is available for the hearing impaired by dialing 711) at least forty-eight hours in advance of the meeting. Most Chula Vista City Council meetings, including public comments, are video recorded and aired live on AT&T U-verse channel 99 (throughout the County), on Cox Cable channel 24 (only in Chula Vista), and online at www.chulavistaca.gov. Recorded meetings are also aired on Wednesdays at 7 p.m. (both channels) and are archived on the City's website. Sign up at www.chulavistaca.gov to receive email notifications when City Council agendas are published online. City of Chula Vista Page 2 Printed on 7/27/2017 Wyl*il CAVnW7u<tiCAh0Is Page 1 Ken Sobel,Esq. Licensed in California& Arizona Since 1980 Practice Limited to Medical&Adult Use Commercial Cannabis Licensing& Operations All Aspects of Cannabis and Hemp Law,Business,Policy&Patient Advocacy 225 Broadway, 19'Floor San Diego, CA 92101 email: kennysocal711 @gmail.com cell: 619-208-2439 July 27,2017 Background Information On Banking and Finance Under California's MAUCRSA• Submitted by Ken Sobel On Behalf of CMA Growers, an Oceanside Legacy Grower I. Banking: A. Cannabis Cultivation/Processing v. Retail/Dispensary: Banking opportunities are more available for cannabis cultivation and manufacturing than retail dispensary operations; B. A third-parry management company handles banking, employment, vendor transactions, etc.; C. Very little cash on hand at cannabis cultivation &manufacturing facilities (pure B2B); D. Policies and Procedures for cash management are part of the Cultivation Facility Business Plan. (i) Federal attempts.to normalize cannabis operations have largely failed. A. Treasury Memo of 2/14/2014 attempted to clarify Bank Secrecy Act("BSA") and allow financial institutions to allow cannabis banking without violating the Controlled Substances Act("CSA"). B. Banks are allowed to host licensed/regulated cannabis operations provided they can verify compliance with state legal requirements and the US DOJ Cole Memo; C. Banks are risk averse and have generally refused or closed cannabis-related accounts, and view their obligations under-the Treasury Memo to be too burdensome and risky; D. Currently,banking through the management company described in I(B) have proven successful. (ii) Pending Federal Legislation May Resolve the Problem: A. H.R. 1227 would solve the problem by removing marijuana from the Controlled Substances Act; B. S. 776 would solve the problem by establishing a federal tax and regulate program; C. S. 780 directly authorizes banking access. D. H.R. 1841 would"regulate marijuana like alcohol"which will presumably allow access to traditional banking in accord with alcohol manufacturers, distributors and retailers. (iii) California Solution: A working group has been established in California sponsored by the California State Franchise Tax Board and the California League of Cities (among others)that has promised a Page 2 banking solution on or before January 1, 2018, when MAUCRSA becomes operative. See attached print out of`Banking the Cannabis Industry." II. Financial/Economic Considerations for Oceanside Under NUUCRSA: A. Economic Challenges to Legacy Growers in Oceanside: (i) High Cost of Labor; High Cost of Water; US Taxpayers have subsidized foreign competition in the ornamental plants and cut flower industry by virtue of NAFTA and the Andean Trade Preference Act("ATPA")that benefits Mexico, Bolivia, Columbia, Ecuador and Peru at the expense of our Oceanside area growers. ATPA adopted in 1991 and continued through 2013. NAFTA 1994-present. This has resulted in many local growers going out of business, and the rest operating on a shoe-string profit margin and constantly in danger of going out of business or selling out for more residential development despite the fact that Oceanside legacy growers are among the best in the world. B. Economic Factors Relating to Legal, Commercial Cannabis Cultivation: (i) At $23.3 billion annually,cannabis is larger than the next 5 California Agricultural commodities—COMBINED: (ii) Under MAUCRSA, cannabis is neither a food nor a drug but is now an AGRICULTURAL COMMODITY; (iii) Currently, 2.6% of California residents have a medical recommendation for cannabis use; beginning January 1, 2018, when adult(or, over-the-counter) use becomes legal, the market will grow THIRTY-FOLD: (iv) In addition, all visitors to San Diego County (approximately 38 million annually) 21 and over will be allowed to purchase cannabis by presenting proof of age without a medical recommendation; (v) In short, the demand will far exceed the supply for many years to come; (vi) With a legal local license from Oceanside, growers are protected from federal prohibition. C. Economic Benefits to Oceanside Under MAUCRSA (i) Fees and Taxes: (a) Typical Fees relating to California cannabis operations range from about $10,000 - $25,000, more than enough to offset any administrative costs; (b) Oceanside growers would support a Cannabis Tax Measure for Oceanside starting at 8% of gross sales (along the same lines as adopted by the City of San Diego voters in 11/16 (Measure N)). (c) It is reasonable to project a range of$5 - $8 million per year in tax revenue for 8 tier 3 mixed light grows when fully operational. Page 13 (d) Other tax revenues derived from related economic activity associated with successful business operations in the City. (ii) Associated Economic Benefits: (a) Direct Benefit: Jobs (Average annual payroll for each Tier 3 mixed light grow $750k/$1 million). Plus, local construction and supplier/vendor economic gain; (b) Indirect Benefit: Increase in general economic activity for rent(housing for workers), local shopping for goods and services, etc. (iii) Adverse Economic Consequences Without Oceanside Licensing for Legacy Growers: Since MAUCRSA is now the law of the State of California, without local licensing in Oceanside, all of the benefits under the Act will go to farmers in other regions like the Emerald Triangle, who have been granted local licenses by their respective jurisdictions, without ANY restriction to ship and sell all of their product in San Diego County. Without the opportunity to participate in the market, Oceanside legacy growers will continue their struggle for survival. ' - fia b s y oyF, ey L.`'Ci c �_° x„ s +` ?�+ 5v�5 ' ' •• 'Qt 5+ - t�$ y's s,-. 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By KURT SNIBBE I Southern Califsrrua Nc.,,s Graup LO�p�®Y ®nN Plants seized in national forests In 2013 As of Nov.9.adults in California ware Tai" The northwestern area of the state produces a vast amount of allowed to grew up to six marijuana ''' marijuana.but enforcement is harder in rough tarain. plants per household as long as the area - is locked and not visible from a public place.Rules may vary depending cn ®R- municipal restrictions.Purchasing Six Rivers,- Modoc �*p �IIA'S�r 1®.A mariu_na for recreational use will not be �� 15,379 9,212 GALIFOR0 allovied until 2018. - California leads the nation by Major growth t" total plants seized every year. One indication of how much mar'juana Here are�3 ��g:. is grown in California is the number of 'K from ZO ithe top tyro states t to 2015: plants seized by law enforcement on cr - 2011 EI Dorado x 1.California,3.98 million federal!ands.Here are some of the 17,911 `_#" 2.Tennessee.600,259 largest areas:where trespass cuitivaticn ��a' gcr•�rred in 2013 in national forests. "� ��,� 2012 1.California.2.08 million Stanislaus' Why on public lands. - 2.Kentucky,414.376 an 18 299 ar 2013 A lot of outdoor cannabis cultivation in California occurs on public lands,:vhere Mendocino 1.California.2.9 million cultivators take advantage of remote 8.105 ��.t 2.Kentucky,443,788 areas to avoid risk of forfeiture of 2014 croperty. 1.California,2-68 mi0ign .: Outdoor growing can yield more per 2 Kentucky,461,543 giant and'^sve less overhead than indoor 2015 �' = -• - •� .,:u grcwirg. t '.California._.64 million California has 1.3 million acres of state 2.Kentucky,571,340 -.,. - park land and more than 8 million acres of national forest and wilderness. Estimated market total F,-•. The United Nations world Drug Report J -Y _ estimates that!awr enforcement around : the world seizes only 10 to e0 percent of drt;gs produced.If the marijuana plants of the mar iL_na ` seized in 2015(2.64 million)arop - ilk lants se:zec in = considered to be 20 percent of the state r:=re California's production,the state would grovrn on public have had 13.2 mlllien plants.If each lands. plant produced a conservatively estimated 1 pound with a market price of ,.• �- t $1,755 per pound,the total value would equal about$23.3 billion. Millions of plants * > v ��,• - 'g. California!eads the natlon every yea:for tota:illegalLin, " plants seized indoors and outdoors. rt L. .., _ California Other 49 states Total If the 181,133-giants 2011 �, .. ._-r 6.74 } r•'�.�.�•� "' seized could produce 'oY 2012 4 F- = 3.93 1 pound each,that would Sim, 2013 4.39 total about$319 million. h'-`i ��� 2014 L 4.3 2015 4.26 The map belc-.v uses data from the website PrIce0f1•:'eed.com,which tracks oftes on the black market and at legal dispensaries.It shows that Top crops In 2015 the states that legalized recreational marijuana have the lowest prices. v.-hereas states such as rdcrth Dakota:where marlivana Is strictly orohib- http://files.onset.freedorn.com/ocregister/ne:vs/2016/focus/FOCUS_pot_farms/pot-DFNi.gif 4/19/17,10:32 AM Page 1 of 2 GROW FOR VETS US&THE CALIFORNIA CANNABIS NURSES ASSOCIATION THE TRUTH ABOUT CANNABIS AND KIDS *Cannabis has been used as medicine for all of recorded history as documented by Chinese medicine 5,000 years ago. *Evidence of an endocannabinoid system (Ecs) has been found in organisms dated 70 million years ago" *Old Testament,Genesis 1:29 provides that God gave all plants to man to use for food and nutrition *Cannabis was used as medicine by Jesus called "kaneh-bosem", extracted using olive oil and applied as anointing for feet and skin conditions(leprosy). Science proves that the skin is chock full of C82 fe receptors which explains why the topical application of cannabis oil provides healing benefits to the et and skin *Cannabis was listed in the American Pharmacopeia for 80 years(1860—1940)and was only removed because of federal prohibition (note: The American Medical Association testified against Cannabis Prohibition in 1937) *Farmers, like George Washington and Thomas Jefferson,grew American Cannabis("hemp"). It was such an important commodity in the Revolutionary War period that farmers were required to grow it and could use it instead of currency to pay taxes *Cannabis is now legal in 46 states,Washington, D.C.,and 2 US Territories. *In 16 states the ONLY patients who can legally use cannabis are....KIDS! *As legalization in the US goes up, cartels go out of business. More than a 10%+decline in illegal cannabis coming through the US/Mexico border in each of the past 7 years *The rate of cannabis use by teenagers in states that legalize it generally goes down or stays about the same after prohibition is lifted *No overdose death due to cannabis in all of recorded history...it's a safe and gentle plant medicine that fits perfectly with our endocannabinoid system *The highest level of human endocannabinoid production occurs in a lactating mother who is nursing her baby as the cannabinoids are vital to the health and well-being of the child *An observational study found that children born from mothers who used cannabis were as healthy at birth (if not more so)than the same from mothers who did not use it i *State Law(MCRSA&AUMA)have strict regulations that prevent diversion of cannabis to underage users(MCRSA—medical—requires proof of age 18;AUMA—Adult Use—requires proof of age 21 and over *No evidence of diversion of cannabis to minors by cannabis dispensaries in San Diego after 3 years of operating a regulated program *No evidence of discipline or license suspension for diversion to minors by dispensaries in Arizona after 5 years of operations KEN SOBEL, ESQ.,VICE PRESIDENT,GROW FOR VETS US; CALIFORNIA CANNABIS NURSES ASSN GENERAL COUNSEL, 619.208.2439; kennysocal711@gmail.com GROW FOR VETS US&THE CALIFORNIA CANNABIS NURSES ASSOCIATION *Smoking Cannabis is Not Harmful. Standing next to someone smoking cannabis is safe. Not the same as cigarettes. On April 21,2016,the FDA approved a controlled study of whole plant cannabis using smoked cannabis to study the effects of cannabis on post-traumatic stress disorder for returning Iraq and Afghanistan veterans. *Cannabis is defined as an "Agricultural Commodity" in California under the Medical Cannabis Regulation &Safety Act(MCRSA) passed by the California Legislature and signed by Governor Brown in September 2015 *80%of the Assembly voted "Yes";77%of the Senate voted "Yes";the Governor signed the bill. *55%of California voters voted for Adult Use of Marijuana Act("AUMA");65%of Encinitas voters voted "Yes" *When legal, regulated cannabis comes in, illegal marijuana from Mexican cartels goes down. More than a 10%+drop year-over-year for the past 7 years! *Cannabis cultivation is supported and endorsed by the San Diego County Farm Bureau *Cannabis is safe and effective for the treatment of opiate addiction (heroin) *Opiate overdose death has declined 25% in states with full medical cannabis program i KEN SOBEL, ESQ.,VICE PRESIDENT, GROW FOR VETS US; CALIFORNIA CANNABIS NURSES ASSN GENERAL COUNSEL, 619.208.2439; kennysocal711@gmail.com GROW FOR VETS US&THE CALIFORNIA CANNABIS NURSES ASSOCIATION A BEGINNER'S GUIDE TO CANNABIS AND THE HUMAN ENDOCANNABINOID SYSTEM In the future, perhaps 20 years from now,cannabis-based medicines will have a prominent place in the worldwide pharmacopeia again. Indeed,we might have even gotten there much faster if it hadn't been for the draconian interference of the U.S.government.To this day,they are still blocking researchers from accessing cannabis to study.Countless thousands have died suffering and millions more continue to be denied access to plant-based medications that could not only mitigate their misery, but also possibly even cure them. Cannabis medications work so efficiently because of the endocannabinoid (EC)system, present in all humans and many animals as well.This system consists of a series of receptors that are configured only to accept cannabinoids,especially tetrahydrocannabinol (THC)and cannabidiol (CBD). Not enough research has been done on the other ones, cannabinol (CBN) and cannabigerol (CBG) plus others,to know much about their mechanisms of effect. This system,an integral part of our physiologies,was discovered in the mid-1990s by Israeli researcher Dr. Ralph Mechoulam who also identified THC as the main active ingredient in cannabis in the early 1960s. Israel has been one of the most progressive nations for cannabis research and currently has one of the most advanced medical marijuana programs in the world.They are international leaders in advanced greenhouse technology, routinely producing flowers with 20 percent or greater THC. Dr. Mechoulam's world-changing research discovered two.main receptors,cannabinoid 1(CB1)and cannabinoid 2 (CB2),that are keyed to both the endocannabinoids that our body naturally produces and phytocannabinoids(plant-based) like THC and CBD.Our bodies actually produce the ECs similar to how our body produces narcotic-like endorphins.Synthetic cannabinoids, like the ones found in Marinol, also fit the receptor sites but don't work as efficiently as the natural ones. This research barely created a stir when first published as the whole world was still wrapped up in drug war madness. A prominent scientist discovers that our bodies not only have receptor sites cued just for cannabinoids but that our bodies actually produce them internally.The next step was to figure out how this affects our body's functioning. CB1 receptors are primarily found in the brain, although they are also-both present in the male and female reproductive organs. Current research shows that THC is specifically keyed to the CB1 site. Therefore it is responsible for the feeling of intoxication that is the most familiar aspect of cannabis. From a therapeutic standpoint, it's most important effect is to modulate and moderate the perception of pain. For example,touching a finger to a hot stove sends an electrical impulse that goes from the finger to the brain.The brain replies, "ouch, hot" and the finger is pulled away. THC moderates pain;this doesn't mean we leave our finger on the stove, but that the intensity of the painful feeling is reduced when THC is present in the C61 site.This mechanism of action is why THC-rich I medicines are so prized by people with intense pain issues.Cannabis and narcotics are also co-agonists, which means that each of them magnifies the effect of the other.This allows people to take lower doses j and still have it be effective.Additionally,CB1 receptors are not present in the part of the brain that regulates heart rate and respiration, so unlike narcotics,there is no lethal dosage threshold for THC, allowing someone to consume as much is needed for its palliative effects. . KEN SOBEL, ESQ.,VICE PRESIDENT, GROW FOR VETS US; CALIFORNIA CANNABIS NURSES ASS'N GENERAL COUNSEL,619.208.2439; kennysocal711@gmail.com GROW FOR VETS US&THE CALIFORNIA CANNABIS NURSES-ASSOCIATION CB2 receptors are primarily found in the immune system with the highest concentration located in the spleen.There is some evidence that the receptors might also be in the micro parts of the brain's basal ganglia,or nerve bundles.Again, a lack of comprehensive research has left many without the knowledge that should be widely available. The C132 receptors are keyed to CBD and works as an anti-inflammatory agent.The immune-boosting functions of CB2 are far less understood as research into CBD is just really beginning. It's only been about five years since CBD re-emerged in the medical cannabis scene and was identified through Steephill Labs.The benefits of CBD-rich medicine,with its anti-spasmodic qualities, is one the most exciting and promising areas of cannabis medical research currently happening. One of the other effects of CBD is that it moderates the effects of THC. It actually knocks THC off the CB1 receptor,so if someone is experiencing THC intoxication, a strong dose of CBD can counteract those effects.The future of CBD- rich medicines is almost limitless. Indeed,we have just barely scratched the surface of planet cannabis. THC and CBD are the two main cannabinoids that are focused on, however there are dozens and possibly hundreds more.Some of the ones that have been identified and studied include CBG,which binds to both CB1 as well as CB2 and is an antagonist to C61, meaning that it moderates the effects of THC. Cannabichromene (CBC) is non-psychoactive and has both anti-inflammatory and analgesic properties.CBN occurs when THC degrades. For this reason, it is rarely seen in fresh cannabis and is only mildly psychoactive, having a mostly sleepy effect.Tetra hyd rocanna biva rin (THCV) is another cannabinoid usually found in central Asian and southern African strains that also acts as a THC antagonist.There are more cannabinoids than can be listed here and they all have the potential to be as life changing as CBD is turning out to be. The fact that there is a system in our body that produces cannabinoids,and is specifically designed to accept just them, should be overwhelming proof of cannabis'efficacy as a medicine. From the pain- killing effects of THC to the anti-spasmodic and anti-inflammatory properties of CBD,we have just scratched the surface of a world of possibilities. People are waking up to the benefits of these medicines as more researchers are exploring the infinite possibilities inherent in this seemingly simple plant. Future generations will look back and wonder why it took so long to figure this out. KEN SOBEL, ESQ., VICE PRESIDENT, GROW FOR VETS US; CALIFORNIA CANNABIS NURSES ASSN GENERAL COUNSEL, 619.208.2439; kennysocal711@gmail.com 4/12/2017 6630507 U.S. Patent 6630507 Hemp i Sitemap i U.S.. Patent 6630507 The U.S. Patent Office issued #6630507 to the U.S.Health and Human Services filed o 2/2/2001. a patent lists the use of certain cannabinoids found wit in a cannabis sativa plant as useful in certain neurodegenerative diseases such as Alzheimer's, ' Parkinson's, and HIV dementia. Since cannabis sativa (marijuana) contains compounds recognized I and endorsed by an agency of the U.S. government- Why is it that marijuana remains on the Federal Schedule One list of drugs? The issuance of patent #6630507 is a direct contradiction of the governments own definition for classification of a Schedule 1 drug. US Patent 6,630,507 Cannabinoids as Antioxidants and hleuroprotectants "Cannabinoids have been found to have antioxidant properties, unrelated to NMDA receptor antagonism. This new found property makes cannabinoids useful in the treatment and prophylaxis of wide variety of oxidation associated diseases, such as ischemic, age-related, inflammatory and autoimmune diseases. The cannabinoids are found to have Dafticular agglication as neurODrQLgELanta, or example in limiting neurological damage following, ischemic insults, such as stroke and trauma, or in the Treat--n—eqo neuro eaenerativesiiseases. such as Iz eimer's disease, Parkinson's disease and HIV dementia. Nonpsychoactive canna inoi s, such as cannabidoil, are particularly advantageous to use because they avoid toxicity that is encountered with psychoactive cannabinoids at high doses useful in the method of the present invention."... i The DEA (Drug Enforcement Administration) classifies marijuana as a dangerous drug with no medical value. That classification contradicts mounds of evidence showing marijuana to be a very safe and effective medicine. Marijuana is more effective, much less expensive, and much safer than many drugs currently used in its place. Marijuana can provide excellent relief for those who suffer from cancer, AIDS, glaucoma, multiple sclerosis, chronic pain, arthritis, rheumatism, asthma, insomnia, and depression. i If knowledge of marijuana's many medicinal uses, its remarkable safety, and hemp's enormous potential as a natural resource become widely known, the DEA fears that support for Marijuana Prohibition will collapse, and thus threaten the DEA's budget. To maintain the myth that marijuana/hemp is useless and dangerous, the DEA prohibits medicinal use of marijuana, denies researchers access to marijuana for use in clinical studies, and rejects all applications to grow industrial hemp. https!/sites.googJe.corn/site/6630507/ 1/2 MfMV 6630507 In 1988--after reviewing all evidence brought forth in a lawsuit against the government's prohibition of medical marijuana--the DEA's own administrative law judge (Judge Francis Young) wrote: "The evidence.in this record clearly shows that marijuana has been accepted as capable of relieving the distress of great numbers of very ill people, and t doing so with safety under medical supervision. It would be unreasonable, arbitrary and capricious for the Drug Enforcement Administration to continue to stand between those sufferers and the benefits of this substance in light of the evidence." Judge Francis Young of the Drug Enforcement Administration went on to say: "Marijuana, in its natural form, is one of the safest therapeutically active substances known. In strict medical terms, marijuana is safer than many foods we commonly consume."Judge Young recommended that the DEA allow marijuana to be prescribed as medicine, but the DEA has refused. -Source: US Department of Justice, Drug Enforcement Administration, "In the Matter of Marijuana Rescheduling Petition," [Docket #86- 22], (September 6, 1988), p. 57. 4 I Sign in I Recent Site Activity I Report Abuse I Print Page I Powered By Google Sites https://sites.google.com/sit&6630507/ 212 POLICY ANALYSIS NO. 799 Dose of Reality: The Effect of State Marijuana gy Angela Dills, Sietse Goffard, and Jeffr on September 16, 2016 EXECUTIVE SUMMARY n November 2012 voters in the states of Colorado and Washington ap- proved ballot initiatives that legalized marijuana for recreational use. Two years later, Alaska and Oregon followed suit. As many as 11 other States may consider similar measures in November 2016, through either ballot Initiative or legislative action. Supporters and opponents of such initiatives make numerous claims about State-level marijuana legalization. Advocates think legalization reduces.crime, raises tax revenue, lowers criminal justice expenditures, improves public health, bolsters traffic safety, and stimulates the economy. Critics argue that le- ;alization spurs marijuana and other drug or alcohol use, increases crime, di- minishes traffic safety, harms public health, and lowers teen educational achievement. Systematic evaluation of these claims, however, has been largely absent. Phis paper assesses recent marijuana legalizations and related policies in Col- :)rado, Washington, Oregon, and Alaska. aur conclusion is that state marijuana legalizations have had minimal effect on marijuana use and related outcomes. We cannot rule out small effects of legal- ization, and insufficient time has elapsed since the four initial legalizations to allow strong inference. On the basis of available data, however,we find little https://www.cato.org/publications/policy-analysis/dose-reality-effect-state-marijuana-1egaiizations 4/22/17,8:48 AM Page 1 of 57 support for the stronger claims made by either opponents or advocates of legal- ization. The absence of significant adverse consequences is especially striking riven the sometimes dire predictions made by legalization opponents. 2ontinue to full version--o D Dosc of Realihr 1'Fh F:�ecc of Statc lfariju�ta l.emlli��tioa. "ECUTM SUNALRY �ecr3ae.vr.�-.a��atr cis .t1c-_-.—�s.,:csr:�_ocEeoef-�. r-a� r�_saCso�r..Yal:�-:t max. y1�t•_aU�:>-a�-e:...oc_trr-- +�a.v=-a+•2:::e`_a7_kb.kk-�:ae ..�.-�..-iv.s+,-4^s�.'•�ai-Tw..t�w�e.l..-.-�iva.e.+x...f......0. r .-.. Downloads L2af Q.75 MB 4.EP UB(1.77 MB) LffOBI 3.01 MB) Introduction In November 2012 the states of Colorado and Washington approved ballot initia- Ives that legalized marijuana for recreational use under state law. Two years later, Alaska and Oregon followed suit.-I In November 2016 as many as 11 other States will likely consider similar measures, through either ballot initiative or State legislative action. https:/,'www.cato.org/publications/policy-analysis/dose-reality-effect-state-marijuana-IegaIizations 4/22/17,8:48 AM Page 2 of 57 e o -®'PL®S!ONE O O TEN T NANNIVERSART • • • 2 RESEARCH ARTICLE The Effect of Medical Marijuana Laws on Crime: Evidence from State Panel Data, 1990-2006 Robert G. Morris,Michael TenEyck,J. C. Barnes,Tom islav V Kovandzic Background Debate has surrounded the legalization of marijuana for medical purposes for decades. Some have argued medical marijuana legalization (MML) poses a threat to public health and safety, perhaps also affecting crime rates. In recent years, some U.S. states have legalized marijuana for medical purposes, reigniting political and public interest in the impact of marijuana legalization on a range of outcomes. Methods Relying on U.S. state panel data, we analyzed the association between state MML and state crime rates for all Part I offenses collected by the FBI. Findings Results did not indicate a crime exacerbating effect of MML on any of the Part I offenses. Alternatively, state MML may be correlated with a reduction in homicide and assault rates, net of other covariates. Conclusions These findings run counter to arguments suggesting the legalization of marijuana for medical purposes poses a danger to public health in terms of exposure to violent crime and property crimes. Citation: Morris RG, TenEyck M, Barnes JC, Kovandzic TV (2014) The Effect of Medical Marijuana Laws on Crime: Evidence from State Panel Data, 1990-2006. PLoS ONE 9(3): e92816. doi:10.1371 roumal.pone.0092816 http://iournals.plos.org/plosone/article?id=10.1371/journal.pone.0092816 4/22/17, 8:49 AM ?age 1 of 3 LIFESTYLES OPPORTUNITY EDUCATION CANNABIS WWW_CANNABISNURSESMAGA7_ I N E.COM OLORADO'S DLCI DICAL CHILD' tE UANA RI PEDIAT �� J � 1 a � PRO GRAM "'XPERIENCE ILDREN B�: Bonni S.Goldstein,MDT _ By:Stacey Linn (Mother of Jack Splitt) i i a A Nurses Perspective: Cannabis Pediatric 'Refugees anti- �" the Reality in Colorado Jass". l.'pdate (Dra, et's & Prevention) - _ Nurses Responsibilities - .Ar Medical Cannabis: The Healing Power of Knowledge • • Letter Now that there are legal Recreational states for cannabis adult use(+21 years)adults are making their way to Recreational dispensaries and able to purchase cannabis,just like alcoh with a proper state ID. This is good news is patients and their families who are sick can nova immediately obtain products without the long process of obtaining a state medical marijuanz card;speeding their recovery and bringing balance to their bodies. However,there is one demographic that is excluded that legislatures have forgotten,The Kids. This issue asks"What about the kids?"Cannabis Nurses Magazine is here to tell you about the kids. As controversial this topic is,it is necessary to discuss. Our children are our future and deserve the same benefits and rights as any human being on this planet. We know that z cannabis aids in bringing balance within our bodies and is the key to our future health and wellness. Now it is time to learn why it is important to include the Kids. We first discuss Using Cannabis Medicine to Treat Children:One Pediatrician's Experience with Dr.Bonni Goldstein,an expert in cannabis therapeutics with children. She provides personal experience and case studies of over a decade of treating successfully with cannabis and how cannabis has benefited her pediatric population. With the use of cannabis,she has broken the barriers to many childhood illnesses,and these kids are thriving. We then took on the challenge of seeking out kids from across the country who have utilized cannabis in their treatment plans. In this issue, we cover the stories of 8 kids:Jaxs,Jack,Mykayla,Trey,Coltyn,Sophie,Logan,and Maddie. These children and their parents have risked their lives in order to incorporate cannabis into their children's treatment plans. These families are eight of thousands of patients who made massive sacrifices to help their desperately ill children,some by moving to Colorado with hope about cannabis in their hearts.The movemer was so profound,these families and patients were given the title"Cannabis Refugees." Today they wish to share their personal stories,some tragic,and some life-changing in hopes of providing future parents options besides traditional western medicine practices and pharmaceuticals. Their children have extended their life-cycles,some longer than what doctors h. predicted,and they owe it all to a simple plant called cannabis. Our Main Cover Nurse,Jennie Stormes,RN,BSN,MSN Student,is known for becoming a Registered Nurse to care for her son of Dravet's syndrome,and through her journey discovered the many benefits of this plant. Her recent Master's thesis formulated the course work of Cannabis Education for Nurses(5.33CEU),which will be presented at the Cannabis Nurses Network Conference 2017 in Las Vegas,NV. She outlines Nurses Responsibilities and Roles with Cannabis Patients and how to include cannabis in The Nursing Process. Through education we believe the stigmas will dissolve and cannabis will be normalized and incorporated into all patient care plans as an offered treatment plan for all. Lastly,we bring you an article on Cannabis and Pregnancy:Maternal child health implications during a period of drug policy liberalization. covers the controversial topics of pregnant mothers who consume cannabis and how Providers must recognize that even in environments where cannabis is legal,pregnant women may end up involved with child welfare. In states where substance use is considered child abuse this may be especially catastrophic. Above all,care for pregnant women who use cannabis should be non-punitive and grounded in respect for patient autonomy. One day,the laws will catch up to the science behind the plant. Until then,we need to provide autonomy and education in order to protect the children from being removed from the family nucleus. All of these children,and so so many more rely on cannabinoid therapeutics to obtain and maintain health and help them find relief from the symptoms associated with these debilitating conditions that have stricken their young lives.Without cannabis,these children are unable to attend school and face the harmful side-effects of pharmaceuticals.These are our kids,they are the children we work with,the ill ones...wh deserve the same opportunity as all humans. Yes,it is important to include the Kids. We must Grow. "One thing for sure,cannabis does not`cure'any disease states,it keeps it abreast and once you choose to incorporate cannabis into your treatment plan i, Julie Monteiro,RN,BSK becomes a life-style change,you will consume cannabis the rest of your life." "Ask Nurse Juhlzie" Nurse Juhlzie Monteiro Editor@CannabisNursesMagazine Contributorsm NURSES MAGAZINE® Heather Manus, RN A native New Mexican and Registered • 1� Nurses specializing p p gin all aspects of medical cannabis care. She is founder of the Arizona Cannabis Nurses Association and was honored for her efforts, and awarded • -•• • • ' the CannAwards "Best Charitable/Comm- • •• - • - . - unity Outreach Program", and Cannabis Business Awards "Activist of the Year 2015" and "Educational " -• - • Achievement Award 2016". She believes cannabis is a gate- way to health and will be a first-line medication of the future. -• - • Sue Degregorio-Rosen, RN - •' • -' - - A pioneer activist and native of New Jersey, • - •••- Sue lives in the lower Hudson Valley of New • ; • • York State. She has held multiple positions in the administration of ER/Trauma/Burns • - throughout her 40 yr career. She is the legal • • ' "' liaison and associate editor for The National Cannabis Patients Wall. She is also an activist and a chapter leader for the 420 Seniors Network of NY and The Cannabis Nurses Network. Sue holds a certificate in Advanced Cannabis Nursing, lending her expertise to communities along the east coast. Marcie Cooper, MSN, RN, AHN-BC • •• •• - • '• Marcie Cooper RN, MSN, AHN-BC is Board • • • " ' Certified as an Advanced Holistic Nurse and .� is working to build a bridge between '' - ''- ' ' • • _j conventional healthcare and holistic nursing ' ' '" ' • - • • -• care including cannabis therapeutics. She ' " - • • • - • - • obtained education, certifications and -• - -• - • training in various complimentary therapies •' - •- -• -•- • • •- • • - • including Hypnotherapy, Auricular • -• • • • • •• • Acupuncture, Healing Touch and Aromatherapy. She • • • •- ' • - • • incorporates cannabis education with patients while • - • - - •• . working in hospice and palliative care throughout Colorado, • • • '- • --• • '--•- and has witnessed the incredible benefits of cannabis. -• -•- • . •- . . Lisa Buchanan, RN, OCN • '• •• • •- •- -• • • ••. . • Lisa Buchanan is an Oncology Certified 4 Nurse (OCN) in Washington state who has worked with the seriously ill and dying for • . . more than 20 years. She a member of the Oncology Nurses Society (ONS), American Cannabis Nurses Association (ACNA), and ' the Washington State Nurses Association. ' ' • • She has earned certificates in the Core Curriculum for Cannabis Nursing and in the Advanced Curriculum for Cannabis Nursing through ACNA. Jennie Stormes, RN, BSN, MSN Student _ -• Jennie Stormes, RN, BSN lives in the state • •• _ ••� _ of Colorado, and formerly in both New • • • •• "' ' Jersey and Pennsylvania, is a member of • • • .• ••• - . the ACNA, a board member of American Medical Refugees as Vice Chair, Colorado Springs Chair for CannaMoms, and a parent member of the Special Education Advisory Committee for Colorado School District 49 (Falcon). She specializes in Pediatrics and Neurology and has a passon for education. Contfibutors - Bio:Janna Champagne, RN, BSN Contact Information Janna Champagne,RN,BSN is a Licensed Publisher Registered Nurse in Oregon focused on holistic ND 1 Media treatments,using natural alternatives to pharmaceuticals including cannabis therapy and Editorial nutrigenomics(genetically individualized interventions). "Nurse Janna"has significant Robert Herman experience using natural interventions to improve Art&Graphic Design symptoms of Autism,chronic Lyme,autoimmune, chronic pain, cancer,and other health conditions. Through her extensive To submit artwork/ad creation Email: research of underlying causation models in chronic illness,Nurse Janna has ads@cwmabisnursesmagazine.com created a system to holistically re-balance the synergy between systems to promote comprehensive healing of many disease states. Advertising & Marketing Bio: Jennie Stormes, RN, BSN,MSN Student For advertising opportunities Email: ads@cannabisnursesmagazine.com Jennie Stormes,RN,lives in the state of Colorado,and formerly in both New Jersey and Pennsylvania,is a member Sales/Product Director Email: of the American Cannabis Nurses Association,a board sales@cannabisnursesmagazine.com member of American Medical Refugees as Vice Chair, Colorado Springs Chair for CannaMoms,and a parent Writers member of the Special Education Advisory Committee for Colorado School District 49(Falcon). In 1999 Jennie's son To submit articles for publication Email: began experiencing intractable seizures related to Dravet editor@cannabisnursesmagazine.com Syndrome without much relief from traditional pharmaceuticals with 62 failedpharmaceutical combinations,2 brain surgeries,VNS implant,and special diets.In 2012,she began a CBD/THC cannabis regimen with Reach Us By Post great success. She has used and seen the benefits of full spectrum cannabinoid sciences in treating many forms of epilepsy,cancer,PTSD and other medical and Cannabis Nurses Magazine mental disorders effectively,especially when guidance and dosing information is 4780 W. Ann Rd., Suite 5 #420 available. She is also very politically active,testifying in both the assembly and N. Las Vegas,NV 89031 senate committees in New Jersey,as well as lobbying with many other legislators in numerous states and has sat on medical and professional panels across the nation. Her mission is to make changes with cannabis as a legal treatment option.Driven by info@cannabisnursesmagazine.com the amazing results she witnessed with her son,she is committed to remain active within the community to make changes by attending rallies,events,educating www.cannabisnursesmagazine.com medical professionals and layperson's whenever possible.She is currently spearheading the efforts in Colorado's D49 school district to allow cannabis medication/administration on school grounds. © Find • Bio: Lisa Buchanan RN, OCN Lisa Buchanan RN,OCN has been a licensed as a Registered Nurse in Washington since 1992 and has been involved in cannabis patient advocacy for the last 16 years. She holds certificates of completion for both the Core Curriculum for Cannabis Nursing and the Advanced Curriculum for Cannabis Nursing. She is a member of the Oncology Nurses Society and the American Cannabis Nurses Association. Lisa founded Paisley Nursing Group,LLC in 2015 which provides evidence-based education and consultation to patients,the public,and governmental agencies. Lisa is participating as a panelist at Seattle Hempfest,August 19th-21st,2016 and is on the Cannabis Nurses Magazine Advisory Board. 2016 Educational Achievement Award HeHeather Manus RN Cannabis Nurses Magazine 1 JuUly/-3 ust Contents 2017 406: A Nurses Perspective: Cannabis Pediatric Refugees and the Reality in Colorado By: Jennie Stormes,RN, BSN, MSN Student 10: Madeline Holt's Story is one of Hope,Love,and Community By: Lisa Buchanan,RN(State of Washington) or- 14: 14: "Jaxs"Update(Dravet's& Prevention)(State of Colorado) By:Jennie Stormes, RN, BSN,MSN Student - -- _ 16:Colorado's Medical Marijuana Program and Children - By: Stacey Linn(Mother of Jack Splitt) 22: Using Cannabis Medicine to Treat Children: One - - Pediatrician's Experience By: Bonni S. Goldstein, MD T 26: What to look for when choosing Cannabis Pediatric Care By:Julie Monteiro,RN,BSK -for Auti,in- 28: The Fall,The Rise& The Research: A Momcologist's Journey By: Tracy Ryan(Mother of Sophie)(State of California) - 34 31:Autism and Cannabis: One Mom's Journey(State of Arizona) By:Brandy Williams(Mother of Logan) 34:Intro to Cannabis for Autism By:Nurse Janna,RN,BSN,Holistic Nurse & Warrior ASD Mama Tu W C.-.W -- - - 36:Nurses Responsibilities-And-Roles with Cannabis Patients By: Jennie Stormes, RN,BSN,MSN Student 40:TBI and Cannabis: A Teenager's Perspective _ (State of Minnesota)By: Trey Brown(now 17 years old) - CANNABIS AND 44:Cooking with Herb: Summer Days at the Beach cROHNSDISEASE www.cookingwithherb.com 48:Cannabis and Crohn's Disease(State of Colorado) By: Wendy Turner(Mother of Coltyn Turner) • 52: Brave Mykayla(State of Oregon) By: Erin Purchase(Mother of Mykayla) 55: Cannabis and Pregnancy: Maternal child health implications during a period of drug policy liberalization By: Katrina Mark,MD and MishkaTerplan,MD 61: Resources MEDICINAL 62: Recommended Books 63:Nursing Conferences MARIJUANA- le PACK ilf MANGER,� 10E . WEORE HEADED FOR COLORADO . A Nurses Perspective: Cannabis Pediatric Refugees • • Reality inColorado By: Jennie Stormes, RN, BSN, MSN Cannabis is recreationally available for those over 21. For the Student medical program,a minor(under 18)requires a recommendation of „°" '"'■ °`na�n '�"�" I two physicians with qualifying conditions. Adults only require one �» "" physician to recommend cannabis as a treatment.In Colorado,the ctweIli Cro hn qualifying y uali conditions are limited with only selected disorders: unser l n'IeC§Cr1e— cancer,glaucoma,HIV/AIDS,cachexia,persistent muscle spasms, •`m`•"'�•OO seizures,severe pain,severe nausea,and just signed into law,PTSD easeii�. (CDPHE,n.d.;Wallace,2017). Children with autism,without another diagnosis or qualifying condition,may not be eligible under Colorado laws for cannabis use. This is the situation for many You have a disabled child?A sickly child with cancer or Crohn's? children who suffer from a disorder which cannabis is known to A child with autism or seizures?Something that cannabis is known help,but do not have a qualifying condition in the state,they are to treat,then the advice most parents receive from the general excluded from the medical marijuana program. These parents are community is"Go to Colorado,they have marijuana and it will forced to administer secretly and are afforded no protection as a cure your kid." Not many are willing to stay and help fight for child who is allowed to possess a recommended physician approval change within those states for many reasons. If they do stay for a and card from the state. As an adult,they would simply access the bit to change the laws,the parent and the child become targets of much needed cannabis through the recreational market,even the state and child protective services. For many of these kids, though their use is medical. This will incur higher taxes and higher they do not have the time to wait for changes within their own costs with less access to all forms of medical products afforded the state. Then there is the reality of moving to another state. It is an medical patient. Additionally,they have different limits on emotional situation with many decisions and implications. amounts to purchase and carry than a medical patient in the same state. Moving is not easy for anyone,especially someone who is disabled.The cost can be$10,000 or more for a family,for a Establishing residency,medical care,finding a medical waiver(if cross-county move. The services and medical supplies,the eligible)and educational services in a safe neighborhood is support system,and education services to be re-established. The stressful. New state residency comes with new rules,new taxes, cost of living in Colorado is not cheap and housing can be scarce and new realities. In Colorado,there is also the altitude,which can in the more populated areas,which are closest to the medical care, impact the existing health condition,especially those with educational,and social services. Jobs are available,but not for breathing issues and oxygen needs. ome of the new realities are, disabled or those who cannot pass a mandatory drug test,which not everyone in Colorado is accepting of cannabis as a medication. includes the very medication needed to address the illness and If you call the doctor to establish care,they do not take cannabis symptoms they are trying to relieve. patients or Medicaid patients. Although there is an established 06 July/August 2017 CANNARISNURSESMAGAZINEXOM medical marijuana program in Colorado,the hospitals are not months,sometimes over 6 month wait,and no or limited assistance accepting of the use of cannabis to treat the qualifying with traditional western medical to supporto tions conditions.If you are currently taking any narcotic or p all the significant changes in abilities and ongoing changing medical needs. I personally prescription medications,the potentially new doctor will not experienced and hear similar stories with the neurological doctors in see you or refill those prescriptions. If you present to the Colorado,but especially at Children's Hospital.While some individual emergency room or need an in-patient stay,there are policies physicians are cannabis friendly,the federal laws may not allow them and procedures which may oppose your chosen treatment plan. to be. Those individual physicians that are against cannabis are quick to condemn and judge anyone choosing to use cannabis under In Colorado schools are legally compelled by state law to allow complete protection of federal prohibition.The children who are soon a parent or caregiver to come onto a"Drug Free School Zone" to age out are at an unfair advantage with aging out into adult and administer cannabis medications to their child,in honor of neurology. Although your child can remain until age 21 or after if Jack Splitt,son of Stacey Linn(Colorado Legislature,2016). agreed upon to be in the best interest of the patient,the neurology Not all schools are compliant with the law and still refuse to department at Children's Hospital is quick to terminate services quickly allow a parent or caregiver on school grounds to administer the or just be so slow in responding that a medical crisis is created. Many cannabis based medication. Equal access to children needing parents have reported to me that the neurologist or epileptologist will cannabis based medicine in public schools can still be a fight look at the medical record and if they see cannabis listed that the with unneded stress and battles to follow the existing laws.For treatment plan changes and all the issues are blamed on the cannabis. some school aged children,this is only mdication that helps The plan of care becomes limited with few options and little support, control their symptoms and allow them to attend school.The until the cannabis is stopped. school nurse or other staff cannot and will not give the cannabis based medication:legally they cannot hold,store,or From my personal experience,my son(Dravet's)was throwing up administer a cannabis based medication during the school day. non-stop,to the point that he was declared a failure to thrive and lost "Jack's Law",signed by Governor Hickenlooper in June 2016 significant weight to 102 lbs at 5'5"tall. Cannabinoid Hyperemesis guaranteed access to cannabis based medication to limit the Syndrome was the reason,the diagnosis,and the suspected cause was intrusion of educational minutes to those children who need "Marijuana Use". If I would just stop the cannabis,he would do cannabis medication to control their symptoms(CBS4,2016). better. In defense of the doctor,research has not been allowed for over This means a parent must take time to come to school,check 80 years,8 decades,so they have a lot to learn.However,more effort in,take the cannabis based medication to the nurse office(or needs to be made to understand cannabis use benefits and cannabis use designated area),administer the medication and leave the side effects. Hyperemesis Syndrome is real,but very rare. While on campus with the cannabis. cannabis I made some dietary changes for my son. Guess what happened when I stopped using the formula prescribed by the doctors But wait,this is Colorado? The Children's Hospital has studies and paid for by the Medicaid insurance?Yep,he stopped throwing up. right?That is the illusion of cannabis in Colorado. It appears to I began making his formula by blending real foods and feeding him in be accepted and for some it is,but not for all,especially those the G-Tube.The cannabis use continued,the formula was discontin- needing THC,not just CBD. Please understand,CBD is a ued,he was fed real food,and he stopped throwing up. The emesis medication and works well for many,especially children,but had nothing to do with the cannabis,it was the pea-protein contained in not everyone. As the children get older,experience puberty, the formula. Until the physician has permission to understand, and grow,their cannabis needs change and they outgrow their research,and incorporate cannabis into treatment plans,they will not dose or cannabinoid mixture. Many children with infantile understand cannabis as a medication. They will continue to take the spasms need CBN,THCa or THC,not CBD. The CBD will easy path with blaming the cannabis for all medical issues and and has made the seizures and spasms worse when there are dismissing the patient,even if it is not true. But,you can see where spasms involved,not just seizures. It is ahnost like the CBD is the use of cannabis-based medications can cloud the picture and distort a neuro-irritant in some cases or disorders. The THC actually finding out the cause of pain,discomfort,disease,and symptom relief has allowed many children become free from the spasms, dystonia,and even the relentless seizures. CBD is not the only Do not be tricked by the media or others who claim cannabis is being medicine in the cannabis plant able to help children,there are studied at Colorado Children's Hospital. It is almost like it is a game many other cannabinoids to utilize. of smoke and mirrors and staying just on this side of legal. There are currently three cannabis related studies, with some funding from the For many families,the reception at Denver Children's Hospital state of Colorado's marijuana tax revenue to understand the use of in Aurora has been chilly and unsupportive concerning cannabis in children cannabis. During one emergency room visit,my son was if you read carefullyeIIand ver Cunderstand osthe hstudies, the2016). Hoy are, labeled as an"illicit drug user"for being administered THC to observational,opinions,and some blood work to understand labs and address the severe dystonia and other juvenile parkinsonism levels when using cannabis. If your child is already taking cannabis, symptoms being observed. The treatment plans,testing,and they may not be eligible for the study. The recruiting for the study is plan of care was limited with services not available for many also skewed to present misinformation as it excludes children already July/August 2017 07 CANNA®1 SN UESESMAGA ZINE.COM on cannabis and is a perfect portal for parents and caregivers who failed cannabis because they did not understand, were afraid of the treatment,or were lost in a world where the physician cannot tell them what to do or how to proceed,because legally they cannot do so. It is easier to be a pharma-kid than a canna-kid in the world of state rights versus the federal prohibition. What is the status of cannabis use in hospitals in Colorado?That Medical all depends on the hospital,their policies,and who is enforcing the rules. Denver Children's Hospital has a policy that has to be signed by a parent/caregiver assuming all responsibility and liability in REFUGEES administering the cannabis product while in-patient. They are doing observational studies(Denver Children's Hospital,2016). Although Wednesday they are friendlier with CBD products,they do not prohibit THC and other useful cannabinoids. As another example,in Colorado Springs, Memorial Hospital has a policy that will allow only epilepsy patients • using CBD to use cannabis products as in patient. Each hospital is ;r a different and has their own policies which can change with little to no notice. 44 V, Is Colorado a great place?Yes! As a parent I can be paid to be my child's caregiver,even under the age of 18. This allows me the ability to tend to his medical needs,ongoing care,and to go to the school to administer his cannabis based medication when needed. We can grow _ ,�•# our own medicine with home grows allowed. There is still judge- e - ments and stigmas,however,there are many supportive communities within the state to help learn about cannabis and thrive here. There are adjustments to be made,but realities to know before making the - move to Colorado. It is a great place with access to a safe medication that someday will be mainstream and accepted. Today,cannabis is available and it is what each person makes of it for their own health and healing. Cannabis is a unique medication that has healed many, offered comfort to others,and created strange friends in the fight to educate others about its many uses and applications. NJ All JV w References tw_ MM CBS4.(2016). `Jack's Law': Medical Marijuana In Schools Bill Signed By Governor.Retrieved from Denver Post: http:H denver.cbslocal.com/2016/06/07/jacks-law-medical-marijuana-in- � - _ = 114 schools-bill-signed-by-governor/ CDPHE.(n.d.).Debilitating conditions for medical marijuana use . Retrieved from Colorado Department of Heath and Environment: https://www.colorado.gov/pacific/sites/default/files/MMR% 20Qualifying%20Medica1%20Conditions.pdf Colorado Legislature.(2016). House Bill 16-1373.Retrieved from Colorado House Bill: https:Hleg.colorado.gov/sites/default/files/ documents/2016a/bills/2016A_1373_signed.pdf Denver Children's Hospital.(2016). Research About Medical Marijuana.Retrieved from Children's Hospital of Colorado: https:// www.chi ldrenscolorado.org/pediatric-innovation/research/marij uana- research/ MEDICINA Wallace,A.(2017).After years of lobbying by veterans,Colorado adds PTSD as medical marijuana condition. Retrieved from The MARIJUANN Cannabist:http://www.thecannabist.co/2017/06/06/colorado-ptsd- medical-marij uana-veterans/80819/ Og July/August 2017 CANNA BISNURSESMAGAZINE.COM ba ance Experience Balance in the Body, Mind & Spirit Nurture your Endocannabinoid System; remedies and ingredients designed by Nature herself. Nature Nurse products are formulated by traditional healers, knowledgeable nurses, and science minded professionals to create a balanced approach to wellness; in the mind, body, and spirit. Learn more at NurseHealhomuNatureursrry,e Madeline Holt's story is one of hope, love, and community. Y r "I am doing what I have to do. Would you just give up if your kid was born with a terminal illness. You can't be okay with that." Meagan Holt(Mother of Maddie) By: Lisa Buchanan, RN Washington State Madeline Holt's story is one of hope,love,and community. Maddie was born in November of 2012 at 28 weeks gestation. She weighed 2lbs 3 ounces at birth and spent the fust 3 months of her life in the NICU. Her care team was proud of her continued improvement and development,congratulating her parents on their miracle baby.Maddie,now weighing 5 pounds,was Maddie receives her care at Seattle Children's Hospital. 077f her discharged from the hospital with formula,a prescription for care teams is the Craniofacial team. The team observed that Maddie omeprazole to treat her gastric reflux,and hope that despite her had some key facial features that were similar to her fathers. In premature birth and mild hearing loss,she would continue to addition,one of the fontanels in her skull was still 6 inches across,a progress and thrive with the love of her parents,Meagan and huge open head space. This led to a consultation with the Brandon Holt. Biochemical Genetics team during the summer of 2013.Biochemical Things weren't so easy for Maddie and her family after her genetics involves diagnosing and treating metabolic diseases.Blood discharge from the hospital.As the Holts began adjusting to their was drawn from Maddie and sent it off to Johns Hopkins Hospital life at home with Maddie they noticed that her hearing loss was for DNA sequencing and evaluation. The results came back on more severe than was initially thought. Maddie didn't respond October 30,2013,2 days before Maddie's first birthday. with a startle stimulus when a door slammed or when their small Maddie has Zellweger Syndrome,a terminal genetic disease that dog barked near her.They also noticed that she didn't visually destroys the white matter of the brain.It is the most severe form of a track items in the middle of her visual field.Maddie was bottle group of four related diseases called Peroxisome Biogenesis Disorders fed and still needed to eat every few hours.Her suckling rhythm (PBD).Peroxisomes are cell structures that break down toxic was unique,and not very efficient.Her mother had to finesse the substances and synthesize lipids(fatty acids.oils,and waxes)that are way that she bottle fed Maddie,attempting to get enough nutrition necessary for cell function.Peroxisomes are required for normal brain into her.When Maddie started projectile vomiting after small development and function and the formation of myelin,the whitish feeds,her family and care team decided that she would have a substance that coats nerve fibers.They are also required for normal gastric feeding tube placed to ensure adequate intake of nutrition eye,liver,kidney,and bone functions.Zellweger Spectrum Disorders and fluids.During these first few months at home,it seemed like result from dysfunctional lipid metabolism,including the over- a new symptom and/or diagnosis happened every couple of accumulation of very long-chain fatty acids and phytanic acid,and weeks,along with new consultations and many follow up defects of bile acids and plasmalogens--specialized lipids found in cell appointments. membranes and myelin sheaths of nerve fibers. Symptoms of these disorders include an enlarged liver;characteristic facial features such 10 July/August 2017 CANNABISNUASESMAGAZINE.COM as a high forehead,underdeveloped eyebrow Maddie had her first grand mal seizure Maddie started using Full Extract ridges,and wide-set eyes;and neurological in January of 2015. Prior to this Cannabis Oil(FECO)containing CBD abnormalities such as cognitive impairment and Maddie could sit,roll on a flat surface, under the care of Dr.Katrina Iiams- seizures.Infants with Zellweger Syndrome also knew 100 signs that she could Hauser,hoping for improvement in her lack muscle tone,sometimes to the point of being communicate with,and her only physical and mental comfort,and unable to move,and may not be able to suck or medical interventions were a feeding reporting her use and its effects to her care swallow.Some babies will be born with glaucoma, tube and omeprazole for gastric reflux. team at Hospice and Seattle Children's retinal degeneration,and impaired hearing. Daily seizures changed everything. Hospital.Refinement of her treatment Jaundice and gastrointestinal bleeding also may Maddie's team tried 26 different regimen included adding THC. Maddie occur.' Zellweger Syndrome is caused by a pharmaceutical medications trying to responded with increased expression of mutation in any one of 12 genes and is inherited in control her seizure activity and to keep emotion,increasing motor skills,and re- an autosomal recessive manner,which means both her comfortable.Her personality and leaming sign language. parents carry copies of the mutated gene. interaction with others was severely blunted by her medications,their side Community and Canna Family are effects,and ongoing grand mal seizure essential to Maddie's ongoing use of ;., activity. More medications equaled less cannabis.Insurance does not cover the Maddie.She was oxygen dependent, cost of cannabis products,even when very sensitive to narcotics,and required authorized by a medical professional. CPR numerous times at home and in the Donations of pesticide free and lab tested S � hospital. FECO come from medical growers, processors,and members of the medical April of 2015 was a difficult month for marijuana community in Washington the Holts and their care team at State.Maddie not only lived,but has •,, Children's Hospital. Brandon and thrived on her cannabis regimen. Two Meagan were told that the medical team years later at age 4,she is no longer on was out of options,having nothing left hospice,has stopped having grand mal for treating Maddie's disease and that it seizures,and continues to improve was time to make end of life plans,due physically and cognitively. She will to her medical fragility and impending always be a medically complex patient. death from seizures.Maddie was enrolled in Hospice,adopted DNR Cannabis did not cure her,but enables her status,and was prescribed morphine for to participate in life and decreases her her comfort. suffering. She is home schooled one day a A s week and her progress awes and inspires The Holts were not ready to accept this. her teachers,parents,and caregivers."We Meagan googled pediatric intractable watched her do everything she never was Historically a child's first birthday is a milestone epilepsy.Her search results included supposed to do"Meagan proudly states. event. Imagine discovering that your child has a Landon Riddle,projectCBD.org,and Maddie loves music and socializing.Her disease with no cure,no standardized treatment, HaleighsHope. She did more research, palliative care team has weaned her and that almost all affected with this genetic finding that cannabis had improved pharmaceutical use from a high of 26 condition do not survive past the first 6 months of quality of life for many children with drugs in April of 2015 to just 5 in addition life.Maddie had already outlived her life life threatening diseases,but Maddie to cannabis products. Her current expectancy upon diagnosis.The Holts were didn't fit in to any one group:deaf, medication list includes: devastated,but realized that they might not have a blind,deaf/blind,cancer,or epilepsy. lot of time with Maddie,and vowed to make each Seeing that there was no road map for hydrocortisone,Keppra,clonidine, day count. Maddie's care,Meagan and Brandon vitamin K,and a aquADEKS(a fat- decided they had nothing to lose soluble multivitamin),45mg of CBD&20 Z E L LW E G E R SYNDROME and everything to gain. They mg of THC twice daily in the form of pursued alternative care using FECO, 10 mg THCA twice daily,and as �'-1 The abnormally high levels of VLCFA(Very cannabis. They were fortunate to needed for stress,a 5 mg THCa isolate as long chain fatty acids ), are most diagnostic. live in Washington State,which needed for seizure rescue,among other There Is no cure for ZeINMer syndrome,nor is had a strong medical marijuana therapies. https://youtu.be/OrLyA- there a standard course of treatrnenc law at the time. NZpfY(9:30),as well as topical JMost rrmtmems arc symptomatic and applications to control symptoms caused supportive. by Zellweger syndrome. Maddie spent more than 200 days at Children's Hospital Mos[infants d4 not survne pas[the first 6 mand�s, in 2015,about 30 days in 2016,and a and usually succumb to res.piretory diacress, week in 2017 for treatment of Rhinovirus. gastrointestinal bleeding,or liver failure. July/August 2017 11 CAN NAB ISNUBSESM AGAZI NE.COM The Holts have always been open with their care teams about Maddie's use of cannabis for quality of life."I give her a plant.I NEVER have and never will hide Madeline's cannabis medicine from her providers because it is crucial to her care. I am completely open and honest about dosing,administration,cannabinoid content.Through positive engagement, by reminding her providers that I am a critical member of her care team they listen.Imagine being in their shoes. Imagine telling a family,it's time to start making end of life plans,we are out of options.Imagine that same child coming back to the hospital off of all those drugs you knew she would die on?Imagine watching cannabis save a life?I advocate for cannabis patients and the providers who are desperate for research.By educating my daughter's medical team, s< showing them cannabis works,they support us.They uplift us,and they accept cannabis as a part of her care even Maddie engaging with Pediatric Nurse luhlzie with mother,Meagan Holt. April 28,2017. when being admitted". Children's Hospital does not administer or provide Schools have the power to adopt cannabis policies for children who need it in Washington any cannabis products to Maddie,but State.However,no school currently has a policy for children to use cannabis at school. That does not obstruct the Holts from leaves special needs students like Maddie,who use medical marijuana in non-smokeable administering the cannabis products to forms throughout the day,without access to safe education. Meagan initiated legislation in Maddie while she is an inpatient. Holt 2017 to allow non-smokeable administration of medical marijuana on school grounds for also credits Children's Hospital for pediatric medical marijuana patients through her legislative representative. She testified at the helping her develop her advocacy skills hearing for House Bill 1060,also known as"Maddie's Law"and"Ducky's Bill",sharing and giving her a more powerful voice Maddie's life story with the committee members with the hope that the bill may allow through the supportive programs they Madeline to attend kindergarten.The bill remains in committee for the 2017-18 legislative offer to patients and families. session,meaning Maddie will be homeschooled for the next year. Meagan has been a strong and vocal What's next for the Holts? A long wished-for family trip to Disneyland,ongoing legislative advocate of families affected by rare and educational efforts to normalize and ensure safe access to cannabis for children at home diseases,patient rights,for cannabis and at school,and the publication of Meagan's poetry and journal entries,titled Just Breathe education,and safe access to cannabis. Baby. Meagan will be speaking at Hempfest in Seattle(August 18, 19,&20,2017). Maddie's She has worked with groups such as progress can be followed at Madelines Whole Plant Journey on Facebook. Hempfest,NORML Women of Washington,22 Too Many,and Project C e S PC. She publicly protested the profound changes made to the medical marijuana law in Washington State by House Bill Sources: 5052 in 2016(ironically titled The Patient Protection Act 2) 1. https://www.ninds.nih.gov/Disorders/All-Disorders/Zellweger-Syndrome- Information-Pag 2 http://gl3fox.com/2016/06/30/hundreds-of-medical-marijuana-stores-shut- down-with-new-rule-kicking-in July-1st/ Other Resources/Videos on Maddie: https://www.ninds.nih.gov/Disorders/All-Disorders/Zellweger-Syndrome-Information-Page https://youtu.be/OrLyA-NZpfY Meagan and Maddie.Cirque 2017 12 Jule/August 2017 CANNABISM;RSESMAGAZINE.COM NOT JUST A WATER COMPANYANYMORE, , s ALM-* LIVING WATER SAVE 10% °ouR FIRST ORFERENTER �, � COUPON :NURSE s at checkout LIVING WATER AMPLIFIEC 1 CBC ti - LII � SL ' r LiVING uFmMwW ON FREEZE LIVING SLEEP NIG til- 1 • G' L I V I'NG EL GEL CAPS RYALL OUR AWARD 4 VINNING PRODUCTS 800-940-3660 1 CBDLIVINGWATER.0 OM By: Jennie Stormes, RN, BSN, MSN Student • If r • "Jaxs" Update (Dravet's & Prevention) Continued from CNM May/June 2016 Issue(pg.14-15) Jackson Stormes,known as"Jaxs"has Dravet syndrome,a complicated and devastating form of epilepsy caused by a genetic mutation,SCN 1 a. In the past 18 years,Jackson has failed over 70 pharmaceutical combinations, 2 brain surgeries,multiple trials on the ketogenic diet,and the vagul nerve stimulator. In 2012,Jackson was started on cannabis:high CBD and THC ' in approximately 20:1 ratio and he thrived and did so well.He was weaned , from phenobarbital,klonopin,onfi,stiripentol,Depakote,and the ketogenic diet. Although there was a medical program in New Jersey,it was not up and running,nor would it prove to be functional for Jackson's medical needs. In 2014,Jackson and his family relocated to Colorado for better access to the life changing cannabis medication. The fycompa was the first new medication with devastating effects. His body contorted more and he lost more skills and Shortly after moving to Colorado,Jackson began to decline and the local abilities.He could not move or reposition himself and he was health professional did little to help because Jackson was on cannabis, locked in his rigid body. He still had the seizures with the Drave especially the THC. Despite the situation,I continued with the cannabis and and the Juvenile Parkinsonism,but now he had more seizures. made changes to address the new diagnosis of Juvenile Parkinonism, He was completely GT fed and was throwing up everything allmay,every day. The formula was healthy,organic,non-GMO, declining skills and abilities,and loss of progress gained with the cannabis vegetarian,and covered by Medicaid. He needed to stop the treatment. Jaxs went from a 20:1 CBD to THE to increase the THC to fycompa medication as it was not controlling the seizures,but lower the ratio to 3:1 CBD to THC. He was getting cannabis for making him worse overall. emergencies,seizure clusters,or times of illness to bridge the lowering seizure threshold. Cannabis was the safest option for Jackson,after all,he had failed 98%of the known pharmaceuticals used to treat seizures or Since the cannabis was not controlling the seizures and now Dravet,and even tried some long shot options without success. the emesis was problematic, he was losing weight and now considered a failure to thrive barely holding his weight at 100 Last summer,a few additional pharmaceutical options were attempted with pounds. Jackson was retried on felbatol. All of the side effects one new drug and retrying another drug from the past he had failed,in continued with the emesis,failure to thrive, increased seizures, addition to the cannabis treatment.The pharmaceuticals were not expected and worsening of the dystonia and Parkinsonism. Jackson to help much with Dravet,but worth a try and came with many known ended up in the hospital where they stopped the felbatol with serious side effects,but the cannabis was not working well to control the no plan. They had no plan because Jackson was on cannabis seizures. Jaxs was declining and few noticed or cared. Jackson's seizures and had already failed all the other drugs, Some of the meds, were getting worse with longer seizures occurring more frequently. He like the Felbatol, have been tried more than twice. The could not walk without support,he lost almost all of his speech(had over neurologist sent him home from Denver Children's Hospital 200 words counted in 2013),could no longer assist in any capacity with his without a replacement pharmaceutical, refused to increase the activities of daily living,no longer able to feed himself,and he just stopped very low dose of the other pharmaceuticals he was on,because eating with these new drugs. of the cannabis medications. Jackson's seizure got even worse. 14 July/August 2017 CA NN A B I SNURSESM AGAZINE.COM N E Finally,he had endure enough distress with the emesis and all formula was stopped. A blend of real food prepared by mom consisting of spinach, beef,garlic,and almond milk. He stopped throwing up. A few weeks later,he began to want to eat by mouth. Without the help of doctors,other than adjusting the pharmaceu-ticals,we were figuring out what was going on and healing Jackson. RARE&CATASTROPHIC EPILEPSY It was decided Jackson would enter the fenflurmine drug trial. For this SEIZURES 11 11,100 medication he would need to be cannabis free. This new adult REGRESSION Epileptologist was willing to adjust medications and to safely take him BEHAVIORAL AND DEVELOPMENT DELAYS off of cannabis in a controlled environment. We were not afraid of the oSPEECH ISSUESMW&ITI&M cannabis, but more afraid of the seizures. The cannabis was stopped WHAT IS DRAVET SYNDROME? over 2 days and there were no seizures. The seizure medications were C 113 � Nincreased to maintain seizure control, but not any benzodiazepines, • �O CURESENSORY narcotics, or other dangerous drugs he had been weaned from with o DIMINISHED QUALITY OF LIFE DISORDER cannabis in 2012. REDUCED LIFE EXPECTANCY ATAXIA BAIX MES �may+ With the cannabis break, the oversaturated cannabis receptors could rest =SING O�FICUITIES WILL NOT OUTGROW and some of the skills which were lost over the past 3 years since moving to Colorado were coming back. Taking a break and carefully selecting an appropriate treatment plan to control the seizures has allowed for Jackson to begin eating better,gaining 20 pounds. He started walking everywhere, with transitions, transfers, and balance. Things are being placed in the microwave, sink,or other hiding places with glee. His smile is bright and he pushes himself to re-learn what he lost. Why is this Important?Cannabis is a medication and was responsible for healing Jackson when he needed it, however as expected, his needs are changing constantly. While he is better off at this time without cannabis in We discussed stopping cannabis,but he was not on any his regimen I will be keenly obsering for any changes that clue me in that significant dose of a seizure drug and stopping cannabis he needs a change in his treatment at which time I would again start the would be dangerous and life-threatening. I was told by the process of determining what ratios would benefit him. What we have neurologist during an outpatient visit,the"I got him on learned and will discover with time, is that cannabis can be complicated cannabis,I could get him off of it." Without prescriptive and can be confusing,especially in complex children.The Parkinsonism is authority I cannot adjust or change his pharmaceuticals and regressing. What cannabinoids were messing with the dopamine levels without their help,I cannot change the cannabis. He and/or receptors causing dystonia, tremors, shuffled gait, and other continued with daily seizures,emesis,weight loss,and neuromuscular concerns? Even though cannabis, or CBD, is not toxic or failure to thrive. deadly,at what dose does CBD stop helping and make symptoms worse or more difficult?In Jackson's case,it appears that higher amount of CBD for he acceptability of cannabis,especially THC for children, prolonges periods of time made his symptoms worse. In patients who are y some physicians is a game of smoke and mirrors. At the non-verbal, dosing can be more difficult with finding the sweet spot, nd of 2016 we found a great adult Epileptologist to assume correct strain,or appropriate ratio. ackson's care,includingthe cannabis use as a seizure reatment. Jaxs was a hot mess with the seizures so out of ontrol,he was close to suffering a deadly seizure. With the Because research is limited on cannabis in America, it is still unknown elp of this Epileptologist,his pharmaceuticals were why a cannabis break is important for chronic, debilitating, and ncreased and a new one was added: Briviact,a relative drug devastating disorders. It is known that cannabis breaks do allow for the o Keppra,but without the side-effects of rage and Endocannabinoid System to reset itself,but it is unclear why this break is ehaviors. The seizure activity went from 1 subclinical so important for chronically ill persons. Although it is consistent with eizure every minute with multiple 3-5 minute seizures daily Dravet to be pharmaco-resistant, when medicaitons sotp working after a one per week with no subclinical seizures. He was short period of time, cannabis was not as sensitive. It took 4 years before tabilizing and getting better with this adjustment in the anti- a break was needed and changes necessary. What is clear?We need to be eizure medications.Jackson was still completely tube fed able to do research and understand cannabis as a medication,applications, nd the specialists wanted to give him a permanent j-tube to pharmaceutics,and more. ddress the still constant emesis. July/August 2017 15 CAN\A BIS\UR SE SM AGA ZINE.COM Medical Cannabis in Schools: Integrating the New Norm ' with "Jack's Law" r Colorado's Medical Marijuana Program and Children As Colorado continues to implement Amendment 20,the legal ramifications continue to unfold. Since Cannabis is still a Schedule 1 substance,making it federally illegal,patients face considerable risk following the path of cannabis treatment.Even in Colorado,laws and By: Stacey Linn (Mother of Jack Splitt) rules of governance have not caught up with legalization of medical cannabis,and the stigma of using a"controlled substance"haunts parents Colorado's medical cannabis program began with the passage at the doctor's office,school,hospitals,long-term care facilities and in the of Amendment 20 in 20001. Cannabis was legalized to treat a Child Welfare System. Patients,and especially parents of pediatric specific list of medical conditions,as designated in patients,face serious risk of persecution.Doctors,school personnel and Amendment 20,with the Colorado Department of Health and social workers are still quick to report even legal cannabis use to child Environment(CDPHE)having authority to add conditions. protective services(CPS).Unfortunately,the resulting investigation These conditions currently include:Cancer,Glaucoma,HIV whether substantiated or not,causes significant harm to families who are or AIDS,Cachexia,Persistent Muscle Spasms,Seizures, already living under duress. Severe Nausea,Severe Pain,and Post Traumatic Stress Despite the scientific evidence that cannabis effectively treats a myriad of Disorder(PTSD)I. Since then,thousands of families have conditions such as epilepsy and cancer,there is considerable work to be relocated to Colorado to treat themselves and/or their loved done in order to bring cannabis treatment into the mainstream,both ones after pharmaceutical options failed them.Among these socially and legally. The key to propelling change is education. In our patients are children who suffer from life-threatening medical paradigm,Nurses are best positioned to lead this change.Nurses disorders/diseases such as epilepsy,cancer,cerebral palsy,and are on the front line with both patients and doctors(both traditional and other genetic disorders that cause neurologic and muscular those who recommend marijuana)so they must be equipped to deliver symptoms,as well as extreme pain.Cannabis provides them knowledge on the Endocannabinoid System(eCS),treatment delivery relief of symptoms,healing from their ailment,and a path to options,and the laws/rules governing the use of cannabis. Nurses can their highest possibility of health. To many families,this lead both doctors and patients into a new health paradigm that includes healing plant has been nothing short of a miracle. the natural,holistic benefits of the cannabis plant. 16 July/August 2017 CANNAB ISNURSESMAGAZINE.CO M Children and Medical Cannabis: One of the most vulnerable populations currently using medical resources,education,and financial support;American Medical marijuana are children—not only medically,but socially.As of Refugees specializes in community support and resources;and April 2017,there are 292 children on the Colorado Medical Cannabis Patients Alliance 12 unites patients and provides advocacy and information about cannabis and cannabis policy. Marijuana Medical Registry age 0-17,and 2,812 age 18-203. patients and their families need Cannabis Nurses to help them Many of these children are medical refugees whose families left work with their cannabis doctors to find the most effective everything in their home state to try cannabis as a desperate,last course of treatment,and counsel them on how to work with ditch effort to save their child's life.Many families move here traditional doctors to incorporate cannabis into their often quickly,without resources or support,and without any knowledge extremely complex treatment regime.Families access cannabis of Colorado's marijuana laws,medical or school systems,or what medicine through dispensaries or caregivers. cannabis treatment even looks like.These families are very vulnerable to begin with due to the nature of their child's So what do children do when they get healthy? condition and often struggle to survive. They go to school! Many children have medical issues that require medication in order to successfully engage in their Fortunately,once a parent discerns the proper course of education. Children commonly take pharmaceutical medication treatment,cannabis begins to heal their child,bringing hope and at school without issue—even controlled substances such as vitality back to the child and the family. However,without the narcotics and amphetamines(Ritalin,fentanyl patches,etc). proper support and education,some families do not even reach this point.That's where cannabis-specific foundations,support groups,nurses and doctors come in. There are several organizations in Colorado which patients and their families can join to help them learn to navigate their medical marijuana path. r For example,CannAbility Foundation" BL11% S provides advocacy, q` The procedure for having a Nurse administer Photo source:Herb.co/Thefreethoughtproject.com medication to a child at school is simple: The PDN administered all of his medications,including his Submit a doctor's note stating the necessity,dosage and time of cannabis. I did not know that marijuana was prohibited at administration.A nurse or nurse's aide administers the school and assumed it was okay because he had a medical medication in the school clinic.However,because marijuana is marijuana card and his cannabis medication was reported on still a Schedule I federally illegal substance,schools do not his school health plan. I treated his cannabis like any other allow it on campus,much less allow nurses to administer it. In medication he was taking. However,the school's district area addition,most schools are considered"Drug Free Zones"under nurse did not. Federal regulation. Tragically,pediatric medical marijuana patients who have finally achieved a level of health that allows The day the school's district area nurse noticed the transdermal them to thrive and engage in their education,are barred from cannabis patch on Jack's arm,she questioned his PDN about it. attending school. Seeing nothing wrong,the PDN fully disclosed what the patch was.The school nurse immediately informed the PDN that it Jack's Law: was not allowed,took the patch off his arm,confiscated his Accessing Medical Cannabis in Schools THC/CBD oils,and told him he had to go home.The PDN I experienced the school barrier in the February of 2015 called me at work and reported what happened. I was so after I began treating my son,Jack Splitt,with cannabis to outraged that a medical professional would take a child's treat his severe spastic quadriplegic cerebral palsy medication off his body that I called the local news. They complicated by severe and debilitating dystonia. Jack immediately met me at the school and interviewed us.The went to school with a private duty nurse(PDN)because story aired on Denver's CBS Channel 7 news that evening°. he was on life support,wheelchair bound,deaf,non- The school principal agreed to return the cannabis medication but asked that Jack not return to school with it. verbal and fully dependent on others for all Activites of Daily Living(ADL's). July/August 2017 17 CANNA BISN UASESMAGA ZINE.COM A few days after the news story aired,I was contacted by He changed the hearts and minds of the legislators that Representative Jonathan Singer's office and Greg Duran from day.The Caregivers Act passed and so did the the patient advocacy group,Cannabis Patients Alliance12.They amendment,which was named"Jack's Amendment"in invited me to the Capitol to see what could be done to address Jack's honor. Governor John Hickenlooper signed it into the issue. While we discussed legislative solutions, law in May of 2015(see below)with Jack sitting across Representative Singer said to me,"Well,if you're willing to from him.The Governor shook his hand and gave him the stick your neck out,so will I." Being new to the world of pen he signed the bill with.The legislators presented him cannabis,and assuming it was safe and legally protected,I did with a certificate,a Colorado flag and t-shirt signed by not understand why he said that.I would later fmd out that all is everyone at the Capitol to honor his work. not necessarily safe for the parent of a medical marijuana patient. Working with other legislators and the Cannabis Patients Alliance,Representative Singer proposed an amendment to another marijuana bill they were working on,the Caregivers Act which created definitions to regulate"caregivers"who help patients who cannot grow/make their own medicine or access it in a dispensary5.The amendment would allow medical marijuana on school grounds6.Jack created quite a stir when he testified in support of the amendment(he's non-verbal,so I interpreted for him). It was impossible for legislators to deny him access to his passion:Leaming. Unfortunately,schools refused to honor the law,stating that they and that it be administered by a parent or caregiver who is feared losing their federal funding for allowing an illegal approved by the school. In addition,the bill included language substance on campus.Representative Singer and I sat down that prohibited school nurses,and other school personnel from again in 2016 to craft legislation to require schools to make administering the medication(which was included to quahn policy allowing children to take their cannabis medication on fears of violating the Colorado Nurse Practice Act-an area that school grounds.Senators Chris Holbert and Vicki Marble nurses can focus on in the future). sponsored the bill in the Senate.We proposed the legislation CannAbility Foundation,(a non-profit organization I founded based on the federal IDEA law(Individuals with Disabilities in Jack's honor that seeks to provide advocacy,education, Education Act)that states with disabled children are entitled to resources to parents of medically fragile children who want to necessary accommodations to treat their condition in order to treat their children with medical marijuana)launched a large receive the Fair and Appropriate Education(FAPE)that every grass roots campaign to garner support for the bill,which child is also entitled to under federal law?. The original bill, included courageous mothers of severely disabled young HB 16-1373,included language that would reimburse schools medical marijuana patients.Together with a new marijuana with money from marijuana taxes for any federal funding they lobbyist who worked for us pro-bono because of how cannabis helped her terminally ill father,we educated legislators,the were denied,but was quickly met with resistance and was community,and numerous stakeholders(including police, amended to say that schools could opt out of the policy if they school boards,the Department of Education,hospitals,and could prove that they lost federal money as a result of a child anti-marijuana groups)about what medical marijuana is,how it using medical marijuana at their school$. The bill required safely administered,and the remarkable healing experienced by schools to allow medical marijuana use, in a non-smokable the severely afflicted children who use it.We were met with form,on school grounds,at school functions and on school both overwhelming support,and hysterical opposition. We heard statements like,"I don't want kids smoking weed in the buses,by students who have a Colorado Medical halls and bringing pot brownies to school in their lunch boxes." Marijuana card. It also requires that the medication be By educating people about these common misconceptions,we given in a private location,away from other students, were able to turn the tide.HB 16-1373 overwhelmingly passed Ig July/August 2017 CA N NABI SN UB SESMAGA ZINE.COM the House by a vote of 56-9. In the Senate,the bill passed committee She reported being able to titrate her son off many of the unanimously with a historic"standing vote"where each committee destructive,side-effect inducing pharmaceutical medications he member stands to cast their vote to honor the people bringing forth a was on,a substantial decrease in his pain and dystonia,and a bill of monumental importance to the state of Colorado.The bill then marked increase in his daily functioning and quality of life. unanimously passed the full Senate,35-0.The bill was amended to be named"Jack's Law",to honor the courageous and charismatic Jack Dosing Splitt who,despite the debilitating and painful symptoms of his After obtaining a medical marijuana card through the Colorado disease,spent hours at the state Capitol changing the hearts and Department of Public Health and Environment(CDPHE) minds of the legislature and the people of Colorado.To this day, Medical Marijuana Registry,I began treating Jack with an oil legislators thank him for changing the spirit of marijuana legislation. extract made from a 20:1 (CBD:THC)strain.The recommending physician gave parameters to start dosing this high CBD strain at 0.5mg/Kg of body weight.I administered the oil via his g-tube twice daily.Remarkably,I saw a decrease in his anxiety, spasticity and dystonia within an hour. I consulted with Jack's neurologist about titrating him off the pharmaceutical medication ' he was on—a daunting process since those medications are extremely addictive.A few months later I learned that CBN has muscle relaxing properties so tried using CBN transdermal patches applied to his wrist.Again,I saw more relief of his r severe muscle spasms.As I titrated more of the pharmaceuticals, it seemed Jack needed more cannabis.His doctor recommend adding THC to his regimen,so I changed his oil to a 15:1 strain and noticed yet more alleviation of his dystonia and pain.As his disease progressed and we experimented with strains and THC levels,we found the best course of treatment for Jack was a high Stacey Linn and lack Splitt during Colorado Legislation.Cirque 2015 THC oil administered via rectal suppository 3 times daily,and a The first school district to write a policy implementing Jack's Law CBN patch every 12 hours for maintenance dosing.In addition,he used a high THC tincture and/or CBN tincture under his was D49(Falcon)near Colorado Springs.Douglas County quickly tongue as needed for breakthrough episodes of dystonia.Thanks followed suit,adding protection for children taking CBD(hemp falls to Jack's Law,Jack's private duty nurse was able to administer under different laws than marijuana).And Jefferson County,where his maintenance and rescue doses at school(that made Jack Jack went to school wrote a policy soon after that. Each of those laugh).Tragically,a few weeks after the start of the 2016 school policies was influenced by a tenacious mother of a child taking year,Jack Splitt succumbed to his disease.The Denver Post medical marijuana at a school in their district—who also helped released a front page,four page story about Jack and the passage worked to pass Jack's Law. of Jack's Law on August 23rd,2016.(9)Jack was so proud and told me he felt blessed to be able to help other children like him. Jack Splitt's Story Having accomplished what he set out to do,he passed away the When pharmaceutical options failed,I began treating my then 14 next morning.With his stunning smile and sparkling blue eyes, year old son,Jack Splitt,with medical cannabis in July of 2014 to his wit and his genuine charm,Jack Splitt changed hearts and relieve the symptoms of his severe spastic quadriplegic cerebral minds all over the world,forever changing the face of medical palsy complicated severe dystonia. This was not an easy cannabis. He will be remembered for his magical smile,his decision as I knew nothing about marijuana and Jack was already contagious sense of humor,and his unwavering perseverance in on 30 or more medications—including benzodiazepines,anti- the face of extreme hardship. epileptics,antidepressants and anti-psychotics(though he did not have seizures,psychosis or depression).These medications left my intelligent,engaging,life-loving child feeling like a "zombie"(Jack's words)and unable to engage in learning and lack Splitt socializing—his favorite things in life.I was afraid to add or pioneered the subtract medications from his treatment plan because,like most way to allow medically fragile children,he was sensitive to changes and children to take interactions.Plus,if cannabis did not work,Jack would have their medicine on been in danger of dying from complications of his condition. He school grounds in was on life support(ventilator/tracheostomy,feeding tube)so Colorado. sustaining life was tenuous already.It took another mother of a Cirque 2016 child with the same diseases reporting success before I would take the plunge. She had treated her son's seizures with marijuana and noticed the symptoms of his dystonia(severe and constant full body muscle contractions)declining. July/August 2017 19 CANNA B I SN URSESMA GAZI NE.COM Where Are We Now? Child Welfare System- CPS Though several school districts in Colorado have written a medical Perhaps the most important place to change the current paradigm marijuana policy,many have not.Some have not done so only is in the child welfare system.Under current laws,any exposure to because they have no children in their district who use medical marijuana can be considered to be child abuse.Exposure can be as marijuana.A few,such as Denver,are refusing.CannAbility is simple as a child being in the presence of a family member's currently working with legislators and policy makers to bring them medical marijuana.Parents who treat their children with medical into compliance.Another issue is the inability of school nurses to marijuana are in the spotlight and are in danger of investigation. administer cannabis medication.This is where more work needs to be Any investigation by Child Protective Services(CPS)causes done in changing legislation. It is cumbersome for parents to get to trauma to the entire family—whether there is a finding of abuse or school to administer medication—and makes rescue dosing almost not. In addition,parents who use medical marijuana themselves impossible in a timely manner.In Colorado,nurses can help by are subject to scrutiny specially pregnant or nursing mothers. , pushing to change the Nurse Practice Act to explicitly allow nurses to Most hospitals test newborns and their mothers for THC and administer cannabis medication.At the federal level,we must all take report positive findings to CPS,which leads to an investigation. action to completely legalize cannabis and get it off Schedule 1 and Investigations often lead to removal of the infant from the mother, decriminalize this simple plant. and at the very least,trauma to the family. Due to lack of education,a gap between child welfare policy and medical Schools marijuana laws,and the prohibitionist stigma attached to marijuana use,many families are unnecessarily persecuted. Jack's Law opened the door to discuss pediatric medical marijuana and Jack's Law not only made it possible for children who depend on brought marijuana into schools.We medical marijuana in order to survive and thrive to go to school,it now have a unique opportunity to QNO— forged a new pathway for disseminating the truth about marijuana. create education programs to teach �'` ® It is crucial that we build on this momentum and continue to parents,school children and school r educate institutions on the health benefits of medical marijuana. personnel about marijuana—both the Jack wouldn't have it any other way.Thanks Jack! medical benefits,and how to prevent children who are not patients R! from using marijuana. In addition,in the 2017 legislative session,a Sources bill was passed which created the Jack Splitt Memorial Marijuana Education Database10•13.This database will be used by schools to teach not only youth prevention,but to educate people about what 1.Amendment 20,http://www.nationalfamilies.org/guide/colorado20-full.htm] medical marijuana is. Education is the key to changing the laws and the social paradigm surrounding marijuana,so it is appropriate to 2.Qualifying medical conditions,Medical Marijuana Registry, start that education in schools. w'ww.colorado.gov/pacific/cdphe/qualifying-medical-conditions-medical- marijuana-registry,2017. 3.CDPHE,Medical Marijuana Database,employee interview,6/14/2017. Hospitals --.a 4 http://www.thedenverchannel.com/news/local-news/marijuana/disabled jeffco- School is not the onlylace that needed p 11 students-cannabis-medication-confiscated-school-cites-federal-law a policy change.Children taking '1 medical marijuana generally see 5.SB 15-014,Caregivers Act,http://lcg.colorado.gov/bills/sbl5-014. several traditional doctors to manage 6 Jack's Amendment,to SB 15-014 http://www.leg.state.co.us/Clics/Clics20l5A/ their conditions,and they end up commsumm.nsf/ spending a lot of time admitted to b4a3962433b52fa787256e5f0067Oa7l/1210d349c232474c87257e34006bafff/ hospitals as a result of their conditions. WILE/150427%2OAtmchD.pdf Some traditional doctors refuse to work with pediatric patients who 7.IDEA https:Hsites.ed.gov/idea;FAPE https://www2.ed.gov/about/offices/fist/ report using medical marijuana,and some become suspicious or give ocr/docs/edlite-FAPE504.html false information about medical marijuana.These practices interfere 8.HB 16-1373,Jack's Law,http:/Aeg.colorado.gov/billsfhbl6-1373. with effective treatment of often complex medical conditions.Very 9 http://www.denverpost.com/2016/08/22/schools-medical-marijuana jacks-law/ few hospitals allow the administration of marijuana while a patient is admitted so children are forced to stop the marijuana treatment that IO.SB-17-025,Marijuana Education Materials Resource Bank,http:// is necessary for them to heal,and in fact many of their symptoms leg.colorado.gov/bills/sb 17-025,2017 worsen while hospitalized. The same holds true for rehabilitation 1 I.http://mww.cannabilityfoundation.org centers and long term care facilities,as well as group homes for disabled children.Providing marijuana education is crucial to 12.https://cannabispatientsalliance.org upholding patient rights and changing the medical establishment's 13.https:Hlocaltownpoll.com/issue/58f94c3b4Ocf46Od7bc49cd2 view on marijuana.Since nurses are an integral part of this establishment,they play a key role in educating and developing new 14.http://www.druglibrary.org/SCHAFFER/hemp/medical/can-babies.htm policy. July/August 2017 20 CANNA BISNUASESMA GA ZINE.COM VAPES , FOR LIVING . CBD NO 1 i a3 250MG �O BUBBLE PG/VG 25DMG NO GV�„� C8D o�s� PG/VG 250MG NO TgIVGI PG/VG cu aLIVING j I=NATURAL FULL SPECTRUM loon NATURAL ORBANIC CBO OIL 100%NATURAL FULL SPECTRUM 500MG FULL SPECTRUM ORGANIC CBO OIL ORGANIC CBO OIL 500MG `°�°��"�` 57EXTRACTED c02 BXTRACTEO BIL -FutAENwRi ' CO2 raumaO[PRvu .TRWU w TEST9 -015w SGsI/CAgTfmoft -FUL TRIPLE LAB TESTE➢ ors�sn81E cnwrwror,E 'DISPOSABLE CARTRIDGE l I SAVE 1 O% OFF YOUR FIRST ORFER Eo PoR:NURSE at checkout NOW 11 AVAILABLE 800-940-3660 7 e _ �i► � 11 i' ': � ^, _ � _; 11 lit i 4 �yy_ ' �I�" '' i�a+i a�+r.► �'�`s�� - ,. ��� ��i�' �•Ii � !i Y' I' i • M'T �� "'E�' Y 1S� M` �-�lit �f � - 71. t t` - � •- Sim Since cannabis is classified by the federal government as an - illegal substance,clinical trials in humans have been largely Bonni Goldstein,MD is prohibited. However thanks to curious and diligent scientists, the Medical Director of we have an advanced understanding of how cannabis works Canna-Centers,a as medicine. Plant compounds, called phytocannabinoids, Califomia-based medical work by interacting with a complex system in the brain and practice devoted to body called the Endocannabinoid System (ECS), a signaling educating patients about system responsible for maintaining balance of the chemical the use of cannabis for messages sent between cells. We humans make compounds serious and chronic called endocannabinoids,"cannabis-like"molecules that are medical conditions. After similar to the plant cannabinoids;endocannabinoids work to years of working in the maintain homeostasis,balance of our cells. If you have an specialty of Pediatric imbalance in these compounds,disease may result. We have Emergency medicine,she only known about this system since 1988,but recent research developed an interest in the has allowed us to understand it is critical in the manifestation science of medical of disorders previously not been well understood or cannabis after witnessing effectively treated. its beneficial effects in an ill friend. Since then she has evaluated thousands of patients for use of medical There is a growing body of evidence that children with cannabis. She has a special interest in treating children epilepsy,autism,and other severe conditions have a with intractable epilepsy,autism,and advanced cancers,as dysfunction within their ECS.When not working properly, well as adults with chronic pain,autoimmune illnesses and the chemical messages in the brain are not balanced,and this other endocannabinoid deficiency disorders. Dr. Goldstein imbalance is expressed as seizures,abnormal behaviors,and recently authored the book Cannabis Revealed:How the overall poor quality of life. worlds most misunderstood plant is treating everything from chronic pain to epilepsy. I am often asked why I recommend cannabis to children when THC is thought to be bad for the developing brain. Research I have been a pediatrician for 25 years and a medical cannabis shows that a normal functioning Endocannabinoid System is specialist for the last nine years,assisting thousands of adults required for the maturation of the developing brain. and children with serious medical conditions in using cannabis Adolescence is a time when the developing brain is treatment. I have evaluated hundreds of children with severe vulnerable. Interference in the normal brain growth that leads epilepsy,autism,and cancer, and have seen many obtain an to a healthy adult brain might alter brain maturation. incredible improvement in their quality of life with cannabis medicine. Studies looking at otherwise healthy teenagers who use In medical school, I was taught that cannabis was a drug of chronic heavy doses of THC has shown that there is may be abuse. I never thought of it as medicine until I saw a friend increased problems with executive function, impulsivity,memory ,deficits,attention deficits,and lower overall and with a serious illness have incredible benefits from it. I started verbal IQ. researching the scientific literature and was shocked to find that cannabis had so many medicinal properties. 22 July/August 2017 CANNABI SNURSESMA GA 21N E.CO M There are other variables involved in assessing these epilepsy. Since CBD does not activate the cannabinoid attributes,but the bottom line is that in a child or adolescent receptor the way THC does,it does not cause tolerance, who is medically well,THC should be avoided so that the ECS can do its thing-- function without interference and and as it is not psychoactive, it is an ideal compound for Pediatric patients. lead to the desired end result: a healthy and mature adult brain. Case Study What about children that are not medically well? Since we One of my patients,a little girl with complex medical are lacking critical studies,we don't necessarily know long- issues including intractable seizures,came to my office at term effects. But we know that phytocannabinoids,such as 9 Years of age with significant delayed cognitive development, due to both her uncontrolled seizures and a THC(tetrahydrocannabinol)and CBD(cannabidiol),have cocktail of anticonvulsant medications. After two years tremendous medicinal value with anticonvulsant, antioxidant,antianxiety, antipsychotic,anti-inflammatory, on CBD oil and discontinuation of the pharmaceuticals, and antitumoral properties. It is important to note there are she had significant reduction of seizures. Most no long-term studies of cannabis use in seriously ill remarkably,she had learned to read and write during this children,but those of us who are treating children with time,skills her parents never thought she would achieve. cannabis medicine are not witnessing any negative long This example clearly shows that the brain can heal and term effects. In fact,we are seeing children who previously develop in children on cannabis medicine. had very poor prognoses with uncontrolled seizures, developmental delay and cognitive dysfunction now Cannabis for Pediatric Autism progressing developmentally instead of regressing. Many Many parents also come to my office seeking help for are able to stop using toxic medications that may have not their children suffering with Autism. Although the FDA been effective. We cannot compare the healthy teenagers has approved two medications,both antipsychotics,for that are chronic heavy users of imbalanced THC-rich treating the irritability associated with autism,they have cannabis-behavior that may result in interference of very significant side effects,may not be effective and thus normal development-with severely ill children using leave these families without a solution. cannabis that may repair the dysfunctional ECS. Children suffering severe disease and not responding to conventional Preliminary evidence links treatment and/or experiencing intolerable side effects should have an option to use cannabis medicine, as the genetic mutations with Autism underlying cause may be within the ECS. and a deficit in the ECS The Endocannabinoid System regulates emotional responses, Cannabis for Pediatric Epilepsy including anxiety, behavioral reactivity to context,social I have found excellent results using cannabis medicine for interaction,and the function of the immune system,all of children who have intractable epilepsy. These patients have which are aspects of autism. I have medically supervised the tried numerous antiepileptic medications without success and administration of CBD-rich,THC-rich,combination have devastating consequences ofongoing seizures.The CBD+THC and/or THCA cannabis preparations in dozens of burden ofthis difficult disorder and subsequent negative children with Autism. Many parents report improvement in impact on quality oflife has triggered a parent-led movement their children, seeing less anxiety,better sleep, improved advocating use ofCBD-rich cannabis. Research shows that speech,better focus and learning,and fewer tantrums. people with epilepsy may have an endocannabinoid deficiency,leading to over excitation ofneurotransmittersin Cannabis for Pediatric Cancer the brain,leading to abnormal firing ofthe brain cells. Parents of children with cancer often seek cannabis medicine Evidence also points to significant neuroinflammation. to help their children with relief of symptoms from the adverse Although more research is needed,we know that CBD side effects of chemotherapy and radiation. In some cases, enhances the brain's own endocannabinoid levels,enhancing having been told the cancer treatment is not working,parents the endocannabinoid system.Also CBD modulates the flow of are desperate to find a cure- calcium and potassium in neurons,thereby stabilizing these cells.Additionally CBD works as an anti-inflammatory, blocking formation ofpro-inflammatory compounds and reducing toxic substances,resulting in a brain that is less inflamed. CBD,with its many mechanisms ofaction,acts at multiple targets in the brain.This is why it works well for +' July/August 2017 23 CANNABISNUBSESM AGAZI NE.COM Cannabinoids have been shown in animal studies to inhibit tumor growth,cause cancer cells to commit Sources: suicide(apoptosis),inhibit metastasis and inhibit growth of new blood vessels in tumors. Additionally Eoilepsv cannabinoids have also been shown to enhance effects Hampson AJ,Grimaldi M,Axelrod J,and Wink D(1998)Cannabidiol and of certain chemotherapeutic agents. There is only one (-)delta9-tetrahydrocannabinol are neuroprotective antioxidants.Proc Nat]Acad Sci USA 95:8268-8273(CBD reduces glutamate and has antioxidant effects) published study in humans that used THC in nine — patients with glioblastoma multiforme,an aggressive Vezzani A.Inflammation and epilepsy.Epilepsy Curr.2005 Jan-Feb;5(l):1-6. brain tumor. The study concluded that THC was safe Lozovaya N,Min R Tsintsadze V,Bumashev N.Dual modulation of CNS and it inhibited cancer cell growth. Recently a second Voltage-gated calcium channels by cannabinoids:Focus on CBI receptor- independent effects.Cell Calcium.2009 Sep;46(3):154-62 trial reported by GW Pharmaceuticals showed a longer survival rate for subjects on THC and CBD compared to Izzo AA,Borrelli F,Capasso R,Di Marzo V,Mechoulam R.Non-psychotropic placebo. Despite these promising results,we are plant cannabinoids:new therapeutic opportunities from an ancient herb.Trends lacking critical human research that answers the Pharmacol Sci.2009 Oct;30(10):515-27. questions of which specific cancers respond to cannabis, De Petrocellis L,Ligresti A,Monello AS,Allara M,Bisogno T,Petrosino S,Stott which cannabinoids to use,what dose to use and what CG,Di Marzo V.Effects of cannabinoids and cannabinoid-enriched Cannabis duration of treatment is needed to achieve survivorship. extracts on TRP channels and endocannabinoid metabolic enzymes.Br J Pharmacol.2011 Aug;163(7):1479-94. The parents of my patients with cancer are convinced Mechoulam R.Plant cannabinoids:a neglected pharmacological treasure trove.Br that the addition of cannabis to the child's regimen has J Pharmacol.2005 December; 146(7):913-915. helped them to achieve improved quality of life and in Autism some cases,reduction of disease. Some patients come Krueger,Dilja D.,and Nils Brose."Evidence for a common endocannabinoid- to me too late in their course,but they often have relief related pathomechanism in autism spectrum disorders."Neuron 78.3(2013): from symptoms and a decent quality of life before they 408-410. pass. Chakrabarti,Bhismadev,et al."Endocannabinoid Signaling in Autism." Neurotherapeutics 12.4(2015):837-847. Cannabis Products for Pediatric Patients Cancer There are a number of criteria that I require for the Zogopoulos,Panagiotis,et al."The antitumor action of cannabinoids on glioma tumorigenesis."Histology&Histopathology 30(2015). cannabis products used by my pediatric patients Guzman,M.,et al."A pilot clinical study of A9-tetrahydrocannabinol in patients with recurrent glioblastoma multiforme."British journal of cancer 95.2(2006): 1. Most are using cannabis in an oil preparation, 197-203. easily measurable and taken sublingually or ingested. https://www.gwpharm.com/about-us/news/gw-pharmaceuticals-achieves-positive- The oil should be concentrated. The more concentrated results-phase-2-proof-concept-study-glioma the oil,the smaller the volume that needs to be taken; Miyato,Hideyo,et al."Pharmacological synergism between cannabinoids and this is easier to give to an uncooperative child. paclitaxel in gastric cancer cell lines."Journal of Surgical Research 155.1 (2009):2. Consistency of strain is extremely important as 4047. epilepsy patients may only respond to one particular Nabissi,Massimo,et al."Triggering of the TRPV2 channel by cannabidiol strain. sensitizes glioblastoma cells to cytotoxic chemotherapeutic agents." 3. All oils must be tested for potency,terpenoid Carcinogenesis 34.1 (2013):48-57. content,and presence of contaminants,residual solvents Donadelli,M.,et al."Gemcitabine/cannabinoid combination triggers autophagy in and pesticides. pancreatic cancer cells through a ROS-mediated mechanism."Cell death& 4. The oil supply must be reliably available as it is disease 2.4(2011):e152 catastrophic for a child with epilepsy who has lower or Donadelli,M.,et al."Gemcitabine/cannabinoid combination triggers autophagy in discontinued other medications to not get their oil. pancreatic cancer cells through a ROS-mediated mechanism."Cell death& 5. The oil should be affordable. Some parents disease 2.4(2011):e152. report that they cannot increase doses because the out of pocket cost is too much. Other Although cannabis may not work for everyone,it Di Marzo,Vincenzo,Maurizio Bifulco,and Luciano De Petrocellis."The endocannabinoid system and its therapeutic exploitation."Nature Reviews Drug must be an option for all of those who are ill, Discovery 3.9(2004):771-784. particularly children. As Dr. Raphael Mechoulam, who has led the investigation on cannabis medicine Mechoulam,Raphael."Plant cannabinoids:a neglected pharmacological treasure over the last 50 years, stated, 'plant cannabinoids are trove."British journal of pharmacology 146.7(2005):913-915. a neglected pharmacological treasure trove." July/August 2017 24 CANNABISN URSESMAGAZINE.COM r i• r • _ 'fit- . , y IF ..I AM 6nchtk Neural produc-rs and remedies. ropored inancient planr wisdom; expanded upon through science. Patients Mr Of Time arrendecs and gurscs ar Harbonside Health Cenrercan purchase and exec nencc Narure Nurw pr,.xium during VOW v1str. JOtip ui online roger Nature Nu me tvt v, u r drionstep_ www.NatureNurseHealth. com Pedl-atri"C Care What to look for when choosing Cannabis Pediatric Care • High-quality physicians with spotless records and are in good standing with the American Medical Association and with their State Medical Board. • Do they understand Cannabis Therapeutics and the Science Behind the Plant?Are they willing to learn? Physicians that know and understand the eCS and the science behind the plant is a must when integrating cannabis care into your child's care plan. Not all physicians know and understand cannabis. They were not taught in medical school. Now that they know of its existence and then still refuse to know and understand it then, it's time to look for a new physician who does. • Do they follow State Medical Board guidelines?Doing it the right way matters when it comes to medical cannabis- remember that this is not only a medical process but a legal one as well—make sure your physician follows the medical board guidelines and state law so that your approval is legitimate and defensible in court. • Do they offer an Attorney Protection Program? Should you need legal advice or representation,will they arrange a free consultation or referral with a reputable and experienced medical cannabis attorney within your state? If not,have one on your team. Despite it may being legal in your state,cannabis is still illegal at the Federal level due to its Schedule 1 Classification. Be prepared. • Is your physician there for you?Once your child becomes an approved patient,are they still there to answer your questions,assist with problems or concerns with your child's use of medical cannabis?Continuation of care and a solid medical team throughout the healing process is pertinent to the success of your child's recovery. . • Utilize Nurses who are trained in Cannabis Therapeutics: Adding a Nurse to your care plan team may be useful in navigating the many obstacles that parents face while treating with cannabis therapeutics. Cannabis Nursing is a developing field and not a subcategory of nursing within the American Nurses Association Credentialing Center however,nurses are able to inform and educate patients and direct you to the answers you seek based on their nursing process. (Note: Guidelines by the National Institutes of Health(NIH)on what nurses can or cannot do when it pertains to cannabis are currently being formulated as we speak and will hopefully be released End of 2017). Beware of Unethical Practices 1. State Laws require that a doctor's office is owned by a doctor-not a layperson just trying to make money. Make sure the medical practice that you get your medical cannabis letter/card from is physician-owned or in compliance with your state laws registry program. 2. The doctor's office should have a fictitious name permit registered with the Medical Board. This permit should be posted in the office and verifiable with the Medical Board at http://www.mbc.ca.gov/Applicants/ Fictitious—Name/ Without a registered fictitious name permit and physician owner,the practice is illegal and any paperwork you get from them is not valid. 3. There is no such thing as a "grow license" under state medical marijuana laws. Approved patients and caregivers should be allowed to grow what is medically necessary for the patient's medical condition according to their state statutes. For instance,in California Physicians are NOT ALLOWED to give a plant number. Some doctors are charging up to$300 for a grow license that supposedly allows you to grow 99 plants-this is not legal nor will it protect you if you are charged with a marijuana crime. Know and understand your state laws! 4. Be aware that Skype evaluations are not valid per the Medical Board. If it is your first time visiting a particular doctor's office,an in-person evaluation is required. 5.Does your state program or provider protect your HIPAA Rights?Is there enhanced patient privacy in regards to HIPAA? What are their requirements and if they are violated,what protections do they have in place?This is the law and important in assuring that your health information remains private. 'a 32 Article source:http://www.canna-centers.com hUftl pasda*- https://www.nih.gov/health-infortnation ham'• ` http://www.mbc.ca.gov/Applicants/Fictitious—Name `spi pe https://www.hhs.gov/hipaa/index.html g i patient x July/August 2017 26 CANNARI SNURSESMAGAZINE.COM Use Promo Code JCAN NA25 for 25% Off Registration ! ! ! CANNABIS .1SCIENCE CONFERENCE jCanna ,, JAC— --3 e ° o Q Q ° 0 0 0 ° 0 O -)n Ore •• ' R Venter • • / • 7 _ --r The World's Largest Cannabis Science Conference returns to downtown Portland for an incredible gathering of analytical scientists, medical professionals, cannabis industry experts and novices interested in learning more about cannabis science! I SPONSORSHIPS & EXHIBIT BOOTHS STILL AVAILABLE. . .rrr Contact Josh Crossney at josh@jcanna.com for more info. r ' i f jCannalnc Can nabisScienceConference. com L) jCanna_lnc V @jCanna_Inc Ow A 1 NO Tracy Ryan The Fall, The Rise & The Research fist's Journey I used to have the perfect life! The world A Momcolo g Y around my family and I was so full of beauty, By: Tracy Ryan (Mother of Sophie) hope,and everything I had dreamt of was finally becoming my reality. When Sophie The MRI she had the day before revealed a very rare tumor in my tiny came into this world it was as if the last baby's brain called an Optic Pathway Glioma'-. We were to appear the puzzle piece had finally been placed. She was very next day at the pediatric oncology ward at her hospital. He everything I had ever dreamt of,and so much explained to us that this tumor had a 90% survival rate, but an 80 to 85% more. Her perfectly round cheeks and her recurrence rate. He also explained that the only option for our precious beautiful blue eyes,all the way down to her little girt was chemotherapy. Chemo was only meant to arrest the hair that would shine like strands of spun development of the tumor, and the tumor would never in fact go away. gold in the sunlight...she was mine and her father's vision of true perfection. We felt I always say that cannabis found us and not the other way around,and invincible! We felt like nothing could stop us that truly is the case. Through a serendipitous chain of events on social and the world was truly our oyster. media we found ourselves in the presence of a celebrity I had long admired Ricki Lake of film and television. She and her producing What we didn't realize was that while this joy partner, Abby Epstein,were introduced to us, as they had just started a was swarming around us with the birth of our documentary only six months prior about using cannabis for pediatric sweet girl,a beast was lurking just beyond our sight. In our beautiful baby's brain a rare cancer. tumor was growing and evolving,just We were shocked when we saw the research they presented us with. How waiting to rear its ugly head and steal our could something with so much medical evidence behind it still be illegal? perfect lives from us. Four years ago when our journey began there wasn't even public conversation happening around this plant yet. Little did we know how all One warm summer day I realized that of that was about to change! Sophie's left eye was shaking,which is called nystagmus'. We took her in to be Regardless of the state in which this plant was viewed at the current time, seen by her pediatrician, and after a string of we trusted these women and we trusted the research we were presented doctors' visits over 3 consecutive days, with. We took in a folder full of clinical research to Sophie's doctors that Sophie was in an MRI scanner by Friday of Ricki and Abby had sent us showing that cannabis oil was killing glioma the same week. On June 23rd,2013 our cells in preclinical mice3. We consulted with Sophie's doctors and got phone rang on a quiet Sunday afternoon from their blessing to try the oils. At nine months old Sophie took her very an unknown number. It was our daughter's first dose of cannabis oil on camera for Ricki and Abby's documentary pediatrician that had called to let us know called Weed the People—to be released later this year. that our world was about to change forever. 2g July/August 2017 CANNABISNURSESMAGAZINE.COM We are now on year four of Sophie's journey Your body's bone marrow is unable to battling her beast. She has had her ups and repair itself like this when being taxed by A downs,and we have absolutely,as a family, weekly chemo infusions. A miracle her had ours.We have overcome near doctors happily attributed to her cannabis homelessness,tens of thousands of dollars in use alone.And the list of miracles goes CannkaKieds.: debt,2 recurrences,dozens of hospital stays, on,and on,and on,and on.This plant Where There is Breath,There is H o p brain surgery,more MRIs then we can wasn't just helping her eat and sleep,and count,nine blood transfusions, Staph mitigate much of the pain inflicted by After experiencing the many infection,and seizures that have been mild her weekly treatments,it was saving her miracles I had been so incredibly in nature,except for the one that lasted a from a life that could've easily been blessed to witness,I thought to full,gut wrenching hour. But the miracles stolen by her beast. myself,"What's next?!"What I we have seen in our child far outweigh the realized deeply after many devastation this tumor has taken on her. Once the initial shock subsided,and we conversations,and after started to see all the beauty that this plant immersing myself in research,is We have heard the words "medical miracle" had brought into our lives,we realized that we are all still really guessing so many times now we lose track of the what challenges we had to endure just to when it comes to dosing and strain actual number of rimes it has been said. We get to where we were with our profile use. kept her from going blind,which was a understanding of this plant. We looked at sentence they served up so easily when she the cannabis landscape,and we realized In 2015,I was introduced to was first diagnosed. We shrank the tumor that there was a vacuum in the Professor Dedi Meiri5 from the not just once,but after every recurrence marketplace for medicines that were Technion Institute of Technology she's had,and this is a tumor that we were crafted for patients,especially children. in Israel by Abby Epstein from told up front wouldn't likely shrink at all. We also realized there wasn't a lot of our Weed the People After nine blood transfusions,she just dosing support available,and people documentary. Dedi was described stopped needing them all together;this was were really trying to figure this out on to me as being one of the foremost four months before she got off her first their own,sometimes enduring great leading researchers in cannabinoid 13-month protocol of chemotherapy. failures and intense bouts of treatments for cancer6. I was psychoactivity due to improper dosing elated to make his acquaintance, they were getting on social media. We and solicit his help with my decided to make it our mission to remedy daughter.What was to unfold next this issue. was something beyond even my greatest dreams and expectations. In 2014 CannaKids& SavingSophie.org, our 501 c3 non-profit,were born. We When Dedi and I began our worked hand in hand with Dr. Bonni friendship on our"get to know Goldstein and Dr. Jeffrey Raber to help you"call,he realized that I wasn't us formulate our patient-focused line of just a mom looking for help. I cannabis oil medicines for CannaKids, educated him about the data we with a focus on cancer and epilepsy. We had been tracking and how .> really took a hard look at terepene meticulous we had been in doing F profiles4 and how they can support such. When he asked if he could A healing. In the last two years,we have have it,my immediate answer was i continued to evolve our offering of "ABSOLUTELY!"For me it has custom blends to include additional always been about the patients, issues like ADD,ADHD,Autism, severe and what better way to help them pain,and sleeplessness,with the faster than by sharing our findings knowledge that these same blends can in for his research. fact help many more issues. The relief that we have seen in our patients has been nothing short of amazing! s Photo So July/August 2017 29 CANNA B I SN URS ESM AGAZI NE.COM When I got the guts to ask him for help The research findings that Dedi and with Sophie,he was happy to return the his team are making gives me so favor. I hand delivered Sophie's very much hope for a better and more last sample of cells from her tumor effective way of treating cancer, 1. https://www.aapos.org/terms/ biopsy surgery from when she was one with hospitals waiting in the wings conditions/80 year old in hopes that they could help me for us to start human trials. And best find a solution for her tumor. I traveled of all, his team is working on a 2. https://www.uptodate.com/contents/ across the world with a tiny brown box, formulation for my sweet, sweet optic-pathway-glioma on a 17-hour flight with my dear friend girl. Autumn, in hopes to find healing for 3. https://www.ncbi.nlm.nih.gov/ Sophie in the holiest of lands. This was a Life could have been very different pubmed/9771884 , trip that would forever change my life, for us,and for our patients had this for it was on this trip that Dedi asked me plant not found us. It's hard to 4. hqs://www.esciencecentral.org/ to be his partner. believe that because my little girl joumals/cannabinoids-and-terpenes-as- got sick all of this has come to chemotaxonomic-markers-in- When I returned to the U.S. I knew I had fruition. I am convinced now cannabis-2329-6836-1000181.php? a lot of work to do to officially secure a more than ever that this wasn't just aid=57624 partnership with Dedi and his team. I was my purpose, it's why God gave me introduced to Rob Davidson at CURE breath in the first place. 5. http://dmeiri.net.technion.ac.it/ Pharmaceutical, and it was in that first selected-publications/ meeting that Rob and I knew we wanted to stay connected and try to work 6. http://dmeiri.net.technion.ac.iU together. We began a wonderful research/ relationship through our shared love for Savin children, and our innate desires to help those that are suffering. Rob and his ' Email: info@cannakids.org team had built CURE's FDA and DEAmg% I [j Facebook: https://www.facebook.com/Website:www.CannaKids.org er licensed pharmaceutical lab so that they _ MyCannaKids/ could produce a patented oral thin film (OTF)technology. They invented the A, t Instagram: @mycannakids OTFs to help dying children in third 3 Twitter: @mycannakids world countries who were dying of Malaria due to the absence of clean E A drinking water required to mix their malaria powders in. As my relationship evolved with both men, it was clear that . together we would make an amazing 4W team! And with that, Rob convinced his - CannaKids' board to fund Dedi's next four years of Where There is Breath,There is Hope cancer research. Just weeks after we have made our official announcement that CannaKids and CURE have officially partnered with Technion, I sit here writing this article still pinching myself in disbelief as to _ how far we have come in just four short _ years. Sophie is thriving, and the healthiest she has ever been. She'll start school in the fall,and just performed in her very first dance recital. I have been traveling the world,speaking at conferences, and sharing our stories of survival to anyone who will listen. 30 July/Au ust 2017 CAN AB[SN BSESMAGAZINE.COM Autism and Cannabis: One Mom's By: Brandy Williams (Mother of Logan) Staq;, ;;Afi1,.na Logan's meltdowns could last up to three hours.All I could do is sit on the floor and hold him to my chest as tight as I could,and block as many blows as possible.He would thrash around violently.My body felt like I was hit by a truck after those episodes.I couldn't imagine what my son felt.One day I got a small dose of what he went through.My son head butted me so hard,I ended up with a pretty serious concussion.I still have vertigo spells,and I get really bad mothers advocating migraines to this day.Was Logan experiencing reoccurring medicalAZ concussions,Total Brain Injury(TBI)from all the head banging? • autism PROPERTY DAMAGE As Logan moved out of the toddler stages,his aggression became even more concerning.Every single door in our home had a hole on it on both sides.The master bedroom door was ripped off the hinges. The metal front door had 30 dent marks on it from Logan banging his head.He destroyed all of our dining room chairs by slamming the DIAGNOSIS backs of the chairs down to the ground,over and over.Logan put his Logan had a regression in developmental mile stones at one head through the living room window.The drawer faces and cabinet years old,and that's when the alarm bells started ringing.His doors in the kitchen and bathrooms were all damaged from him pediatrician dismissed my concerns,but I kept pushing forward slamming them over and over. to find answers. Logan was diagnosed with Regressive Autism,and ISOLATION Encephalopathy on Feb.20th,2013. The developmental Going into public was a nightmare.We couldn't go to the store.We pediatrician told me that my son was severely Autistic,and I never ate together as a family in a restaurant.No movies,no family didn't even know what Autism was. She told me Logan most vacations.We tried to take Logan out into public and do normal likely will never speak to me,and that I would be my son's things as a family.We wanted him to have as much fun as possible. caretaker for the rest of his life,or mine. But to be honest,it was the complete opposite.Logan didn't have fun at all,and it was quite overwhelming for everyone.Logan would just During the appointment the doctor observed abnormal eye drop to the ground and scream.And everyone would stare,make movements Logan had,and she sent him in for an EEG.He rude comments,and give us dirty looks. went on to receive another diagnosis,Absent Seizures. Logan was also diagnosed with Enterocolitis in May 2016. SELF INJURIOUS BEHAVIOR AND AGRESSION As soon as Logan woke up and his feet hit the ground, everyone was on high alert.Logan used to bang his head 75-150 times per day.His needs were so extensive,we had a Habilitaion specialist in our home for 40 hours per week.My -; sons HAB worker and I witnessed him head butt a brick wall, . and the concrete patio.Those memories will never leave my V — mind.I thought Logan's head was going to cave in.I was so worried about skull fractures and concussions.When the ER doctor showed me how to tell if a skull had been fractured,my stomach started to roll. Continued on next page July/Au.qust 2017 31 CANNABISN RSES GAZINE.COM Sensory Issues Self Help Logan has such bad sensory issues,and hated wearing clothes Logan is potty training! He is going on the potty at school,and at home. and shoes.He would rip the clothes off his body.When we If he soils his diaper,he lets me know,and is completely cooperative. could get shoes on him he would sit on the ground and bring his His sensory issues are attenuated.He gets dressed in the morning no foot to his head with his hand and bang his head with his shoes. problem.He can even dress himself most of the way. This made it extremely difficult to get Logan to therapy and preschool on time.Transitioning him to the car was one of the hardest feats of the day,as well as diaper changes. Social/ Emotional Logan makes eye contact with everyone now.He says hi and bye to Sleepless Nights people.He is aware of his environment now.He is actually responding Logan had to sleep in our room.I was always afraid of him to his name when I call him,and his receptive speech is amazing! He is eloping,or having a seizure in the middle of the night. We responding to the things I ask him to do.Like find your shoes,or throw something away. would tum everything off around 9:30-1OPM,and Logan would lay in bed and flop like a fish.He would jump up periodically, It's much easier to redirect Logan,and avoid melt downs all together. and open and close the door five or six times.Lay back down, We can eat together as a family at restaurants now.He can go to the flop back and forth,then jump up and open and close the washer grocery store with us,and he even gives me time to read the labels. three or four times.Eventually he would pass out from Most of the time he behaves better than the nuero-typical children. exhaustion at one,two,or three in the morning. Sometimes he would fall asleep for 3 or 4 hours,and wakeup and start We actually have FUN out in the world.We have taken him to the stimming.We had to sleep with one eye open most nights. water park.We visited the snow.We took our first family vacation to Santa Monica last summer.We have a sense of normalcy in our lives now. CANNABIS SAVES THE DAY! Cannabis attenuates the frequency,duration and intensity of Logan's Day One melt downs,anxiety,aggression and self injurious behaviors and it helps Logan self regulate. It also attenuates his speech apraxia, All that changed June 19th,2015. 1 gave Logan his first dose of dyspraxia,bruxism,stimming,seizures,and reduces inflammation in Full Extract Cannabis Oil(FECO)and 20 minutes later his hand his brain and gut. flapping,jumping up and down,verbal stims,and teeth grinding all slowly started to melt away. He came and SAT DOWN next Logan's Medicine to me for a long time,and watched a movie with me for the first time in his life! Logan takes FECO twice a day on food.One dose before school,and another after school.The more strains we mix in the oil the better! I am Logan has Speech! learning how important terpenes are.We like to add in Nature NurseTM Logan added 180 new words to his vocabulary in the first two CBD chocolate in his diet like a vitamin. A lot of the glycerin based months,and his ATEC score dropped 56 points in six months! CBD tinctures are problematic with Logan's gastro issues,so the Before cannabis,Logan was non-verbal before.We worked chocolates are perfect! Cannabis is therapeutic for ALL of the really hard on speech.He could only approximate 10-15 words conditions Logan has.! at any given time.But he would regress often,and I would never hear him say the words again.Now Logan will say almost every My Advise to Parents word I prompt him to say,and now he has over 200 words he can use spontaneously and in the proper context.He can Start low and go slow.Everyone's stories are great guidelines,but verbalize his basic needs,and he keeps adding speech.No keep in mind everyone is different.Johnny's sweet spot isn't going to regressions. be the same as Logan's.KEEP a journal and Log everything. It will help you figure out whats working and whats not. Buy small amounts until you find what works. That way if it doesn't work your not Thriving in Therapy and in School wasting money. LISTEN to your child and never stop learning! Logan can sit through an entire therapy session,and attend a therapist lead task.I felt like therapy was such a waste of time before cannabis.Our whole therapy session was spent waiting out meltdowns,and now he actually engages in therapy. Logan is no longer a threat to teachers and peers.We wrote his IEP and in 52 days he mastered all his goals.His teacher told me - she has never see a student blow through their goals so quickly and easily.He can say his ABC's,shapes,colors,and he can name at least two dozen animals and mimic their sounds.He can count to count to 20,and can name all the coins. 32 July/August 2017 CANNABISNURSESMAGAZINE.COM Cannabis Nurses- Our Heroes I first met Nurse Heather Manus at the Southwest Cannabis conference in October 2015,and I have been bugging her ever since. ` d Logan has always been a big fan of blonds,so • of course they connected right away.Arizona _ Cannabis Nurses Association filed a petition P on behalf of Arizona Autism Families in �,.► January 2016,and again in July 2016. They still continue to fight for other conditions to be added and are leading the way by example. i 1 Logan sitting the first time with Logan Shopping cooperatively with Easter Bunny,April 2017 Mom on candy isle,2016 References & Resources: Brandy Williams(Mother of Logan) Logan's AZ MAMMA Mothers Advocating Medical Marijuana for Autism,Arizona State Director MAMMA's website: https://www.mammausa.org Logan and Nurse Heather,August 2016 http://65270571-826658179892236009.preview.editinysite.com/ uploads/6/5/2/7/65270571/ Family Impact variationinhumancannabinoidreceptorcnrlgeneautism.pdf When we first started this cannabis journey,the http://65270571-826658179892236009.preview.editmysite.com/ goal was to just get the seizures to stop. I was uploads/6/5/2/7/65270571/autism- not expecting much outside of that. Cannabis associatedneuroligin-3mutationscommonlydisrupttonicendocann ended up saving the sanity of my family by abinoidsignaling.pdf providing my son with relief. Some Autism patients have no medical explanation for their http://65270571-826658179892236009.preview.editmysite.com/ self injurious behavior. Risperdal and Abilify uploads/6/5/2/7/65270571/ should not be the only option us parents are left canautismbetriggeredbyacetaminophenactivationofendocannabin with. oidsystem.pdf It turns out I wasn't the only parent out there www.NatureNurseHealth.com that felt that way. I joined forces with a www.AZCNA.com grassroots organization established in Texas in 2014 called MAMMA;Mothers Advocating Medical Marijuana for Autism. I was asked by the founder,Amy Lou Faywell,to start the second MAMMA's chapter in Arizona. July/August 2017 33 CA NNA BI SNURSESM AGA ZI N E.COM Intro to a abis for Auti* sm By: Nurse Janna, RN, BSN, Holistic Nurse & Warrior ASD Mama In the Autism Parent community,word spreads FAST. offer hope of resolution upon connecting with kindred If you've been paying attention,you've surely heard ASD parents.After recovering my own daughter from the stories about seemingly miraculous results from a her ASD puberty crisis, my resulting passion turned parent who discovered cannabis for their Autism our trauma into purpose: to help other families. Spectrum Disorder(ASD) child. I'm one of those parents,and can personally vouch for the extreme I've since personally guided many ASD parents positive potential of this most controversial herb. through optimal application of cannabis therapy. For most it has provided safe and effective relief,and eased As a Holistic Nurse focused on natural alternatives their family crisis. As an added bonus, many using to pharmaceuticals, residing in a cannabis-legal state cannabis have successfully weaned off harmful mental (Oregon), learning how best to apply medical health pharmaceutical medications,some of which cannabis therapy was a logical decision for me. have permanent side effects(google extra-pyramidal Cannabis quickly became a major life passion, as symptoms-not a good scenario). *Disclaimer: I highly this amazing plant was integral in saving my own recommend medical oversight for pharmaceutical ASD teen daughter from out-of-home placement. I weaning.* thought of doing�%-hat many consider unthinkable (foster placement), due to safety concerns when my The only shame of this process is how many parents daughter suffered a major puberty crisis,with high- don't consider cannabis therapy until every other level behaviors including self-injury,aggressiveoption to manage their ASD child is completely rages, and property destruction. I can attest: there's exhausted. No judgment by the way. It's lack of nothing more helpless than watching your child education about cannabis that prevents consideration suffer to the extent of injuring themselves and others of this safe and effective option. in a blind rage. The trauma of puberty crisis is Now that word is spreading, many parents are experienced by an estimated 50% of Autism families, using cannabis as a crisis prevention strategy and is therefore an exceedingly common presenta- (sometimes well before puberty)and the ASD tion during many a child's coming-of-age'. Having biomed treatment addage "the earlier the better" been there myself, I completely empathize and certainly seems to apply. 34 July/August 2017 I want to be clear that the goal of medical In addition to its symptom management efficacy,cannabis also promotes cannabis use for ASD isn't for parents to get their balance of some underlying issues that cause Autism...hence my inclination to kids"high"to mellow them out. Instead,the goal call it potentially"curative". Biomedical ASD 101:Autism is caused by a is to improve internal balance and optimize combination of genetic and environmental impacts that result in pervasive function,through individualized microdosing and imbalances,predominantly in the gut,brain,and immune systems(9). experimenting to find the"sweet spot"titration. The experimentation process is needed because When cannabis activates the Endocannabinoid System,the effect includes individual cannabinoid needs vary greatly. With balancing of all three of these major organ systems gone defunct in ASD. successful medicinal cannabis titration,even with Cannabis is immune modulating(10), neurotransmitter balancing and use of psychotropic components such as THC,a neuroprotective(11),plus anti-inflammatory to the gut and brain(7,9),to -"high"is rarely discernable. With successful name a few of the profound curative effects. Cannabis itself has definitely been medicinal cannabis titration,even with use of one of the"big hitters"in recovering my own ASD daughter,who made more psychotropic components such as THC,a"high" progress between the ages of 11-14(post-cannabis)than in the biomed-heavy is rarely discernable. Now for the science decade prior. supporting cannabis therapy for Autism. If you have a child with Autism who you believe may benefit from cannabis, but are unsure where to begin,I highly recommend connecting with Mother's First and Foremost: Endocannabinoid Advocating Medical Marijuana for Autism(MAMMA). I urge you to seriously Deficiency Predisposes Autism(2). Read that a consider this safe and effective therapy if you have a child with Autism. few times and let it sink in for a minute.For those who are brand new to the Endocannabinoid For more information about Nurse Janna,please visit: system(ECS),think of it as the motherboard that http://www.integratedholisticcare.com manages the interactions within and between our body's organ systems.The role of the ECS is homeostasis(maintaining balance)throughout the rest of the body. In response to an imbalance, itations / Resources: the ECS will intelligently rebalance what's out of 1. Ballaban-Gil,K.et al(1996).Longitudinal examination of the behavioral,language,and skew.This includes some important areas for social changes in a population of adolescents and young adults with autistic disorder. treating ASD such as neurotransmitter balance, Pediatric Neurology, 15(3):217-223 immune modulation,and mitigating inflammation(3). In fact,one cause of ASD is 2• Chakrabarti,B.,Persico,A.,and Battista,N.(2015).Endocannabinoid signaling in autism. genetic Endocannabinoid System receptor Neurotherapeutics, 12(4):837-847. mutations which lead to ECS deficiency(4). 3 De Petrocellis,L.,Cascio,M.G.and Di Marzo,V.(2004)The endocannabinoid system:a general view and latest additions.British Journal of Pharmacology 141,765-774. The cannabis plant has the most prolific source of 4. Dilja,D.,Krueger,N.(2013)Evidence for a common endocannabinoid-related phytocannabinoids available to supplement what pathomechanism in autism spectrum disorders.Neuron:78(3):408-410. is lacking in the ECS of those with ASD.This explains why cannabis can have such a profound- 5. Blessing,E.,Steenkamp,M.,Manzanares,J.,Marmar,C.,(2015).Cannabidiol as a potentii ly positive impact as an intervention for Autism. treatment for anxiety disorders.Neurotherapeutics: 12(4):825-36. 6. Russo,E.B.(2008).Cannabinoids in the management of difficult to treat pain.Therapeutic and Clinical Risk Management,4(1),245-259. So,how exactly does cannabis benefit one with Autism?Well,let's start with symptom 7. Nagarkatti,P.,Pandey,R.,Rieder,S.A.,Hegde,V.L.,&Nagarkatti,M.(2009). management.Cannabis is very effective at Cannabinoids as novel anti-inflammatory drugs.Future Medicinal Chemistry, 1(7), 1333- minimizing or completely stopping extreme 1349. Autism behaviors before,during,or after 8. Medical Marijuana vs.Traditional Pharmaceuticals(2016).Medicinal Marijuana puberty. The anxiolytic(5),pain-relieving(6), Association,accessed online at:http://www.medicinalmarijuanaassociation.com/medical- and anti-inflammatory(7)effects of cannabis marijuana-blog/infographic-medical-marijuana-vs.-traditional-pharmaceuticals seem to come in particularly handy for managing Autism behaviors. In addition,cannabis is 9. Caroline,G.,Lopes,S.,Silva,P.,et al(2011).Pathways underlying the gut-to-brain considered very safe with much milder side connection in autism spectrum disorders as future targets for disease management.Europea effects compared to its pharmaceutical Journal of Pharmacology,668:S70-S80. alternatives(8).Hence the symptom 10. Thomas,W.,Klein,L.,Newton,C.,Larsen,K.,et al(2003).The cannabinoid system and management piece that is renowned for immune modulation.Journal of Leukocyte Biology.74(4):486-496. alleviating harsh situations in ASD families, even when at or near their breaking point. 11.Hampson,J.,Grimald,M.,Axelrod,J.,Wink,D,(1998).Cannabidiol and tetrahydrocannabinol are neuroprotective antioxidants.National Academy of Medial Sciences,Vol.95,pp.8268-8273. July/August 2017 35 CA NNAB I SNURSESN A G A Z IN E.CON L Nurses Responsibilities - And - Roles with Cannabis Patients By: Jennie Stormes, RN, BSN, MSN Student 36 July/August 2017 CANNABISNUASESMAGAZIN E.COM Nursing in a medical or recreational marijuana state can be challenging with the conflict in state and federal laws. People, young and old, will present to the emergency room, hospital, doctors office, home care, hospice, and so many other places, for medical care while using some form of cannabis. The use can be general wellness, recreation, and symptom control, cancer fighting, life-saving from some catastrophic disease or disorder. The bottom line is, they still need medical care and deserve medical care. What does the typical cannabis user get? It varies on their appearance, needs, and who is working at that moment of need. It should not be this way. As a professional nurse, you should be offering the same Moral of the story: Cannabis is a medicine. compassionate care,regardless of the choice of medication. After Patients should be informed about cannabis as a medical option. all, isn't choice in one's own care a patient right. If the patient Understandably,there are limitations on prescriptive authorities, doesn't have the right to choose their own medications, medical ability to prescribe a dose,and to monitor cannabis. As a Nurse, care, or choices of recreation, then what does the patient bill of we have to present all options and treatments to our patients and rights cover (NIH: US National Library of Medicine, 2017)? their families. They are the ones who decided if the treatment Exactly,the choice to take a medication with few side effects and a using cannabis is useful or not. They are the ones who will need safer medical profile than almost every prescription and over the to decide if they would like to explore this medical option,just counter drug, is a right. As a Nurse, you need to support all the like any other drug,surgical procedure,or medical test. The rights of the patient, including the choice of a controversial patient needs to be informed. Nurses should be able to medication. administer the cannabis based medication if this is the patient's choice. Doctors should be able to prescribe and direct a nurse to The irony in a medical state,is that cannabis is considered medicine, administer cannabis-based medicine,because it is safer and more yet has no official medicinal value. History can prove cannabis is a effective than many medical treatments(ProCon.org,2017). medicine with many medicinal uses (ProCon.org, 2017). The Federal Government has once done the following: Many patients will just say no without considering cannabis as a treatment. That is ok since this is their right and their choice. 1.Classified cannabis as a medicine with medical What the nurse did when including cannabis as a treatment purposes. option is to educate and share knowledge and open a 2. Allowed compassionate-use through a federal conversation. The conversation will lead to more IND-FDA run program(now closed)which conversations,and maybe someday,that will be an option they supplied cannabis cigarettes directly to patients. may be willing and ready to consider. 3. Holds at least one US patent on cannabis use as The Nurse must be informed and educated about cannabis and a medicine(Patent No.6630507) the science behind the plant. Since there are currently no nursing 4. Has approved as a Schedule 3 drug synthetic school officially offering cannabis education,it is up to the forms of cannabis as a medicine,and is currently professional nurse to seek out the knowledge and educate allowing investigational drugs and ongoing themselves about cannabis use and nursing. This does not mean studies using cannabis-plant-based research in a nurse needs to run to a corner and purchase a bud and smoke it. the United States(Lee,2013). Although,it might help feed the Endocannabinoid System(eCS), improve memory,and help lower stress and anxiety(Lee,2013). July/August 2017 37 CA N N A B I S N U R S E S M A G A Z I N E.C O M The Professional Nurse Combining these main points of knowledge will help the nurse with understanding cannabis as a medicine. The presence of needs to understand and know: the eCS and the use of both endocannabinoids and phytocannabinoids will be huge. The next step would be to understand the use and application of the medication to treat 1. All mammals have an eCS in which deficiency can lead disease and disorder.How to use cannabis and methods of to disease and disorder(ACNA,n.d.). treatment other than just smoking a joint. Sadly,with research and knowledge being suppressed for over 80 years because of 2. Endocannabinoid Deficiency-Lack of cannabinoids prohibition,this is not well known or documented like a can make the other systems in the body to not function traditional FDA approved drug readily available to make a properly and for the person to become ill and seek medical patient sicker with side effects and other ailments(Lee,2013). " care(Lee,2013;Russo,2008). This is the root cause of many diseases. Simply feeding and treating the eCS with "What needs to happen is that the nurse needs to be cannabis from the plant,called phytocannabinoids,can bold enough to recommend cannabis for any and all improve symptoms. symptoms that could benefrts from cannabis as a 3. Treatment does not mean the person will be high or medication, regardless of the state, because the unfunctional. It simply means that they will be treated,like any other treatment option prescribed by a physician,but it is recommendation is in the best interest of the patient not allowed by federal laws. and their care". Nurse Jennie Stormes, RN, BSN 4. The presence and purpose of the endocannabinoids. An endocannabinoid is an endogenous cannabinoid made by Doctors,in states where cannabis is legal for use,should be the body and used,like the phytocannabinoids,at the same able to continue with the existing care and nurses should be receptors(Lee,2013;Russo,2008). The most common able to administer the cannabis-based medications when in- endocannabinoids are anandamide and 2-AG and bind to patient,long-term care,hospice care,and anywhere someone the same receptors as the phytocannabinoids(Grotenhermen needs medical care. &Russo,2008). The endocannabinoids have a role and function within the body and promote a sense of wellness or How does a Nurse include Cannabis? happiness. The Nursing Process 5. The use of phytocannabinoids. These are the components contained in the cannabis plant that are medicine and treat so Simply by using the Nursing Process and including cannabis in many different ailments,conditions,diseases,and the plan of care steps,commonly known as ADPIE: symptoms. The cannabinoids attach to the CB 1 and/or CB2 Assessment,Diagnosis,Plan,Implement,and Evaluate(ANA, receptors within the body,comprised of the endocannabinoid 2017). system(Grotenhermen& Russo,2008). Assessment this steps includes collection of objective and subjective data about the patient(ANA,2017). A nurse should always ask and inquire if there is any medical cannabis use? If the answer is yes,then inquire as to why?What symptoms? Is it working to relieve the symptoms? Is there any other benefit they notice from the cannabis use,like better sleep?Increased hunger and weight ain?Less nausea?Any unwanted side effects? ow is the patient taking the cannabis: smoking,vape,tincture,oral,rectal, sublingual,topical,or another method? Diagnosis includes the analysis of the data collected and creating nursing diagnosis to improve health outcomes for the patient(ANA,2017). Where can the use of cannabis be included in the diagnosis to assist in the positive outcome? Neuroprotection?Anti- inflammatory?Analgesic?And so many other known properties possible. July/August 2017 38 CANNABIS N U 8S ESM AGAZI N E.COM M. Ajhm�l, Planning incorporates the data from Nursing Process the assessment and the diagnoses to create a plan of care with priorities in care needed to achieve the goals,plan of care to improve medical outcomes,and interventions to increase the odds of a s. mom-rvn.r"s..ts positive outcome(ANA,2017). Pkykian-"AUJ The nurse should consider each °"; 3.�0'ols�iep - intervention and when cannabis would be 4.PWU the safest option with the fewest side effects,cannabis should be included and f i f�ripriva implemented. For ineffective airway 2-Ortca.%cs 31 Lvhd& exchange,the use of cannabis can effect - AMWWsn vasodilation of the bronchioles and open a. iA the airways. With acute or chronic pain, Flow Chart Credit:Jennie Stormes,RN,BSN. All Rights Reserved. cannabis is an analgesic. Imbalanced nutrition can be alleviated with cannabis to stimulate appetite and halt It is important for the nurse to include the Endocannabinoid nausea and vomiting. The nursing plan should include safe cannabis System(eCS)in all steps of the nursing process. The patient options to compliment the endocannabinoid system to heal disease and deserves complete care,which addresses all body systems and address symptoms present. all sources of disease,along with all possible treatments,even the forbidden one:cannabis. Even in an illegal cannabis state, Implementation of the nursing plan would involve following it is not illegal for a nurse to share knowledge and teach a through with the plan and doing what is needed for the patient(ANA, patient about cannabis who could benefit from the many 2017).Even if the plan of care includes the use of cannabis based medicinal cannabis abilities. medication in the treatment of the patient. Obviously in a hospital, smoking would not be an option,but there are other choices to deliver MWeferenceS the medication and to achieve the intended effect. Topical application (salve or patch)to an area of pain could relieve pain or treat skin ACNA.(n.d.)..Our mission.Retrieved from American Cannabis Nurses lesions of psoriasis. Tinctures can be administered sublingual,orally, Association:https://cannabisnurses.org/ via a gastronomy(GT)or jejunum(JT)tube,and even rectal dosing to ANA.(2017).Nursing process.Retrieved from American Nurse Association:hap:// treat seizures,muscle spasms,dystonia,and so many other symptoms www.nursingworld.org[EspeciallyForYou/What-is-Nursingrrools-You-Need/ managed by a nurse. Thenursingprocess.html Grotenhermen,F.,&Russo,E.(2008).Cannabis and cannabinoids:Pharmacology, toxicology,and therapeutic potential.New York,NY:Routledge. Evaluation of all interventions implemented is important to determine if they are effective and did the health outcome improve or t Lee,M.E.(2013).Smoke Signals:A social history of marijuana-medical, decline(ANA,2017). The evaluation is a reassessment of the health recreational and scientific.Scribner. situation by the nurse. When considering cannabis,determine if the NIA:US National Library of Medicine.(2017).Patient rights.Retrieved from cannabis based medication was effective. If yes,then repeat if Medline Plus:https://medlineplus.gov/patientrights.htmi necessary until no longer needed. If no,then consider a different ProCon.org.(2017).60 Peer-reviewed studies on medical marijuana.Retrieved from delivery route,different dosing,different strain,different The Leading Source For Pros&Cons of Controversial Issues:http:// medicalmarijuana.procon.org/ cannabinoids,different ratios,cannabis break,and many other options view.resource.php?rmourcelD=1008U for cannabis-based medications. ProCon.org.(2017).Historical timeline.Retrieved from ProCon.org the Leading Source for Pros&Cons of Controversial Issues:http://medicalmarijuana.procon.org/ The Nursing Process should be repeated until the patient care is no view.timeline.php?timetine1D=000026 longer necessary. Until that point,the nurse will repeat the Russo,E.B.(2008).Clinical endocannabinoid deficiency(OECD):Can this concept explain therapuetic benefits of cannabis in migraine,fibromvalgia,irritable bowel assessment,diagnosis,planning,implementation,and evaluation to syndrome and other treatment resistent conditions?Neu roendocrinologv Letters,192-20 improve the health outcomes(ANA,2017). Making adjustments -� along the way is important. Taking into consideration the need for adjustments in cannabinoids, dosing,or ratios is an important aspect of cannabis use as a _ medication,especially with chronic,long-term diseases. Sometimes a — cannabis break or`holiday'can be beneficial to let the cannabis & c become more effective with maximum benefits at the receptor sites. . Use of micro-dosing can help many. The use of various strategies for patients can help manage disease and discomfort. There is so much to know about the science of cannabis. Rx given to a patient in an ER in Denver Children's Hospital 2017. (Permission from the person granted on FB when posted) July/August 2017 39 CANNABISNURSESMAGAZINE.CO N l�. Z "Cannabisinto Trey's life when he was at his lowest. �. When death seemed like the only way to end his pain." .s BrownAngela TBI and Cannabis : A Teenager ' s Perspective By: Trey Brown (now 17 years old) State of Minnesota Background: Trey Brown was a normal thirteen-year old child that played community sports in the heart of Minnesota with his family. His entire life and health changed on April 25th,2011 when a line drive baseball struck by an aluminum bat,imbedded into the left side of his head. "I have an inch and half whole in the left side of my brain-the learning center." He was diagnosed with TBI(Total Brain Injury)which is a sudden injury from an external force that affects the functioning of the brain. It can be caused by a bump or blow to the head(closed head injury)or by an object penetrating the skull (called a penetrating injury). Some TBIs result in mild,temporary problems,but a more severe TBI can lead to serious physical and psychological symptoms,coma,and even death'2,3,4 As a young teenager fighting for his life for solutions to his many ailments of TBI,Trey began to suffer with secondary conditions such as but not limited to Hypothalamic Storms, Seretonin Syndrome,and Thyroid Storms. Pharmaceuticals were used in a variety of forms and if Trey even missed a dose of levothyroxin it would throw him into a Thyroid Storm. TBI is no joke. He and his mother searched for non-conventional solutions as the current pharmaceuticals hindered his growth and PTSD and depression set in,a common condition of TBI sufferers. Medical cannabis was and is his solution yet due to a lack of program in his state of Minnesota he was forced to move to Colorado and become a Cannabis Refugee. He contributes his medicine-Cannabis-as the reason why he is here today. Now he shares his knowledge in hopes to help future teenagers and their families struggling on whether medical cannabis-as a treatment option-is right for them. 40 July/August 2017 CANNABISNUYSESMA GAZINE.CO M What is it like being a Cannabis Refugee and the challenges you experienced? There have been many challenges moving to Colorado. My dad hindered the move because he didn't want to leave his opiate dealers in Minnesota. We really had very little support here in Colorado to assist in getting us here. Jennie Storms, Sierra Riddle,and our private grower friends are who to thank. Without their open doors I would not have survived,literally. So Mom had to fight every step of the way to get me here. It took her two pain filled years,the realization she needed to make this move as a single mom,her massage business,friends and all that was familiar. We left behind my older brother, Delany, and my niece who is more like a sister; Kourtny,Del's lady,and her daughter who have wormed their ways into our hearts. It has not been easy to be so far from home. However,through all that loss we have gained so very much. My dad is now clean,Mom made sure he would be around to realize everyone has worth if you just look. Now he can speak out about how my cannabis saved his life every time he tried to take it via opiates. My Mom met her new partner because of our struggles here.With him comes his knowledge and ability to grow amazing cannabis,his love and support,my now youngest brother and a sister,as well the promise of an amazing future. Cannabis is quite controversial and there are many stigmas. Do your peers think you are just a stoner? I am more than just a stoner. I am a young man who enjoys the freedom of a clear mind and a body I have some control over-thanks to cannabis. What routes of administration work best for you? I have been using a PAX Vaporizer since the beginning. It was my go to during `The Storms' before it broke. I enjoy my Beta bong,various spoon pipes that I smoke flower out of. My Mom makes infused coconut oil in our Magical Butter MachineTM that I take on a regular ' schedule throughout the day. I enjoy making edibles,cause why not have fun with my meds?! Topicals that my mom makes come in handy after long days too. I consume Dabs,wax, j whatever as long as it is from clean bud with clean ingredients. The above kinda explains I have a routine,but I know damn well how fast a Storm can come in or how hard an Overload hits. So I need to be prepared. I got an opportunity to try Ebbu's isolated cannabinoid solution during an overload once. Hopefully we can have their products around here soon. It was the first time I had ever had control while in overload,that is epic. My body has been through so much. So often I was diagnosed with'stuff that was opposite then the real issue. My Mom pushed till we found answers. Has cannabis hindered you from working and living a normal life? My boss is cool with me medicating while I work. I can work and earn my own way in life because I have cannabis. My Stashlogixs travel bag(https://www.stashlogix.com/collections)helps me keep my meds organized and safe while out and about. What are your favorite strains that work for you and your conditions? Favorite strains?The next one I smoke. I do believe someone famous dubbed that phrase. I do enjoy White Dog,Golden Goat, and currently the strains being grown by my mom's partner,David Lippoldt, specifically for issues with brain injuries. He couldn't find strains that worked right after his TBI so he is creating them for us. I am grateful he started this journey, it has eased mine. Golden Goat: is a heavy hitting mind expanding sativa with a sweet and piney terpene profile and THC in the high 20s. https://www.leafly.com/products/details/calyx-garden-golden-goat White Dog/Chemdawg: is a hybrid(sativa/indica)that provides a relaxed, euphoric,happy,uplifted,and creative mood. Known for decreasing stress,pain, depression, lack of appetitie, and insomnia. https://www.leafly.com/hybrid/chemdawg I want to feel relief of swelling in my brain. I want to be clear headed,open to learning, and open to new experiences. I enjoy being able to relax and sleep. So whatever strain helps me to be the above average teen,bring it on! July/August 2017 41 CANN ABISNU RS ESMAG AZI N E.COM What is the best advice you can provide I have learned that kids need cannabis,even the seemingly for TBI Sufferers? healthy ones. Who knew a CBD/THC gummy could help a guy pass his algebra test?Did you know that a cannabis suppository We figured out diet and nutrition is extremely important will ease pain,cramps,mood swings,etc-I bet there are a few to the healing body. young ladies that would enjoy sanity. Here are some very helpful tips for TBI Did you know that cannabis can help our teens by opening their minds,easing their anxiety,reducing all the messed up things sufferers that we discovered: that happen as we grow into ourselves?Dr. Komandis does,it's Gluten is the devil,don't touch it or anything that may worth your time to look into his work.(Minnesota's Cannabis resemble it. Processed soy is a pseudo hormone that will Summit 2016). f@ck your world. Glutamate destroys already damaged areas,taking out more and more healthy cells as it floods What advice do you give to other Teenagers your brain. That MSG(Monosodium glutamate)in your and Parents who are considering medical processed food is so not worth the self-harming cannabis? Dr.Jekyll/Mr.Hide that happens when brain injury meets chemicals that cause it to swell and release floods 1. Cannabis creates new life.The turmoil and all the negative of that glutamate and excess serotonin creating attention my mom's case caused-aside from the Cannabis-has Serotonin Syndromes(SS). It often occurs when two greatly,positively impacted our lives.We are better people for wallcing medicines that affect the body's level of serotonin are through the Valley of the Shadow of Death.Through the hell fire that taken together at the same time. The medicines cause cannabis creates within uneducated people.It made us fight to rise too much serotonin to be released or to remain in the above it,made us want to open eyes to the truth.A truth that must be brain area. told just right for it to be heard. It took my mom awhile to figure the foods out. We have 2. Do not believe everything you are told.There are many lies out Jennie Stormes,RN,BSN and Mike Morse,both from there even if you think they are the truth,they may not be. Do your Colorado,to thank for helping us weed through what own research,look deep and far.Ask those who have come before,we hadn't already been cleared out-The what to and what have paved a way and it was so very hard,so let us help you. not to cat,How to pair foods so you can have some fun, and so on. 3.Start Low and Go Slow.Low and Slow really is the way to go. Keep acidic juices and foods around-don't let a possible bad trip ruin you for the wonders of cannabis.Acidic foods cut down THC in your For Example: If I want to eat cashews I better have a fat cells to lower your"high"euphoric effects.You can also vape your cup of green tea too so that I don't rip another door flower at low temps to bring out more CBD to lower effects of THC. off its hinges. Green Tea helps me chill out. 4. The first person you talk to about your use should be someone Green tea contains the amino acid L-theanine, which is who will fully support your journey.That person may not be in found almost exclusively in tea plants (Raj Juneja et al., your circle.Thankfully there are many well educated advocates, 1999).L-theanine acts as a neurotransmitter in the nurses,doctors,scientists,and experts. In the state of Minnesota you brain, meaning that it sends signals to neurons. Several can go to Sensible.MN for all your questions and concerns. studies have shown that L-theanine appears to increase c not be afraid!! Do not fear your neighbor's views while your alpha-wave generation in the human brain, signalling a childd lays suffering! state of relaxation(Raj Juneja et al., 1999). What impacts has cannabis made on you and What is the most profound thing that your future? What are you doing now? you have learned about kids and cannabis before and after Sensible Minnesota just had their first Summit. I had the privilege of speaking on the Patient Panel.This August 2017, (change in perception)? I will be speaking at Seattle Washington's HempFest. The All I really knew before was that my grandpa used to more people that know Traumatic Brain Injuries are unlike any grow and used it in his final days for comfort from the other creature when it comes to cannabis,the better. cancer that killed him. If the world had just allowed us our rights,I would have known him. 42 July/August 2017 CANN A B I SNURSESMA G AZI NE.COM Education is Power -a phrase handed down from Sources: my Grandpa Elsner along with his desire and love of growing a plant that brought him a lot of fun in his youth 1. Centers for Disease Control and Prevention.(2012). How and eased his pain at the end. Cannabis wasn't allowed to many people have TBI?Retrieved June 12,2012,from save his life back then. So I thank all those who have made http://v ww.cdc.gov/traumaticbraininjury/statistics.html[top] it so Cannabis could save mine. Right now I am making myself proud. I never thought I would get to go back to 2 https://www.nichd.nih.gov/health/topics/tbi/conditioninfo/Pages, school and excel at it, attend prom, speak out and save default.aspx lives,bust my butt digging trenches for an awesome boss, and I sure never thought I would ever get a drivers license. 3. https:Hmedlineplus.gov/traumaticbraininjury.hhW My Mom was told I was going to die. She didn't listen, so why should I?This is my life,Mine to do as I see fit with. 4. http://www.traumaticbraininjury.com/understanding-tbi/what- Regardless of what my birth certificate says,the is-traumatic-brain-injury/ government does not own my body. I have a right to consume a plant that gives me life. Resources: 1. https://en.wikipedia.org/wiki/Contact—Sport Sensible Minessota: 2. http://patft.uspto.gov/netacgi/nph-Parser? Founded in February 2015 Sect 1=PTO 1&Sect2=HITOFF&d=PALL&p=1&u=% 2Fnetahtml%2FPTO% Mission: 2Fsrchnum.htm&r=1&f=G&1=50&s 1=6630507.PN.&OS To educate the public on the uses,benefits,and relative =PN/663 0507&RS=PN/6630507 safety of cannabis; to support persons harmed by 3. https://www.google.com/patents/TJS6630507 prohibition;and to advocate for sensible policy changes. 4. http://www.medstarsportsmedicine.org/research/which- Sensible Minnesota is a 501(c)3 tax exempt non-profit youth-sports-cause-the-most-concussions organization working on sensible cannabis policy changes in Minnesota. We offer a number of different services for 5. https://www.nebi.nim.nih.gov/pmc/articles/PMC2140075/ the public including assisting patients with accessing medical cannabis,working with communities harmed by 6. http://jamanetwork.com/joumals/jamapediatfics/ fullart prohibition, speaking to and engaging communities in icle/2375128 discussion,and providing resources for outside agencies 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865832/ and organizations. We envision safer communities as a result of sensible policies through education and advocacy. 8. https://medlineplus.gov/ency/article/007272.htm https://sensible.mn 9. http://www.health.state.mn.us/topics/cannabis/about/ update l 016.pdf ■ ensu ble -IUW*k ensibMN a po e • • �• � � er commu es • le.mn July/August 2017 43 CA NNA B I SN UA SESM AG AZI NE.COM 'Summer Days Af The 1�each , Lakesi4e lor jusf your �avorif e Picnic S�of : Chef Herb has created some of his favorite recipes for his classic days of summer time fun. Check out cookwithherb.com to see how he can help you learn to cook with, and make, THC oils and butter. PREP RATION AND FOR MORE 1.To prepare the cocktail sauce,mix all the cocktail sauce ingredients CHEF HERB together in a medium bowl and refrigerate until ready to serve. 2.Have a large bowl of ice water ready and set near the sink Add the Q' O O Old Bay,lemon,granulated garlic,garlic,chili powder,and salt to an & 8-quart pot of water.Bring to a boil.Add the shrimp to the pot and WITH HERB when the water returns to a boil,the shrimp should be done!The shrimp should be bright pink GO TO WWW.COOKWI THHERB.COM 3.Immediately drain and place the shrimp into the ice bath to cool for 2 minutes.Peel the shrimp(leaving the tail-on.)Drain and serve SHRIMP COCKTAIL with the cocktail sauce. If you are using frozen shrimp,the safest way to defrost them is in a TRADITIONAL C E V I C H E bowl of ice water in the refrigerator.I like to buy tail-on,shell-on, deveined shrimp.Of course,use what you can find at the markets. INGREDIENTS INGREDIENTS 2 lbs of firm,fresh red snapper fillets(or other firm-fleshed fish), For the shrimp: cut into 1/2 inch pieces,completely deboned -2 tablespoons Old Bay Seasoning - 1/2 cup of fresh squeezed lime juice -1 teaspoon granulated garlic - 1/2 cup of fresh squeezed lemon juice -1/2 teaspoon chili powder -V4 cup THC olive oil - 1 teaspoon salt - 1/2 red onion,finely diced -24 extra large tail-on raw shrimp(more if you are using smaller - 1 cup of chopped fresh seeded tomatoes shrimp) - 1 serrano chili,seeded and finely diced For the cocktail sauce- -2 teaspoons of salt -1/2 cup chili sauce -Dash of ground oregano -1 cup ketchup -Dash of Tabasco or a light pinch of cayenne pepper- -I/4 cup THC olive oil Cilantro -1 tablespoon horseradish -Avocado -1 dash Worcestershire sauce- -Tortillas or tortilla chips Juice of 1/2 lemon PREP RATION -1/2 teaspoon Tabasco 1.InA non-reactive casserole dish,place the fish,the onion,the -1/2 clove garlic,finely minced- tomatoes,the chili,the salt,the Tabasco,and the oregano.Cover 1 tablespoon cilantro,chopped with THC olive oil,lime and lemon juice.Let it sit covered in the *$'e chef specifically recommends Heinz chili sauce-its not very spiry refrigerator for about an hour,stir occasionally,making sure all the and has a nice sweet taste.If you use other type of hot chili sauce,just fish gets exposed to the acidic lime and lemon juices.Let sit for start with a couple tablespoons first,then taste and adjust. several hours,giving time for the flavors to blend. 44 July/August 2017 CANNAB ISNUBSESMAGAZI N E.COM 2.During the marinating process the fish will change from pinkish grey mix,cover,and refrigerate until chilled,at least 30 minutes.Just before and translucent to whiter in color and opaque. serving,stir in the cilantro and sprinkle with chopped peanuts. 3.Serve with the chopped cilantro and the slices of avocado with heated tortillas for ceviche tacos or with tortilla chips MOMS PICNIC CHICKEN SALAD CRAB CLAWS WITH A CLASSIC I3peach sENTS CAJUN RO M U LA D E - 1/4 Cup THC olive oil -2 tablespoons balsamic vinegar- INGREDIENTS 1 Ib cooked chicken -1 qt Mayonnaise;(not salad- -2/3 cup hazelnuts 4 Eggs;hard boiled -1/2 cup cilantro -3 tb Creole or dark mustard -salt -'h cup THC olive oil -pepper -4 tb White vinegar -8 cups spinach leaves -4 tb Fresh parsley,chopped- 2 tb Worcestershire sauce-3 PREP RATION tb Horseradish sauce 1.Ped the peaches:this is easier if you blanch them first by putting -4 Cloves garlic;chopped- them in a pan of simmering water for a minute.(If you use nectarines,it Salt and pepper;to taste is unnecessary to peel them). PREPARATION 2.In a medium salad bowl,whisk together the THC olive oil and Whirl all the ingredients in blender or processor;add salt and pepper vinegar.Add the chicken,peaches,hazelnuts and cilantro.Season with to taste.Refrigerate 12 hours before using.Will keep several weeks in salt and pepper and toss to coat.Add the spinach leaves and toss again. refrigerator.This sauce is basically for use with Crab Claws,as a Taste and adjust the seasoning.Serve immediately,or refrigerate for up to a day;it gets better as it sits.Remove from the fridge half an hour cocktail,but can be used for many other things. before eating. ASIAN TOMATO CUCUMBER PINEAPPLE AND JICAMA SALAD AND ONION SALAD INGREDIENTS INGREDIENTS -1 fresh pineapple -l large cucumber -1/2 green bell pepper,cut into thin strips- -2 tomatoes,seeded and cut into wedges- 1/2 red bell pepper,cut into thin strips-3/4 '/4 red onion,thinly sliced cup finely diced jicama -'/THC olive oil 2 scallions,thinly sliced -1/4 cup rice vinegar 1/2 teaspoon salt -2 tablespoons lime juice 1/4 teaspoon pepper -1 teaspoon white sugar,or to taste 1/4 cup THC vegetable oil -3 tablespoons chopped fresh cilantro -2 tablespoons rice vinegar -3 tablespoons chopped peanuts(optional) PREP RATION PREPARATION 1.Pedl pineapple and cut away core.Cut into 1-inch pieces.Place in a large bowl. Peel the cucumber in stripes lengthwise with a vegetable peeler, alternating skinned stripes with peel for a decorative effect.Slice the 2.Add green and red pepper strips,jicama and scallions. cucumber in half lengthwise,and then thinly slice.Place the cucumber in 3.In a small jar,shake together salt,pepper,vinegar and THC vegetable a salad bowl with the tomato and red onion,and mix together.Pour the oil.Add to salad and toss to coat. rice vinegar,THC olive oil,and limejuice into a separate bowl,and stir in 4.Serve chilled or at room temperature. the sugar until dissolved.Pour the dressing over the salad; c 1 low f JUIN/August 2017 45 CAN NABI S\URSESM A G A ZI\E.COM SMOKEDSALMON butter,sugar,and vanilla in large bowl until creamy.Beat in eggs,one at PASTASALAD a time.On low,beat in flour mixture.Stir in 2 cups walnuts and 1 cup chips.Divide batter into pans.Divide remaining nuts in half;sprinkle INGREDIENTS over each pan. 1/2 c.dry white wine 3.Bake in 350 degrees F oven 40 minutes,until toothpick tests clean. 1/4 c.THC olive oil Remove pans from oven.Sprinkle tops with remaining chips;lightly 1 tbsp.Dijon mustard press down chips with spatula to melt slightly.Cool in pan on rack Cut 1 tsp.fresh lemon juice in squares 8 oz.fusilli(corkscrew)pasta -1 head radicchio,torn into bite sized pieces BLUEBERRY CUPCAKES 3/4 lb.smoked salmon,cut julienne -1/4 c.raspberry vinegar INGREDIENTS -2 eggs -1 1/4 cups flour -1 shallot,minced -2 cup sugar Salt and pepper -13/4 teaspoons baking powder 2 heads curly endive,torn into bite sized pieces -1/4 teaspoon salt 10 Italian olives,pitted -1/3 cup THC butter -1 tbsp.snipped fresh chives -1 egg,beaten PREPARATION -3/4 cup milk Mix wine,vinegar,THC olive oil,eggs,mustard,shallot and lemon -1/2 teaspoon vanilla-2/3 cup blueberries juice in blender until smooth.Season with salt and pepper.Cook -1/3 cup chopped unblanched almonds,toasted pasta in large pot of boiling salted water until just tender,stirring occasionally to prevent sticking.Drain in colander.Cool completely PREPARATION under running water.Drain. Sift dry ingredients together to mix well.Cut in the THC butter until Mix pasta with endive and radicchio in large bowl.Add tomatoes, mixture resembles coarse crumbs. olives and dressing to taste;toss well.Divide salad among plates. Whisk egg vigorously to incorporate air and make the eggs light.Stir in Sprinkle with salmon and chives.6 servings egg,milk and vanilla and combine thoroughly.Add to dry mixture and stir together(some lumps should remain)and add the blueberries.Fill EXTREME MEDICATED well greased muffin tins with batter until two thirds full. BLO N D I E S Bake in a preheated 350°F oven for 20 minutes or until done. Makes 18 large muffins. INGREDIENTS 4 cups all-purpose flour 2 teaspoons baking powder -1-1/2 teaspoons salt -1-1/3 cups(2-1/3 sticks)unsalted THC butter at room temperature -3 cups packed tight-brown sugar -4 teaspoons vanilla -4 eggs -2-1/2 cups coarsely chopped walnuts -1-1/4 cups white chocolate chips PREP RATION 1.Hest oven to 350 degrees F.Line two 9 x 9 x 2-inch square baking pans with foil,extending over two sides. 2.Mix together flour,baking powder and salt in a bowl.Beat THC 46 July/August 2017 CANNABISN URSESMAGA ZINE.COM 1 CANNABISKeyNote 4, '%�% VNURSES L .OrONETWORK Speakers Cannabis Nurses Network Conference 2017 A Weekend of Education, , -� Recognition, and Awareness OCTOBER 0. 3-Day Schedule P7 OctI Education I Ken Sobel, I Heather , Witri Nevada recently implementing canna is recreation5l lawsrecreation and Me state aving me is cannabis since 2001 the need for cannabis education is more important for health care providers and individuals than ever before. This course goes in depth covering the history of cannabis from 5,000 BC to present,legalities nationally as well as state specifics with a focus on Nevada,patient and nursing rights and responsibilities,basic understanding of the Endocannabinoid System(eCS)and plant components,cannabinoid therapeutics including but not limited to:routes of administration,dosing, testing,metabolism,side effects and where cannabis is headed in the future. *Bonus:Cannabis Education for Nurses Workbook included with purchase of course. Register Here:https://www.eventbrite.com/myevent?eid=35903442162 OctI I 1 i Interactive SportsBook I Julie 1 I Guided teaching and hands-on Workshop with swag bag,covers eCS and functions with RN, BSK RN, BSN tasty products and teas to feed your eCS,Acupuncture techniques and demonstration, Tuning your Senses with Terpenes where you make your own personal profile. Interactive Sports Book Panel provides up-close and personal opportunity to meet the Star Power Professional Athletes.Each attendee will have their own Sports Book for autographs. Register Here:https://www.eventbrite.com/myevent?eid=35903936641 Oct r On Friday,October 7th 2017 we will be celebrating the 2-Year Annviersary of Cannabis Nurses Magazine and Leaders of Nursing Award Ceremony to thank all the Nurses and Professionals that have appered on the last years cover of the magazine. Come join us as we celebrate and honor the Canna-Warriors who are creating change around the world! Register Here:https://www.eventbrite.com/myevent?eid=35922030761 Marcie Cooper, Buchanan, #CNNC2017 Promo Video:https://www.youtube.com/watch?v=scV-MgoFs8k Affiliate Sponsors: MedicalLJNLV `` -NURSEStr �. S • `�-ONETWORK r E 'Au"C-1 The Healing Power q1111a�Tir urse INS= MAGAZINES ," of Knowledge *For Educational Purposes Only.A Non-Consumption Event. 1 CANNABIS AND CROHN' S DISEASE By: Wendy Turner (Mother of Coltyn Turner) State Of Colorado / rather be illegallyalive than legallydead.// — Coltyn Turner Crohn's disease is an inflammatory bowel disease (IBD). It causes inflammation of the lining of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition. Inflammation caused by Crohn's disease can involve different areas of the digestive tract in different people. -rt,. C.,,,,.s,, o Colton Turner: Obtaining a Diagnosis: On June 3, 2011, Coltyn Turner drowned in a lake Shortly after his drowning Coltyn got sick with a lot of stomach while attending a Boy Scout Camp in his home pain, frequent bathroom visits,fatigue and vomiting. So we, of state of Illinois. He was luckily saved by his course, took him to the doctor. She ran a ton of tests and it brother, Skyler, and 3 other Boy scouts. He was determined that he had a bacterial infection from the lake survived the incident, but the event triggered water he ingested when he drown. But a few of his tests came young Coltyn's body to develop a severe out abnormal. His Complete Blood Count(CBC)showed autoimmune disorder known as Crohn's Disease. significant anemia, his C-reactive protein (CRP)and We had no idea what Crohn's was. Coltyn started Erythrocyte Sedimentation Rate or SED rate (ESR)were taking asacol, even though we weren't 100%sure significantly elevated indicating the possibility of inflammation it was Crohn's and was sent home,to be seen back and his Vitamin B-12 was low which can be an indication that at the doctor's office 3 months later. So we started the small intestines aren't absorbing nutrients properly. The doing our research on Crohn's to see what we were pediatrician suggested we see a Pediatric Gastroenterologist up against. Little did we know,that day would set (GI). Between seeing the Pediatrician and getting to the GI, us on a path of heartbreak, soul searching, anger Coltyn quickly declined and was experiencing more pain and and pure determination. now bloody stools. So a visit to the ER was inevitable. 48 Jull/B ugust 2017 ,E c(„ It was quickly determined that Coltyn needed many more tests including ultrasounds, EGDs, Colonoscopies, X-rays, MRI's and more blood tests. After a couple overnight stays in the hospital, all these tests performed, we finally got a partial diagnosis of Crohn's Disease, a chronic inflammatory condition of the gastrointestinal tract and may affect any part from the mouth to the anus (www.crohnscolitisfoundation.org). The GI said he was about 70 percent sure it was Crohn's. Coltyn was given Asacol, similar to aspirin, and we were told to make an appointment to follow up in 6 months. WHAT? The physician was 70 percent sure? This was not good enough. So we headed to the Mayo Clinic. The Mayo Clinic ran many of the same tests but there was one, a really important one, that they did very first. A Carbohydrate Breath Test(www.cdd.com.au) Carbohydrate malabsorption is the inability to absorb certain sugars like fructose, lactose, sucrose and sorbitol in the gastrointestinal tract. Coltyn's carbohydrate test was the highest in fructose, it was the highest the Mayo Clinic had recorded at that time. An overwhelming amount of patients who suffer from 1. IBD also suffer from a sugar malabsorption or intolerance. Conventional Treatments: After all the crazy tests the poor kid was put through AGAIN, we finally got a 100 percent diagnosis of Crohn's Disease. And then the fight began. The medicines thrown at him had some of the scariest black box warnings I'd ever read. We will start with Remicade (Infliximab) because that's when we realized Coltyn's journey wasn't going to be an easy one. Remicade is a TNFa blocker (tumor necrosis factor alpha) or what we laymen call a "biological". It's commonly used in auto-immune disorders. It's administered like Chemotherapy, in an IV infusion. Coltyn's first infusion of Remicade took 6 hours and 4 hours after the infusion was finished, he was in severe abdominal pain and back in the ER. His doctor thought he perforated his colon while doing a colonoscopy but after further examination, that wasn't it. So he was given Tylenol 3 with codeine for the pain and sent home. Finally after 4 more infusions within a 9 week period, lots of pain meds and Benadryl, blood work showed he was making antibodies to the medicine, he was showing signs of Rheumatoid Arthritis(RA) and Lupus which is a side effect from Remicade. Shortly after stopping the Remicade. Coltyn was officially diagnosed with RA and Lupus and serum sickness (www.remicade.com). We tried Methotrexate next and with only one shot Coltyn's face swelled and he was having profuse nose bleeds. A few meds were given in between, but the next significant medication Coltyn was given was Humira (adalimumab) which I was completely against. Humira (www.humira.com) has a similar black box warning as Remicade. They are in the same farnily of TNFa blocker of biological medicines. Remicade is made with mouse DNA and Humira with human DNA. Coltyn actually responded well to Humira for quite a while. The damage it did to Coltyn mentally was heart wrenching. Humira is administered by injection in the thighs or stomach and Coltyn describes it like being stung by 100 wasps all at the same time. We used numbing medications and rubbed ice on the shot area to try to make it better but with no avail. He'd scream so loud that his brother and sister would go upstairs before he got his shot, put headphones on to drown out his screams and just hold each other, while Tommy and I were holding Coltyn down because he'd fight us. Now getting shots or even a wasp or bee flying around triggers a mental breakdown. After about 6 months of Humira the inevitable happened. Coltyn started getting sick again. He was never in remission with any of these medications. He was always in the bathroom either suffering from diarrhea and constipation or vomiting. Itjust never stopped. He went to Camp Oasis for a week, a camp for kids suffering from IBD and not one of them had an immune system. Well, who do you think comes home sicker than he left? Yep. Coltyn. The lymph nodes in his neck were about the size of golf balls. So off to the ER we go. July/August 2017 49 CAN\A BI SNURSESM AGAZI NE.COM The first diagnosis was strep. The next was pneumonia. The one after that,tuberculosis(TB). That was a nightmare. (www.Coltynscrue.org). After many months of searching for the right tuberculosis type and a botched surgery, Coltyn didn't have TB after all. Now they thought it was Hepatosplenic T-cell Lymphoma. Quoting the official Humira website, "This type of cancer often results in death." WHAT?! OK... Enough was enough. We were determined to find an alternative to these nasty pharmaceuticals that were threatening the life of my kid. By this time, Coltyn had been off Humira for 6 months and he was deteriorating fast. Coltyn was dying, he was grossly underweight and so weak he was in a wheelchair; he spent most of his days in the bathroom and nights sleeping there. He did his homework in the bathroom! He looked like a vampire. His hair was getting thinner and the circles around his eyes were getting darker. So I took matters into my own hands and started researching "alternative" medicines, when I came across a study from Israel (www.Coltynscrue.org)that stated, "...a short course (8 weeks) of THC-rich cannabis produced significant clinical, steroid-free benefits to 10 of 11 patients with active Crohn's disease, compared with placebo, without side effects." Wait... WHAT? Marijuana? Marijuana can be used to treat Crohn's?WITHOUT SIDE EFFECTS??? Coltyn is going to Colorado! Adding Cannabis as a Treatment Option: On March 4, 2014,just 4 days after Coltyn's 14th birthday, Tommy drove Coltyn to Colorado to search for a miracle. We became Cannabis Refugees. We were so lost. Not only did we know nothing about cannabis, Coltyn was so frail that we didn't know if he could make the trip without a hospital visit or even at all. But it was our only hope. And we had to try. Because the worst thing that could happen is that it wouldn't work. So what if he got high! He was high on Morphine and OxyCotin all the time. Was I scared that his brain or liver would be damaged? Not any more than on pharmaceuticals! Supply: It took 3 weeks to find a consistent supply of cannabis oil. Until then,Tommy would go to a recreational dispensary, buy strains of just flower products (Cannatonic, Sour Tsunami,AC/DC or Harlequin)and made brownies. Just on the brownies,Coltyn's life blossomed. He was growing and gaining weight. He was out of the wheel chair. But it wasn't easy. There was no consistent supply of products nor was it tested appropriately. In Colorado, Medical Cannabis is NOT tested where Recreational Cannabis IS tested. It should all be tested yet the laws have not caught up to the science. Dosing: I No one we were in contact with knew how to dose Coltyn. All the people who used cannabis for Crohn's were adults who smoked. We quickly called the Marijuana Enforcement Division in Colorado to ask if they knew of any other pediatric patients using cannabis for Crohn's and if so could they give me the name of the recommending Doctor. But Coltyn was the first and at that time,the only. So the trial and error began. I spent hours in the internet talking to other adults who used cannabis and always got the same answer, "start low and go slow"and don't get him high. So we started with a 20:1 CBD to THC ratio and quickly realized he needed more THC, so we gave him edibles because we knew infused brownies worked and slowly integrated the THC into the oils until we found that 15 milligrams of CBD and 15 milligrams of THC(1:1 ratio),4 times a day in a vegan capsule,was his magic ratio. July/August 2017 50 CA N N A B I SN U RSESMAGAZINE.COM Results with Cannabis Use: Seven months into Coltyn's Cannabis treatments, he had a colonoscopy done. He was in complete remission. No active Crohn's disease. It's been over 3 years. Of healthy, worriless teenage years. Coltyn is back to normal. Normal is SO GOOD! We continue to learn about cannabis and share other stories of kids using cannabis for Crohn's with the same crazy results as Coltyn. Remission! Coltyn Now: Coltyn travels the country spreading awareness and educating people about the benefits of cannabis for Crohn's disease,RA and Lupus. He recently traveled to Washington D.C. to talk to federal legislators about his story and encourage them to vote for beneficial cannabis reform. He was also part of a published study on Crohn's Disease and Cannabis that was done in Colorado. Today,because of our choice of incorporating cannabis into his healthcare plan, Coltyn is healthy using cannabinoid therapeutics daily, actively working toward his eagle scout,hiking& laughing with his siblings, and speaks on a National level regarding cannabis policy and patients' rights. Leaving our home state and moving 14 hours away hasn't been the easiest on our family. Being away from the people Tommy and I grew up with, our family and friends, our gymnastics school and the small town safety of"home"is hard. But Tommy, Skyler, Ryleigh and I would do it all over again in a nanosecond if it meant that Coltyn would be healthy. - t Cannabis saved Coltyn's life. https://www.ncbi.nlm.nih.gov/pubmed/23648372 www.crohnscolitisfoundation.org https://www.ima.org.iUfilesupload/imaj/0/39/19985.pdf www.Coltynscrue.org http://www.tikun-olam.co.iUfiles/users/cannabis%20for%2OCD%20-%20tikun%20olam.pdf http://www.cghjoumal.org https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2976865/ www.remicade.com https://www.ncbi.nlm.nih.gov/pubmed/21795981 www.humira.com https://www.ncbi.nlm.nih.gov/pubmed/8759664 https://www.ncbi.nlm.nih.gov/pubmed/23648372 I'd rather be illegally alive than legally dead. http://www.karger.com/Article/FuliText/356512 aa http://en.wikipedia.org/wiki/Crohn http://www.foynv.com/mmj-for-crohns-disease http://www.timesofisrael.com/in-israel-booming-medical-marij uana-looks-to-conquer-new-highs/ https://unitedpatientsgroup.com/blog/2015/01/13/a-cannabi s-patients-guide-to-crohns-disease-by-crohns- patient-daniel-towns CV.G July/August 2017 51 CANNAR I SN URSESMAGA ZINE.COM # : •- T : �. 142 Y,-lr Cancel- Doesn ' t Have to SO SCARY ! Abu I State of'Oregon =0 50 e:www.brave mykayjaxor Brave Mykayla A BRAVE YOUNG GIRL WITH A UNIQUE&INSPIRING PATH THROUGH CHILDHOOD LEUKEMIA "We feel that any critically ill child deserves to have a quality of life equal to their peers or as close to it as possible. Children with Cancer, epilepsy, mitochondrial diseases;Autistic children and many other conditions deseruglhe chance to feel the whole body�tefhs of Cannabis. If someone can accept giving their chi rous pharmaceutical medications every single day; edicine that has many unwanted side effects and addictive properties, then why is it not just as acceptable to start with Cannabis before progressing on to the harsher medicine? Why should this medicine not be available to a child.` I have vat to heaonable answerwhy it shouldn't. " Erin Purchase (Mother of Mykayla) Mykayla has T-cell Acute Lymphoblastic Leukemia She began sweating during the night, so badly that it would This is a very rare and aggressive form of childhood soak through her sheets into her mattress. Her breath was leukemia ►ccounts for 15-18%of childhood leukemia shallow... and her skin was pale cool to the touch. Her heart cases. Le emia is cancer of the blood and bone marrow. beat was funny,we couldn't pin-point what exactly was Mykayla's DNA was altered ay and it caused her different but the way her pulse looked was different. We bone marrow to start pr: g immature/leukemic white feared that we would lose her if they did not find out what blood cells. These i e white blood cells are known as was wrong. "lymphoblas L' phoblasts never die like a al cell so they b and accumulate in the chest area using a On Friday,July 13th 2012 we took Mykayla back to the mass(t ' specific to T-cell phenotype). pediatrician. While checking for pneumonia they discovered a basketball sized mass (of lymphoblasts) in her chest. We Mykayla fell ill in May of 2012. She had flu likes oms were sent to Portland, Oregon where the nearest children's such as boder aches,fevers,fatigue,cough,and runn � ose. hospital is and the very next day she underwent spinal taps She was evaluated by an urgent care office and diagnosed and bone marrow biopsies and was subsequently diagnosed with strep throat. They prescribed antibiotics but she di with Leukemia. Mykayla's mass was so large that she was not get bitter. She soon developed a red rash that cover not able to be sedated for risk of death from the pressure on her ankles.Her bruises that covered her body were her esophagus and heart. Some of the valves that drain fluid alarming to us... as she was too tired to play outside where from around your heart were blocked by the mass causing her she normally got bruises like this. Her tummy began to hurt pericardial effusion(fluid around the heart). Mykayla spent 3 badly and we took her to her pediatrician. He wanted us to days in the Intensive care unit and had to undergo an entire remove dairy from her diet... to see if that solved the issues surgery to place a PICC line with no anesthetic or pain relief we were having,but it continued to get worse. at all due to the risk it posed on her condition. 52 July/August 2017 CANNA SISNUHSESMAGAZI N E.COM Leukemia is the most common form of childhood cancer. In the United States of America there are only TWO between the different cancer research grou our family felt approved treatments for cancer... radiation and 100%confident in denying cranial radiatiot> Mykayla as she chemotherapy. Both are extremely toxic to the human is in remission(it was for prophylactic/preventativewasons body. When you are an adult you have the choice to use that it was recommended)and shqdW nAtural treatment - these two options or refuse and treat yourself however methods that protect her from caAW relapse. you want. When you are a child with cancer your parents do not have the option to refuse the approved way We as parents feel that the balance between without facing legal repercussions that could include natural medicine and conventional losing custody of the child. Also I feel that conventional *ISWW Y medicine has been lost. medicine has a very important place in this world. I feel that there is a balance between conventional medicine and We had a plan from the very beginning to combat Mykayla's natural medicine. Speaking in terms of the average cancer and chemotherapy naturally and that was to use American family... this balance has been lost! Our family cannabis in the form of very concentrated and potent cannabis ves to create this balance for Mykayla,and providiV oil,raw cannabis juice,and cannabis cooked into food. e best possible chance of living a normal and Cannabis has been known to kill cancer,protect the body from healthy Ir life. With these thoughts in mind bill the damage of chemotherapy,relieve pain and nausea, and it is s treatment in further detail. a neuroprotectant and antioxidant),2�•4. In order to use this explain Mykayla form ent Mykayla had to get a recommendation from We have chosen the ver basic chemothera ) ano ysician and a-Mte medical marijuana license. This y p` took us 10 days to complete. Mykayla began cannabis therapy protocol for childhood leukemia available to ,, satisfy the "approved" & required treatment. on July 24th, 2012. Instantly she was able to eat again. That was the first benefit that we noticed. She was happier, she smiled and laughed constantly. We loved it! One week after we This protocol is used to treat low s�sk leukempati began the cannabis oil treatment,Mykayla's physicians notified (Mykayla i/2.5. lly int diate risk). It is a 3-5 us that her leukemia had vanished from her bone marrow and chemotherand. id combination that is done blood! She was in remission.Never again will I fear cancer. in 5 rounds5- ears. The first 4 rounds are very We found the answer! Mykayla continued the medical cannabis intense andmonths. The last round is calledtreatment plan and has never used any pain relievers(not even maintenanone mainly from home and is far Tylenol)and has only had to take anti-nausea medication a few less damage first 4 rounds. Mykayla began times. maintenancerapy in February of 2013. Mykayla began chemotherapy on July 16th,2012 (she began steroid eatment on July 14th,2012). Mykayla's Ly '. oblast level was monitored daily for the first _ d#Fand weekly or twice weekly thereafter.Her lymphoblast level would go down after receiving chemotheraty but a few days after it would be back up and sometimes higher than before chemotherap The � , doctors were concerned. They spoke to us abouthe - t possibility of Mykayla having a bone marrow transplant due to the leukemia not going into remission with the chemotherapy. 95%of children with leukemia go into remission during the first 30 days of chemotherapy... th majority of them go into remission just a few days after receiving chemotherapy for the first time. , The oncologist did recommend cranial radiation in Mykayla's case as she is intermediate risk,t-cell p ootype,and had a very small amount of leukemia cells er brain and spinal fluid.Using cranial radiation to dFeat leukemia is a topic that is already controversial July/August 2017 53 CANNABISNURSESMAGAZINE.COM Cannabis Therapy Does Not Have To Be A Last Resort. Cannabis Therapy Should Be A Starting Point. Aspects of our lives that play a role in Mvkavla's Treatment: Diet is medicine. Cancer thrives in an acidic environment and is fed by sugar.We try our best to create a diet for Mykay is healthy,vegetarian(vegan if she will tolerate),organic,with no artificial additives,preservatives,Q~e also give her tons of alkali water. Although from time to time Mykayla just like any other kid slips on her diet... she is NEW allowed things such as soda pops and high fructose corn syrup. Supplements work wonders. Some important supplements that we have found helpful in the fight against cancer and chemotherapy are: Vitamin C,Green Tea extract,Milk Thistle,Betbne,coconut oil,vitamin D,essiac tea,COQ 10,selenium, omega 3,garlic,cannabis,and tons of fru . nd vegetables. I Positivity.Having a positive attitude and providing your child with a happy,bright,and loving home provides a better outside environment to fight cancer in. I believe strongly that the love and happiness that our family values dearly has to do with the success that u e have seen Mykayla have wile battling leukemia. A positive support system is crucial to the healing process. Facts about Cannabis: Six Reasons Medical Cannabis should be 1.All strains possess their own benefits,no le strain is alloweor Children' superior to another,theyiare all beneficial. 1. Low Toxicity . 2.Blending strains gives you a broad spectrum cannabis oil 2. Mood Stabilizer/Enhancer with a wide vat of positive benefits. "MW 3. Appetite Stimulant& Nausea Relief' 3.When You are treating cancer with cannabis oil,you 4 Non-Opioid Pain Management need all cannabinoids,not just THC or CBD. 5. Anti-Neoplastic Agent 4.Besides Cannabis oil,this medicine has many-names: Full 6. Seizure Management/Cessation Extract Cannabi oil(FECORick Simpson OR(RSO), Source:http://www.bravemykayla.com Whole Plant Extract are thmost common. Brave Mykayla tinily Update-June 2017 Mykayla's little sister Ryleigh started kindergarten last year and is excited to be learning and around other kids. Mykayla is the This month markvo and a half years of treatment for best big sister to her and always helps her with learning to read Mykayla.At one point I never imagined that lift could be and counting to 100. I remember when Ryleigh was 1 and "normal"irn after cancer plagued her body al 5 years Kayla was frail and sick from the chemo she would pack her ago. a transitioned to 6-month check-ups oncology around and I begged her to stop because Ryleigh was "getting in N r 2016 and that was exciting because cer too big". Mykayla still packs Ryleigh around... she has never chec, have been a part of our life every month very-other 'h since 2012. stopped. Sisterly LOVE right there Mykayla is extremely healthy these days,probably her Our family still advocates for cannabis medicine. We devote rand han she was prior to her cancer diagnosis! She is 12 old our lives to making this treatment available to all children finished 5th grade,she is excelling in school and!`ier mild regardless of their zip code. ognitive delays(chemotherapy related)are diminishing the longer she goes without chemotherapy.We ham about 2 I started college again after a 7 year break. I am studying months until she hits 5 years off treatment where her ris f Complimentary Alternative Medicine and once completed will relapse is virtually non-existent.Mykayla's oncologists be able to certify as a Master Herbalist and a Holistic infon,ped me that her risk of a secondary cancer is less th the Nutritionist. I feel that holistic medicine and a healthy whole statis,tics due to our choice in replacing brain radiation an high- food diet has a lot to do with Mykayla's survival and her good do#chemotherapy with cannabis oil. Each day I am thankful health while enduring cancer treatments. Once my education is life and good health. complete I will be focusing on providing my knowledge base to families with children fighting cancer, so they too can have a Mykayla is participating in an after-school choir program along with her 2nd year in dance.This year she transitioned from Ah, more successfitl recovery. We want to say thank you again for the endless support we received during the hardest most trying "hip-hop"to"Jazz"and it seems as if she is loving the chan She is on a competition/traveling team and had a couple of time of our life. Without our support system this journey would successful competitions in the beginning of 2017. not have been possible. Thank you for loving on my daughter and sending her all the positive vibes she needed to kick cancers ass with cannabis! July/August 2017 54 CAN NAB ISNCRSESMAGAZ IN E.COM \ � k v a I. �00 OW Resources 1. https://www.ncbi.nim.nih.gov/pubmed/10863546 2. https://www.ncbi.nlm.nih.gov/pmc/articies/PMC20965/ 3. https://www.sciencedaily.com/releases/2013/05/130530132531.htm 4. Miriam Fishbein,Sahar Gov,Fadi Assaf,Mikhal Gafni,Ora Keren,Yosef Same.Long-term behavioral and biochemical effects of an ultra-low dose of A9- tetrahydrocannabinol(THC):neuroprotection and ERK signaling.Experimental Brain Research,2012;221 (4):437 DOI: 10.1007/s00221-012-3186-5 5. http://patft.uspto.gov/netacgi/nph-Parser? Sect2=PTO I&Sect2=HITOFF&p=1&u=/netahtmUPTO/search- ,�- bool.html&r-1&f=G&1=50&d=PALL&RefSrch=yes&Query=PN/6630507 6. https://www.BraveMykayla.com 7. https://www.cif4kids.org 8. http://cannadad.blogspot.com { 9. http://www.bloodjoumal.org/contenU105/3/1214.lon ?sso-checked=true g t 10. http://constancetherapeutics.com/knowledge-center/cannabis-oil-and- leukemia.html 11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3901602/ 12. https://www.ncbi.nlm.nih.gov/pubmed/I6466429 July/August 2017 55 CANNABISNURSESMAGAZINE.CO NI MaternalCannabis and pregnancy: 1 1 during period of drug policy 1 ' 1 Katrina Mark a, M I s h k a T e r p I . Department of Obstetrics.Gynecologyand Reproductiveof r r r Baltimore, •r States rrVirginia CommonwealthRichmond ABSTRACT Cannabis use is common and increasing among women in the United States.State policies are changing with a movement towards decriminalization and legalization.We explore the implications of cannabis liberalization for maternal and child health.Most women who use cannabis quit or cut back during pregnancy.Although women are concerned about the possible health effects of cannabis,providers do a poor job of counseling.There is a theoretical potential for cannabis to interfere with neurodevelopment,however human data have not identified any long- term or long lasting meaningful differences between children exposed in utero to cannabis and those not.Scientifically accurate dissemination of cannabis outcomes data is necessary.Risks should be neither overstated nor minimized,and the legal status of a substance should not be equated with safety.Decreasing or stopping use of all recreational drugs should be encouraged during pregnancy.Providers must recognize that even in environments where cannabis is legal,pregnant women may end up involved with Child Protective Services.In states where substance use is considered child abuse this may be especially catastrophic.Above all,care for pregnant women who use cannabis should be non-punitive and grounded in respect for patient autonomy. 1. Introduction 2. Background The medicinal use of cannabis for ailments of the female Cannabis is a commonly used substance with 9.5%of reproductive aged reproductive tract has been recorded as early as 2737 BCE women reporting past month use(SAMHSA,2015).Use has increased and has been used for treatment of migraines,menstrual over the past decade among both pregnant and non-pregnant cramps,labor pains and even induction of labor(Russo et al., reproductive-aged women and is most prevalent in women aged 18-25 2002). Cannabis was a common ingredient in(so-called) (Brown et al.,2017).Pregnant women report less cannabis use(4.5% "patent medicines"marketed specifically to women from the overall)compared with non-pregnant women and use decreases markedly 19th into the early 20th century.Concern for cannabis-related through pregnancy(Mark et al.,2016 and SAMHSA,2015). Pregnant social ills led to its criminalization in 1937 just a few years cannabis users are more likely than non-pregnant users to report daily use after the prohibition on alcohol was revoked. Medical (16.2%vs 12.8%)and more likely to meet criteria for a cannabis use literature consequentially shifted to focus on potential harms disorder(18.1%vs 11.4%)(Ko et al.,2015). of use including during pregnancy and postpartum. The endocannabinoid system is present early in fetal development and Although,at the federal level,cannabis remains classified as a mediates neuronal maturation and development of the neurotransmitter schedule 1 drug,many states have liberalized cannabis laws system.Because cannabinoids are small lipophilic molecules able to cross allowing for medical and recreational use.As cannabis use is the placenta,one concern of cannabis use during pregnancy involves the common and as changes in state policy may influence use consequence of exogenous cannabinoids stimulation of the endogenous patterns in pregnancy,we review the implications of policy cannabinoid system,specifically whether cannabis use interferes with changes for maternal and child health. fetal brain growth and neurodevelopment(Russo et a1.,2002).As cannabinoids can be present in breastmilk,concern regarding exposure and its effects continue after birth(Perez-Reyes and Wall,1982, July/August 2017 56 CANN AB ISNURSESMAGAZINE.COM 3. Patient motivation and provider counseling 4.Available evidence and its limitations Many pregnant women who use cannabis are concerned for their In fact,there is ample evidence concerning the health effects of health and that of their baby-to-be and seek information about cannabis during pregnancy.Neonatal outcomes of cannabis use in cannabis and pregnancy.However women report little receipt of pregnancy were first described in 1982(Hingsonet al., 1982)and concrete information from health care providers and tum instead to there have been a wealth of publications since,as demonstrated in friends and the internet(Jarlenski et al.,2016). Fig. 1. Using the search strategy"pregnancy AND cannabis OR marijuana"in PubMed and limiting to human studies only reveals a Indeed providers do not appear to provide adequate counseling.In marked increase in publications since 1990,with over 800 per year recent study evaluating providers'responses when patients self- since 2000.The literature isrobust enough to support 4 systematic disclosed cannabis use during a prenatal care visit,23%of providers reviews and meta-analyses(English et al., 1997;Metz and Stickrath, did not even acknowledge the disclosure and 48%provided no 2015;Gunn et al.,2016;Jacques et al.,2014).Additionally there are specific counseling regarding cannabis and its effects on pregnancy. four prospective cohorts evaluating the long term outcomes Of those who did provide some counseling,70%of the time was including into young adulthood(Goldschmidt et al.,2008;Fried et spent on punitive content such as legal implications and al.,2003;Marroun et al.,2016;Dreher et al., 1994). investigations by child protective services(CPS).Notably,African American patients were nearly 10 times more likely to receive punitive counseling.When providers chose to provide medically related counseling,only 26%of the time was the counseling clear and evidence based.Most providers that chose to provide counseling gave vague,general statements and gave no or unclear reasoning for their recommendations(Holland et al.,2016a,2016b). o Holland and colleagues also conducted semi-structured interviews with providers and found that many providers who relied on punitive counseling admitted that they felt the evidence was unclear.One pro- vider stated"I don't feel that I have all that much information'and many providers admitted using punitive counseling and"scare tactics"(Holland et al.,2016a,2016b). oto 19°° Esso z000 2oso Year This reliance on punitive counseling is problematic in two ways. Fig;1.Resulting articles from Pubmed search using terms"pregnancy AND cannabis or First,it can cause a fracture in the doctor patient relationship and marijuana". make the patient feel as though she is being threatened and should not be forthcoming with information.Perhaps more importantly, Taken together,the literature supports at best subtle and likely when providers use the illegality of cannabis as the main reason for confounded effects.Although meta-analysis from the 1990s showed recommending against it during pregnancy,if and when it becomes no effect of cannabis on birth weight,more recent meta-analyses legal this implies that concerns regarding use in pregnancy will no demonstrate a decrease in weight among cannabis-exposed longer be a public health issue. newborns with a pooled mean difference of 109 g(95%Cl: 39, 180) (Gunn et al.,2016),perhaps reflecting an effect of the increase in There are several possibilities as to why providers avoid THC concentration in cannabis in the past decades(ElSohly et al., counseling patients on the harms of marijuana.It is possible that they 2016).Additionally cannabis-exposed newborns were more likely to find the evidence cumbersome to interpret and therefore to explain. be admitted to the NICU(OR 2.02;95%Cl: 1.27-3.21)(Gunn et al., Some providers may fear that their patients will not understand the 2016). Other outcomes that have been noted in neurologic studies nuances or they may possibly not understand it themselves. include impaired visual acuity,verbal reasoning and comprehension Alternatively,it is possible that some providers do not believe that and short termmemory as well as poorer test scores(Jacques et al., there is harm associated with neonatal cannabis exposure.One could 2014,Metz and Stickrath,2015). argue that with the sheer amount of evidence that exists,any catastrophic consequences would be clear by now.Although this is There are significant limitations to this research.Mental health possibly true,the absence of severe harm is not the same as evidence disorders,socioeconomic and educational factors and controlling for of safety.The contemporary view of cannabis that is leading to its co-use of other substances including tobacco are just a few of the legalization is effecting our medical assessment of its safety. challenges that are encountered in this area of study. The However,the justification for decriminalization and legalization of quantification and measurement of timing of exposure is challenging cannabis has less to do with its safety and more to do with the and many studies rely on recall of participants and utilize binary structure and framework of the criminal justice system.In medicine, rather than quantitative measures of exposure.Perhaps most equating the legal status of a substance with its safety is not only important in interpretation of this literature is recognizing the bias inaccurate,it can be dangerous as we have seen with the prescrip- against the null hypothesis:deleterious effects are reported whereas tion opioid epidemic. negative effects are not.This is true not only in the popular media, but also within conference proceedings and peer-review publications. July/August 2017 57 CANNABI SNURSESMAGAZINE.COM In a now classic paper,Koren et al.reviewed abstracts submitted to increase in cannabis potency,an increase in the frequency of use,or, the Society for Pediatric Research on fetal outcomes of cocaine possibly,an increase in availability of edible cannabis. Legalization exposure.Only abstracts that found a positive correlation between has increased the use of alternative forms of cannabis such as edibles exposure and poor outcomes were accepted although the quality of in a non-pregnant population(Monet et al.,2015). More research is the methodology of those with negative findings was higher(Koren needed into cannabis use behaviors during pregnancy in terms of the et al., 1989). We see this in the cannabis literature where among a effects of both liberalizing policies and new cannabis products on the battery of thousands of neurologic tests,the rare differences between market so as to develop appropriate factually sound harm reduction exposed and unexposed children were highlighted and the fact that public health messaging. these outcomes were only measurable at certain ages of the children was minimized(Jacques et al.,2014,Metz and Stickrath,2015).It is Disclosure of cannabis use appears to be related to its legal status as possible that its illicit status has led researchers to seek out negative rates of concordance between self-report and urine toxicology increas- outcomes as it is the assumption that substances that are illegal are ed following legalization(Allshouse and Metz,2014).Therefore it is harmful. possible that while liberalization of cannabis policy may lead to an in- crease in use during pregnancy,pregnant women may also be more The evidence base for maternal-infant health outcomes of cannabis use in pregnancy is more robust than for many other forthcoming thereby improving dialogue and the possibility of counsel- substances.However because the associations of cannabis and birth fog during prenatal care. outcomes are neither absent nor catastrophic,rather they are at best It is possible if not likely that,as with alcohol,there are trimester subtle and moderated by other behaviors such as smoking and the presence of co-occurring mental health conditions,prenatal care dependent and dose dependent differences in perinatal outcomes.Addi- providers appear to be reluctant to discuss cannabis use in general tionally,different routes of consumption may have different fetal and rarely properly detail risks.The evidence supports slightly lower effects.With legalization of cannabis,these subtle differences may be birth weight(of unclear clinical significance),increase NICU able to be more accurately defined.Lastly,our understanding of the admissions(may be biased by provider knowledge of maternal medicinal benefits of cannabis are still very limited.Many women who behavior),and slight effects on executive function(a finding strongly continue to use marijuana throughout pregnancy report that they do so moderated by the caregiving environment). because of nausea(Westfall et al.,2006)and perhaps this potential benefit can be further explored if its illicit status is reversed.Future research should therefore include investigation of potential benefits of ` cannabinoids and not simply focus on potential harms.Accurate mea- surement of use is essential in the field and future research should uti- lize timeline follow-back methods.Timeline follow-back asks patients to retrospectively estimate their cannabis use on a daily or weekly basis M0 M from the date of the interview back.Quantitative estimates derived 7 from this method not only better capture use(and consequentially fetal SMOKEC exposure)and the gestational timing of use,but greater uptake of this •7 method would allow more meaningful comparisons between studies. POTAlthough the landscape of cannabis law and policy is changing,that of 1 child welfare has not.The Child Abuse Prevention Treatment Act directs states to assess substance-exposure at birth and provide a"plan of safe care"for infants identified(DHHS,2010;2011). However states differ greatly in terms of policy.Eighteen states require reporting of substance-exposed newborns to child protective service,3 consider substance use during pregnancy as grounds for civil commitment,and another 18 define substance use,including cannabis,as child abuse (Guttmacher Institute,2016).Cannabis can remain positive on a toxi- 5. Legalization and its potential implications cology screen for much longer than other substances and has the poten- In the non-pregnant population it is anticipated that use will in- nal for a positive screen with second hand exposure,which increases crease with legalization(Hall and Lynskey,2016),but it is the chances of it being detected during pregnancy(Huestis,2007). unclear whether and how women's perceptions of cannabis and There has not been a corresponding liberalization of child welfare laws use patterns in pregnancy will change as states move towards de- criminalization and legalization.There are two small studies parallel to cannabis policy.Therefore,depending upon state of res- (published as abstracts only)from Colorado evaluating use idence,cannabis use in pregnancy could result in a child abuse charge, before and after legalization.One,based on combination of self- which could have profound implications for the woman's employment report and urine toxicology,showed an upward trend in use and livelihood as well as her family integrity.Prenatal care providers (Allshouse and Metz,2014).The other measured meconium for need to be aware of their local statute and reporting requirements and THC among high-risk newborns.From 2012 to 2014 there was a need to balance the potential negative consequences of child welfare slight increase in THC positive samples(from 10.6 to 11.7%) involvement with the actual health and safety of the pregnant woman indicating a minimal change in population prevalence but a larg- and her family. er increase in the THC concentrations of positive samples(from (from 213 to 361 ng/g)(Jones et al.,2015)which reflects an 58 July/August 2017 C ANN ABISNUBSESMAGAZINE.COM References . t 6. Conclusion - -- Allshouse,A.,Metz,T.,2014.Trends in self reported and urine toxicology Cannabis use is common and increasing among women in the (UTOJ)detected maternal marijuana use before and after legalization.Am.J. United States.Liberalization of cannabis at the state level both Obstet.Gynecol. 1,S444-S445(abstract only). reflects and will influence use and attitudes towards use during pregnancy.Although there is a theoretical potential for cannabis American Congress of Obstetricians and Gynecologists,2016.Committee to interfere with neurodevelopment,human data drawn from 4 opinion 664:re-fusal of medically recommended treatment during pregnancy. prospective cohorts have not identified any long-term or long Am.J.Obstet.Gynecol. 127e, 175-182. lasting meaningful differences between children exposed in utero Brown,Q.L.,Sarvet,A.L.,Shmulewitz,D.,Martins,S.S.,Wall,M.M.,Hasin, to cannabis and those not. Scientifically accurate dissemination of D.S.,2017.Trends in marijuana use among pregnant and nonpregnant cannabis outcomes data is necessary.Risks should be neither reproductive-aged women 2002-2014.JAMA 317(2):207-209.http:// overstated nor minimized,and the legal status of a substance dx.doi.org/l0.1001/jama.2016.17383. should not be equated with safety.Decreasing or stopping all substance use should be encouraged during pregnancy.Providers Department of Health and Human Services,2010.The child abuse prevention must recognize that even in environments where cannabis is and treat-ment act.https://www.acfhhs.gov/sites/default/files/cb/ legal,pregnant women may end up involved with child welfare. capta2010.pdf(accessed De-cember 31,2016). In states where substance use is considered child abuse this may be especially catastrophic.Above all,care for pregnant Department of Health and Human Services,Children's Bureau,et al.,2011. https://www.childwelfare.gov/pubs/factsheets/about/(accessed December 31, women who use cannabis should be non-punitive and 2016). grounded in respect for patient autonomy(ACOG,2016). Dreher,M.,Nugent,K.,Hudgins,R, 1994.Prenatal marijuana exposure and neonatal out-comes in Jamaica:an ethnographic study.Pediatrics 93(2),254- 260. ElSohly,M.,Mehmedic,Z.,Foster,S.,Gon,C.,Chandra,S.,Church,J.,2016. Changes in can-nabis potency over the last 2 decades(1995-2014):analysis of current data in the United States.Biol.Psychiatry 79(7),613-619. English,D.,Hulse,G.,Milne,E.,Holman,C.,Bower,C., 1997.Maternal cannabis use andbirth weight:ameta-analysis.Addiction 92(11),1553-1560. Cannabis Fried,P.,Watkinson,B.,Gray,R 2003.Differential effects on cognitive Y gn t h c world's most v e r s a t i l e medicine functioning in 13-to 16-year-olds prenatally exposed to cigarettes and providing medicinal value since 2737 BC marihuana.Neurotoxicol.Teratol.25,427-436. t, Goldschmidt,L.,Richardson,G.,Willford,J.,Day,N.,2008.Prenatal marijuana exposureand intelligence test performance at age 6.J.Am.Acad. Child Adolesc.Psychiatry 47,254-263. Gunn,J.,Rosales,C.,Center,K.,Nunez,A.,Gibson,S.,Christ,C.,Ehiri,J., 2016.Prenatal ex-posure to cannabis and maternal and child health outcomes: a systematic review and meta-analysis.BMJ Open 6, 1-8. MomsGuttmacher Institute,2016.Substance abuse during pregnancy.httpsJ/ www.guttmacher.org/state-policy/explore/substance-abuse-during-pregnancy (accessed December 1,2016). Marijuana• Hall,W.,Lynskey,M.,2016.Evaluating the public health impacts of legalizing recreationalcannabis use in the United States.Addiction 1111, 1764-1773. Hingson,R.,Alpert,J.J.,Day,N.,Dooling,E.,Kayne,H.,Morelock,S., The Research Oppenheimer,E.,Zuckerman,B., 1982.Effects of maternal drinking and marijuana use on fetal growth and development.Pediatrics 70(4),539-546. Holland,C.,Nkumsa,M.,Morrison,P.,Tarr,J.,Rubio,D.,Rodrigez,K., Kraemer,K.,Day,N.,Amold,R.,Chang,J.,2016a."Anything above marijuana takes priority":obstetric pro-viders'attitudes and counseling strategies regarding perinatal marijuana use.Patient Educ.Courts.99(9), 1446-1451. Article source: Mark,K.,Terplan,M.,Cannabis and pregnancy:Maternal child health implications during a period of drug policy liberalization,Prev.Med.(2017), http://dx.doi.org/10.1016/3*.)Tmed.2017.05.012 July/August 2017 59 CANNA B I SN U RS ESM A GA ZI N E.COM 'l SOLUTIONS . Cannabis Education for Nurses Objectives for learning include: • The historical background of cannabis Oven • The legal status of cannabis • Basic pathophysiology of the endocannabinoid system • Application and use of cannabis plant as a medication • Potential future uses of cannabis-based medicine Thursday, October 5, 2017 19AM-5PM UNLV Greenspun Hall Auditorium 4505 S. Maryland Pkwy., Las Vegas, NV 89154 5.33 Credit Education Units including 2.0 hours for APRN Pharmacokinetic For questions about CEU, please contact Jennie at (209)327-3366 Regi s t e r at www . jennieStormesRN . com Criteria for successful completion includes: • Attendance of entire session • Pre-testing • Post-Testing • Completion of a survey form at end of event Faculty and planning committee have declared no conflict of interest This continuing nursing education activity was approved by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Approval valid through 06/01/2019 ONA #20866 Affiliate Sponsorship through: University of Nevada,Las Vegas Students for Sensible Drug Policy(SSDP) Resources Recommended Books CANNABIS Cannabis Revealed Marijuana Myths, REVEALED MARIJUANA Marijuana Facts: "�;,.:,.T How the world's most misunderstood plant FACTS is healing everything from chronic pain to by Lynn Etta Zimmer, epilepsy John Morgan Authored by Bonni Goldstein M.D. Great eye opener,I had the Did you know you have a widespread pleasure of reading this book my receptor system that interacts with the first year at college back in compounds in cannabis?Cannabis 1997.Definitely changed my Revealed is the only book written by a views and has opened me up to medical cannabis specialist,explaining the being an advocate for science behind the use of this amazingly legalization. therapeutic plant and describing in easy-to-understand detail the I would attribute this book as a key work that has educated recently discovered endocannabinoid system,involved in almost America about the Truth about marijuana and I think anyone every human physiologic process.Although 28 states have medical who is concerned about the legalization movement that is cannabis laws,most physicians are reluctant to discuss how this finally coming to fruition should read this book. plant may be beneficial to health.Over 4 million people in the U.S. are healing difficult-to-treat illnesses with cannabis medicine.This book is an educational tool for patients and their loved ones who have not found answers with conventional medicines. HEALTHY PLACE, ealthy Places, Healthy People: *rw Handbook of Cannabis HEALTHY PEOPL Truly global in scope and A Handbook for Culturally with contributions from Competent Community - leading researchers around the world,The Handbook of Nursing Practice Cannabis is the definitive HANDBOOK- resource on this fascinating This revolutionary book is the first of its F CANN . drug.Combining scientific kind designed to provide nurses theme' perspectives and clinical tactics and tools to help them approach Elttt! applications,it covers a vast public health nursing through the tapestry nett rettwea:1 array of topics,from why Q of culture and community instead of the = =---_ ;; =-- over the centuries cannabis individual.By looking through the clarifying lenses of _ u :a: has been used as a medicine, anthropology,economics,political science,sociology,and through the regulations epidemiology,and other soft and hard sciences,the authors show a facing those wishing to self- clear and powerful connection to health of the larger community administer cannabis or provide cannabis-based medicines,to and the health of individuals.Once this connection is made,the the chemical structure of its many constituents and the rapidly health care team--of which the public health nurse is uniquely growing group of synthetic cannabinoids that are currently being used for'legal highs'. July/August 2017 61 CANN AB ISNURSESM A G AZI N E.CO M Cannabis Science • CANNABISlow- pre-Conference Workshops: # SCIENCE &CANNABIS • O1 CONFERENCE NURSES fc `#0Canna Boot Camp & NETWORK Healthcare Professionals Workshop We are hosting our Full-Day Pre-Conference Workshops in Exhibit Halls A& B at the Portland Oregon Convention Center I Monday,August 28th,2017 Register online at: www.CannabisScienceConference.com Exhibit Hall A Exhibit Hall B 2nd Annual CANNA BOOT CAMP HEALTHCARE PROFESSIONALS WORKSHOP Covers everything from Cultivation, Pre-Processing, We welcome Cannabis Nurses Network to our team Sample Prep,Analytical Testing, Extraction and Edibles providing certificate courses taught by Cannabis Nurse Manufacturing. Companies join forces to demonstrate Network Experts and Professionals covering techniques,instruments and technologies to share their the eCS, Methods of Administration,Terpenes& experiences. In one day you can get a full understanding Aromatherapy,Ending Prohibition- Our Ethnobiologica. of many aspects of the cannabis industry and analytical Right, Incorporating Cannabis into Practice,and Bridgin; testing&extraction. the gap to our Healthcare stytem Workshop! (FB): Cannabis Nurses Network r•.- � (oT�, icy r•; te�c�Pscree� rte' oo`t,,ide 2�a1�5�5 z aide 4 :��9' �Solven _. � ,1Pr� �' �Mycotoxins J Aflatoxins 2016 Educational a ! J Heary metals Achievement Award Heather Manus RN •y Cannabis Nurses Magazine - Network with professionals NURSEs if Making Endocannabinoid Connection.- INE-1 WORK includes hands-on aromatherapy & holistic approach Worhsho CANNABIS �• ! SCIENCE August 28. 2017 •`•' CONFERENCE Oregon Convention Center. Portland Dive deep into the endocannabinoid system during our pre-conference session & worksho offered at the Cannabis Science Conference Sweet gift bag & Workshop supplies included! Featuring:- :.cnTiNc rt Register at CannabisScienceConference.com Nursing 2017 August 2017 Conferences Cannabis Science Conference 2017 August 28th-30th,2017 1 Portland,OR wwww.CannabisScienceConference.com Pre-Conference Courses&Workshop for Health Care Professionals-Cannabis Nurses Network August 28th,2017 1 Portland,OR (In conjunction with the Cannabis Science Conference&Bootcamp) (FB): Cannabis Nurses Network I www.CannabisScienceConference.com Cannabis for Healers August 9th,20171 San Diego,CA www.NatureNurseHealth.com September 2017 Conferences The Cannabinoid Conference 2017 IACM 9th Conference on Cannabinoids in Medicine September 29-30,2017 1 Cologne,Germany www.CannabinoidConference20l7.org October 2017 Conferences Make Noel Cannabis Nurses Network Conference 2017 October 5th-7th,2017 1 Las Vegas,NV (FB): Cannabis Nurses Network I www.CannabisNursesMagazine.com I NatureNurseHealth.com Weekend Itinerary: Oct. 5th:Cannabis Education For Nurses(5.33 CEUs)-UNLV Greenspun Hall Oct.6th:Making eCs Connections&Interactive Sports Book Panel-UNLV Foundation Bldg. Oct. 7th:CNM 2-Year Anniversary&Leaders of Nursing Awards Ceremony November 2017 Conferences ` MJ Biz Conference 2017 November 16-18,2017 1 Las Vegas,NV www.MJBizCon.com If you know of other Conferences available that are based on Cannabis Therapeutics that you wish to be listed in future issues please email us at: editor@cannabisnursesmagazine.com July/August 2017 63 CANNARISNU RSESMAGAZIN E.COM Orderyour Subscription Today! dle� � Inside _you'll find: va�able Informative and Evidence-Based Education with Resources and 0'0 en by Real Nurses,Doctors, and Scientists. 1-Year Subscriptio 6 issues (1 year) for $36.0(k,+ S.H. 2-Year Subscription: _6 issues (2 years) for $60.00 + S.H. je $12.00) To Order your Printed Copy go to www.CannabisNursesMagazine.com How do I Advertise? Contact Us and Request a Media Packet today! Reach thousands of people Nationally looking for stories every day about Medical Cannabis and Cannabis Therapeutics regarding: Nursing,News, Politics, Research, Education, Nutrition, Current Trends, Organizations, Events and Much More! Why advertise with us? We are endlessly striving to gather the most targeted audience of Cannabis Nurses, Medical Professionals, and Medical Cannabis Patients available anywhere,_ to not only benefit you and your company, but to grow the industry as a whole. Reac our Target Audience Marketing Solutions AffordabRates By advertisin Cannabis Nurses We offer a wide range of advertising Our servic competitively Magazine,you' to reach the most and sponsorship packages, as well as priced atioal standards so targeted audience a for Nurses, graphic design and video production y - eep more of your hard- Doctors and Medical Ma a Patients. services, to supplement your ed money in your pocket. marketing strategy. a Contact Us To request a Media Packet email us at any time or call us during regular business hours, PST, Monday through Friday (excluding national holidays) at: ads@cannabisnursesmagazine.com 1 March/April 2017 -4U - F� -i -S S MAGAZINEo Arizona: Medical Cannabis Using Medical Cannabis Programs Expand by Adding for Opioids Sparing and New Qualifying Conditions Heather Manus, RN Opioids Tapering A ROADMAP OF HOW TO CREATE in Chronic Pain CHANGE IN YOUR COMMUNITY Dr. Gregory Smith New Jersey: DOH Panel to Consider Petitions Adding Anita Briscoe, MS,APRN-BC Nurses Must Advocate for Qualifying Conditions Patient Access to Cannabis to Medicinal Marijuana Program Stem the Opioid Epidemic Ken Wolski,RN, MPA Mary Lynn Mathre ,RNA', MSN,CARN r 0`Il3 01P s= �z�A� 1�tA W=su WKE i Anita Willard Briscoe, MS,APRN-BC Editor's Letter The abuse of and addiction to opioids such as heroin,morphine,and prescription pain relievers is a serious global problem that affects the health,social,and economic welfare of all societies.Currently,the CDC has estimated 91 opioid overdoses per day in the U.S.and there is a greater need within our healthcare system to find solutions d end this epidemic. Medical Cannabis is a solution to our Opiate Dependency and we bring to you the evidence-based research to validate this claim in this important Issue of Cannabis Nurses Magazine:Opiate Dependency. What can we do as Nurses?As Nurses,advocating for the Rights of Patients is the most honest,ethical,and compassionate care we as Nurses can provide. In this Issue we explore three states,Arizona/New Jersey/New Mexico,where Nurses stand up for patients rights and assure that health is'a Universal Right' (ANA,2015) and patients are receiving access to health care and education,which includes safe access that is no based on zip codes. We begin with Nurse Heather Manus,President of AZCNA,who has been trailblazing an uncharted path in Arizona,while championing the cause for cannabis patient's rights,and has taken repeated administrative and legal action since 2013 to include additional medical conditions to the Arizona Medical Marijuana Act. We then explore in detail with Dr.Gregory Smith on `Using Medical Cannabis for Opioids Sparing and Opioids Tapering in Chronic Pain'. He defines pain and the opioids use problem and how Medical Cannabis is used in treating chronic pain,use as an adjunct medication,therapeutic effects,safety,and uses in clinical practice that can be applied to your nursing practice. Our Cover Nurse:Anita Briscoe,MS,APRN-BC,provides Nurses A Roadmap of How to Create Change in your Community and shares her original 'Petition to the NM Medical Advisory Board to the New Mexico Medical Cannabis Program to Add Opiate Dependence as a Qualifying Condition'. Learn how to create positive change to end the Opioid Dependence epidemic in your community by following her outlined example. She also discusses the misdiagnosis of Cannabis Dependency under the DSM-5 Diagnosis Cannabis Use Disorder. For patients who are legally using medical cannabis in the states which allow them,the term 'dependency'is an inaccuracy. Re-evaluation of our DSM codes are in order. Our New Jersey Nurse,Ken Wolski,RN,MPA,champions the 'NewJerseyDepartment ofHealth Panel to Consider Petitions Adding Qualifying Conditions to State's Medicinal Marijuana Program with the aid of Members of the Coalition for Medical Marijuana-NewJersey'(CMMNJ). Unfortunately,this program has been under the direction of Governor Chris Christie,who has delayed and obstructed the full implementation of the CUMMA. It is the Commissioner of the DOH who makes the final determination in this matter,after the panel of healthcare professionals makes their recommendations. Perhaps it's time to investigate who sits on these panels of healthcare professionals and assure they are properly educated and/or held accountable for their recommendations. If denied,then are they not blocking a human's`Universal Right'to access to health care and education concerning the prevention of health issues? We end with our legendary and long-time educator,Mary Lynn Mathre,RN,MSN,CARN,who writes Nurses Must Advocate for PatientAccess to Cannabis to Stem the Opioid Epidemic'. It is here where she states the need to educate our colleagues and patients about the use of cannabis for the management of chronic pain. Cannabis should be removed completely from the Controlled Substances listing and patients allowed to grow this natural plant and,have it finally recognized for what it is: a medicinal herb. It's that simple. Nurses have been provided a roadmap to create change and are supported by the ANA Position Statement of 2016 which actively supports patients'rights to legally and safely use marijuana,as well as the Nurse's promotion of quality of life for patients using such therapy. The ANA House of Delegates has gone on record as supporting Nurses'advocacy for patients using marijuana and other related cannabinoids for therapeutic use (ANA,2003). So now is the time to advocate for patients in your community utilizing the tools and resources outlined in this important Issue on Opiate Dependency. We must Grow. Julie Monteiro,RN,BSK "Ask Nurse Juhlzie" Editor@Cannabis Nurses Magazine Contributors NURSES Heather Manus, RN MAGAZINEe A native New Mexican and Registered ' • 7 Nurse specializing in all aspects of medical r cannabis care. She is founder of the Arizona Cannabis Nurses Association and was honored for her efforts, and awarded • " ' ' ' the CannAwards "Best Charitable/Comm- .. _ • _ • ; unity Outreach Program", and Cannabis Business Awards "Activist of the Year 2015" and"Educational • - ' - -• - • Achievement Award 2016". She believes cannabis is a gate- way to health and will be a first-line medication of the future. -• - • Sue Degregorio-Rosen, RN - - -•• • '• " • - A pioneer activist and native of New Jersey, •••- • Sue lives in the lower Hudson Valley of New • York State.She has held multiple positions in _ the administration of ER/Trauma/Burns throughout her 40 yr career. She is the legal liaison and associate editor for The National • Cannabis Patients Wall. She is also an activist • . - and a chapter leader for the 420 Seniors Network of NY and _•• The Cannabis Nurses Network. Sue holds a certificate in Advanced Cannabis Nursing, lending her expertise to �• • • • • communities along the east coast. Marcie Cooper, MSN, RN, AHN-BC • •• • • - • Marcie Cooper RN, MSN, AHN-BC is Board • _ • • • __ ' •• • Certified as an Advanced Holistic Nurse and is working to build a bridge between • -•- - • • • - conventional healthcare and holistic nursing • • •' • • - • • -• care including cannabis therapeutics.She • - - • • • - • - • obtained education, certifications and -• - -• - --• training in various complimentary therapies • - - • • -•- • • •- • • - • including Hypnotherapy, Auricular • -• • • • • •• . - Acupuncture, Healing Touch and Aromatherapy. She • • • •. - • - • • incorporates cannabis education with patients while • - • - - .. - . working in hospice and palliative care throughout Colorado, • - - • -- • --• • -.•- and has witnessed the incredible benefits of cannabis. .. .- . - Lisa Buchanan, RN, OCN • -• •• • •- •- -• . • ••. Lisa Buchanan is an Oncology Certified ,. Nurse (OCN) in Washington state who has worked with the seriously ill and dying for more than 20 years. She a member of the Oncology Nurses Society (ONS), American Cannabis Nurses Association (ACNA), and the Washington State Nurses Association. She has earned certificates in the Core Curriculum for Cannabis Nursing and in the Advanced Curriculum for Cannabis Nursing through ACNA. _ Jennie Stormes, BSN, RN Jennie Stormes, RN, BSN lives in the state • •' '• of Colorado, and formerly in both New ' ' ' " "• - • Jersey and Pennsylvania, is a member of • - • • •• - .•• - , the ACNA, a board member of American -- Medical Refugees as Vice Chair, Colorado Springs Chair for CannaMoms, and a parent member of the Special Education Advisory Committee for Colorado School District 49 (Falcon). She specializes in Pediatrics and Neurology and has a passon for education. Contributors Gregory L. Smith, MD,MPH Contact Information '� Dr.Gregory Smith earned his medical degree from Rush _ Medical School in Chicago,and a Masters of Public Health Publisher from Harvard University.He completed residency training in Preventive Medicine at Walter Reed Army Medical Center. ND I Media Since getting out of the US Army as a Major,Doctor Smith has been in primary care practice in California,Georgia and Florida for the past 25 years.He first trained on use of Editorial Amedical cannabis in California in 20M and made medical Robert Herman cannabis and CBD oil,part of his practice since that time. Dr.Smith is an avid writer, having published two medical textbooks,a novel called"Malpractice,"and articles with Art&Graphic Design many magazines and over a dozen peer reviewed medical publications. His most To submit artwork/ad creation Email: recent book,is en tided Medical Cannabis.Basic Science and Clinical Applications (Aylesbury Press,2016—wwwAylesbuTyPress.com) It is the first,scientifically-based ads@cannabisnursesmagazine.com textbook directed at educating medical students and medical professionals on the science and applications of cannabinoid medications. Advertising& Marketing E Heather Manus,RN For advertising opportunities Email: Heather Manus is a native New Mexican and Registered ads@cannabisnursesmagazine.com Nurse specializing in all aspects of medical cannabis care. She was a board member of the American Cannabis Nurses Sales/Product Director Email: Association,serving as Chairwoman for the ACNA conference committee.She also holds a certificate of sales@cannabisnursesmagazine.com completion for The Core Curriculum for Cannabis Nursing. Nurse Heather has shared her knowledge and assistance writers regarding cannabinoid therapies in Colorado,Arizona, Massachusetts,California,Nevada and New Mexico. To submit articles for publication Emai She was honored to be a presenter and panelist for multiple conferences around editor@cannabisnursesmagazme.com the nation.Her deep understanding,unique perspectives and professional delivery make learning,a positive and enriching experience. In addition to educating,advising,and speaking;under Nurse Heathers direction,the Arizona Reach Us By Post Cannabis Nurses Association was successful in petitioning and appealing for the inclusion of Post-Traumatic Stress Disorder(PTSD)as a recognized debilitating Cannabis Nurses Magazine condition under Arizona's medical marijuana act. 4780 W. Ann Rd., Suite 5 #420 Ken Wolski,RN,MPA N. Las Vegas,NV 89031 Ken Wolski,RN,MPA has been a Registered Nurse(RN) since 1976,currently licensed to practice in New Jersey and Pennsylvania.He retired in 2006 from the State of info@cannabisnursesmagazine.com New Jersey after 25 years of service with the Department of Human Services and the Department of Corrections as www.cannabisnursesmagazine.com a Staff Nurse,Head Nurse,Supervisor of Nurses,Quality Assurance Coordinator and Health Services Manager.In addition to his state service,Ken worked for eight years in Find us on: Acute Care Facilities as an Intensive Care Unit and © facebook: Cardiac Care Unit(ICU/CCU) Nurse.Ken also worked as a Public Health Nurse for the City of Trenton.Ken is currently self-employed and is the Executive Director of the non-profit educational organization CMMNJ. We are honored to h Nurse Heather be '*' Mary Lynn Mathre RN, MSN, CARN awarded the 2016 Mary Lynn Mathre,RN,MSN,CARN has 40 years of experience as a Educational Achieve Registered Nurse. Her nursing career began in the US Navy Nurse Corps ment Award with thi for 4 years,followed by acute care medical-surgical nursing and support of Cannabis specializing in addictions nursing in 1987. She received her Masters Nurses Magazine. V degree from Case Western Reserve University in 1985 and her masters are leading by examl thesis was on marijuana disclosure to health care professionals. Since that and could not be mo time Mrs.Mathre has studied the medical use of cannabis. She is the co- proud. Thank you tc founder and President of Patients Out of Time,an educational charity who support our created in 1995 to educate health care professionals and the public about the therapeutic use mission and cause it of cannabis. She is the editor of Cannabis in Medical Practice:A Legal,Historical and educating the world Pharmacological Overview of the Therapeutic Use of Cannabis(1997)and co-editor of nurse at a time! Women and Cannabis:Medicine,Science and Sociology(2002)and has written numerous "Educational Achievement Award" papers and chapters on the topic. Ms.Mathre is also the President and Founding member of the American Cannabis Nurses Association. She works as an independent consultant on Heather Manus RN medical cannabis and addictions nursing;has authored several position papers on medical Cannabis Nurses Magazine cannabis,testified at legislative hearings and served as an expert witness on the topic. Cannabis Business Awards 2016 Table o MarchlApril •f iw_+.or��r1rYH.rrfr+`rrrrA� - a.irrca�.rrrmrsrsdrW�..I.p � r Contents 2017 dirr ... .,p _.. ,,.�...r4 . ♦.. .. .-,i1t e0d$rP.at Wieter .�.... ..�......r._� _e Yrt Ad=M•heA� is Or•W Y nh�W O�IW i�W�Y �iQ Features ' ' • 06: Arizona:Medical Cannabis Programs Expand by 091 ANA Position Statement 2016 Adding New Qualifying Conditions 241 New Mexico Petition Letter: To Add Opiate By: Heather Manus, RN Dependence as a Qualifying Condition 10: Using Medical Cannabis for Opioids Sparing and 341 Chef Herb & Cook with Herb Opioids Tapering in Chronic Pain 381 CREATING HER-STORY! By: Dr. Gregory Smith 401 Nurse Talk: Issue Interview 22: COVER: A ROADMAP OF HOW TO CREATE 43 Top 10 Apps for Health-Care 44 Resources: Recommended Books CHANGE IN YOUR COMMUNITY 45 Job Opportunities: Perm&Travel By: Anita Briscoe, MS, APRN-BC 46 Nursing Confrences for 2017 29: New Jersey: DOH Panel to Consider Petitions 471 Cannabis Education Network Adding Qualifying Conditions to the State's Medicinal Marijuana Program By: Ken Wolski,RN,MPA 32:Nurses Must Advocate for Patient Access to Cannabis to Stem the Opioid Epidemic By:Mary Lynn Mathre,RN,MSN,CARN The Arizona Cannabis • • Medical Cannabis Programs Expand by Adding New Qualifying Conditions As Nurses,we have a duty to advocate diseases.The cannabinoids are found additional medical conditionssuch as for patients and to educate as needed to have particular application as Post-Traumatic Stress Disorder when understanding or knowledge is neuroprotectants,for example in (PTSD),Parkinson' s Disease (PD), lacking.Knowledge and understand- limiting neurological damage Huntington' s Disease (HD), ing regarding the science and following ischemic insults,such as Traumatic Brain Injury (TBI), practical use of cannabinoid stroke and trauma,or in the treatment Neuropathy,Arthritis,Tourette' s therapeutics within the context of of neurodegenerative diseases,such as Syndrome,Autism,and Diabetes. healthcare is an area that is deficient Alzheimer's disease,Parkinson's After a fierce legal battle,in July 2014 within our public health and medical disease and HIV dementia."' AZCNA celebrated a precedent setting communities.Worldwide research court case win which resulted in the related to cannabis and cannabinoid Based on this information,in addition successful recognition of PTSD as a therapeutics is plentiful and growing to a multitude of research studies it qualifying condition under the rapidly,despite the current Schedule I may be assumed thatstate medical Arizona Medical Marijuana Act.All status that impedes our ability for high cannabis programs would include all other medical conditions submitted by level clinical research trials to be `oxidation associated diseases,such as AZCNA have been summarily denied conducted on humans in the United ischemic,age-related,inflammatory by the Arizona Department of Health States. and autoimmune diseases"and Services,resulting in multiple court specifically allow patients who have cases which are currently in process Meanwhile,state medical cannabis experienced"ischemic insults,such as due to the dedication of AZCNA and programs have swept our country, stroke and trauma,or in the treatment their legal counsel,Ken Sobel,Esq providing safe legal access to cannabis of neurodegenerative diseases,such as who continues to fight for the rights of and cannabis derived products. Alzheimer's disease,Parkinson's patients in Arizona. Medical cannabis programs vary from disease and HIV dementia."This state to state,including who may assumption would be incorrect. The work done by AZCNA in Arizona qualify as a medical cannabis patient However,States are slowing beginning has created a ripple effect which based on a list of each states'list of to add new conditions due to the resulted in 10 additional States adding recognized medical conditions. tremendous efforts made by those PTSD as a qualifying condition for within the community who understand medical cannabis access.Adding new Information contained within patent the importance of recognizing specific medical conditions to the cannabis US 6630507,Cannabinoids as diseases within the cannabinoid program in Arizona has proven to be a antioxidants and neuroprotectants; therapeutics context. very difficult challenge. Due to a states that"Cannabinoids have been harsh anti-cannabis political climate found to have antioxidant properties, In Arizona for instance,Nurses are and resistance from the Arizona unrelated to NMDA receptor leading the way.The Arizona Department of Health to expand the antagonism.This new found property Cannabis Nurses Association program,safe legal access for seriously makes cannabinoids useful in the (AZCNA) has been championing the ill patients continues to be blocked on treatment and prophylaxis of wide cause for cannabis patients'rights,and the basis of"not enough research." variety of oxidation associated has taken repeated administrative& Although cannabis is proven to be diseases,such as ischemic,age-related, legal action since 2013 to encourage nontoxic to humans,with no reported inflammatory and autoimmune expansion of the Arizona Medical Marijuana Act(AMMA)to include I 06 March/April2017 CANNA■ISNURSESMAG AZINE.COM overdose deaths in 5000 years of cannabis The Therapeutic Use of Marijuana and history,we as medical practitioners are AZCNA Advocacy Related Cannabinoids Revised Position driven to provide an evidence-based i Statement of 2016 was written by ANA practice for our patients. T I M E L I N E Center for Ethics and Human Rights,and Adopted by ANA Board of Directors which The American Nurses Association (ANA) 1 2013 "addresses the roles and responsibilities of recognizes the vast benefits related to A January-AZCNA Foundednurses related to the use of cannabinoids medicinal usage of cannabis,as well as 1 Petition Submitedfor health care." addressing the issues related to why 0 October- 1Public Hearing cannabis research has been difficult to 2014 According to annual Gallup Poll surveys, conduct in recent years by stating, 0 January- 1 Denied by AZDHSnursing is consistently rated the most "Marijuana was widely prescribed in the 1 ealed trusted profession in the US. "Americans United States until 1937 when the have been asked to rate the honesty and Marihuana Tax Act of 1937 prohibited its 0 June- 1 P Administrative orders 1 to ethics of various professions annually since use (Musto, 1972). By 1970,the b• added to AMMA 1990,and periodically since 1976. Nurses Controlled Substances Act completely N July- 1 Approved 1HS have topped the list each year since they prohibited all therapeutic use of with Restrictions were first included in 1999,with the marijuana by making it a Schedule I drug E July-Parkinson's disease(PD) exception of 2001 when firefighters were (Public Law 91-513).Schedule I drugs are Petition Submitted included in response to their work during defined as"drugs with no currently N August- 1 Restrictions and after the 9/11 attacks. Since 2005, accepted medical use and a high potential Appealedat least 80% of Americans have said nurses for abuse" (Drug Enforcement Agency, December- , 1 1 1 have high ethics and honesty."3 2016). Because of this designation,a limited number of DEA licenses to2015 Advocating for the rights of patients is the perform clinical research using marijuanaN January- 1 Appeal most honest,ethical,and compassionate exist (Nutt,2015).In addition,the DEAM May- • 1 Appeal Denied care we as nurses can provide.According has one single source of marijuana 0 July- 1 Restrictions Appealto the American Nurses Association,`"The approved for medical research (DEA, Deniednursing profession holds that health is a 2016).The Food and Drug Administra- 1Huntington'suniversal right,which includes access to tion (FDA) supports scientific researchAutism.Arthritis. Diabetes. health care and education concerning the into the use of marijuana and related Tourette'ssyndrome, prevention of health issues (ANA,2015). cannabinoids for medical purposes,but Petitions Submitted ANA has supported providing safe access has not approved marijuana as a safe andd August- 1 RestrictionsAppealto therapeutic marijuana and related effective drug for any indication (FDA, Superior , 1 cannabinoids for over 20 years.In 1996, 2016).While numerous scholars and PD, , (HD). ANA's Congress on Nursing Practice organizations have called for anAutism,Arthritis,TBI,Diabetes. supported research and education for expansion in research,regulatoryTourette'ssyndrome,Neuropathyevidence-based therapeutic uses of restrictions have impeded this effort. Denied by AZDHSmarijuana and related cannabinoids.In Why should nurses take on the 2016 addition,the ANA House of Delegates has challenge of advoca • for medical gone on record as supporting nurses' g ' 1 ' HD Appealedadvocacyfor patients using marijuana and condition expansions with in State other related cannabinoids for therapeutic medical cannabis programs? Diabetes. use (ANA,2003)." The American Nurses Association has NeuropathyPetitions ' taken the position that, "ANA actively References: supports patients'rights to legally and 1 ' ' ' ' safely use marijuana and related NeuropathyDenied b 1 1. Patent US 6630507 htzps:// cannabinoids for therapeutic symptom � 1 ' 1 Appeal" goo•gl/72Q8wX PD ' 1 Judges* 1 2. ANA Position Statement,The management,as well as the nurse' s promotion of quality of life for patients Denied by AZDHSPD& Therapeutic Use of Marijuana and using such therapy.' 1 Appeal' ''rior Court Related Cannabinoids,Revised 2016 https://goo.gl/cIVNVt 2017 3. Gallup Poll on Ethics https:// E January- 1 &HD Legal Brief goo.gl/g6nE7F Submitted,Trial Date Court, 0 January- 1 Appeals 1gsow --- ch/Apri12017 07 CANNARISNU RSESMAGAZINE.COM POSITION STATEMENT OANA AMERICAN NURSES ASSOCIATION Therapeutic Use of Marijuana and Related Cannabinoids Effective Date: 2016 Status: Revised Position Statement Written by: ANA Center for Ethics and Human Rights Adopted by: ANA Board of Directors Purpose The purpose of this statement is to reiterate the American Nurses Association's(ANA)support for the review and reclassification of marijuana's status from a federal Schedule I controlled substances to facilitate urgently needed clinical research to inform patients and providers on the efficacy of marijuana and related cannabinoids. This position statement speaks only to the use of marijuana and related cannabinoids in the context of health care. It addresses the roles and responsibilities of nurses related to the use of cannabinoids for health care. Statement of ANA Position Marijuana and its derivatives continue to be used to alleviate disease-related symptoms and side effects. The findings of anecdotal and controlled studies regarding the efficacy for patient use are mixed. Current federal regulations impede the research necessary to evaluate and determine the therapeutic use of marijuana and related cannabinoids. This position statement does not extend to the current debate on the legalization of marijuana for recreational purposes. The goal is to develop an evidence-based approach to its use in the treatment of disease and symptom management. Recommendations "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. • 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. 08 March/April 2017 CANNABISNURSESMAGAZINE.COM Background Marijuana and related cannabinoids are widely used to treat disease or alleviate symptoms, but their efficacy for specific indications is not clear(Whiting et al.,2015). Marijuana has been used for alleviating symptoms of nausea and vomiting;stimulating appetite in HIV patients;alleviating chronic pain;easing spasticity due to multiple sclerosis;decreasing symptoms of depression,anxiety,sleep disorders and psychosis;and relieving intraocular pressure from glaucoma (Whiting, 2015). Some of these indications have moderate evidence to support treatment with marijuana; however,many do not(Hill,2015). Marijuana was widely prescribed in the United States until 1937 when the Marihuana Tax Act of 1937 prohibited its use(Musto, 1972). By 1970,the Controlled Substances Act completely prohibited all therapeutic use of marijuana by making it a Schedule I drug(Public Law 91-513). Schedule I drugs are defined as"drugs with no currently accepted medical use and a high potential for abuse"(Drug Enforcement Agency,2016). Because of this designation,a limited number of DEA licenses to perform clinical research using marijuana exist(Nutt,2015). In addition,the DEA has one single source of marijuana approved for medical research (DEA,2016). The Food and Drug Administration(FDA)supports scientific research into the use of marijuana and related cannabinoids for medical purposes,but has not approved marijuana as a safe and effective drug for any indication (FDA,2016). While numerous scholars and organizations have called for an expansion in research, regulatory restrictions have impeded this effort. ANA recommends additional scientific research of marijuana and its related cannabinoids in order to guide evidence-based practice for therapeutic use in patients. Twenty-four states and the District of Columbia have legalized the use of marijuana for some medical purposes. Despite this,the United States Supreme Court voted that Congress had the legal authority to criminalize the use of home grown marijuana even in states where it is legal for therapeutic purposes(Gonzales,2005). As a result, patients and families who gain access to or use marijuana for therapeutic purposes in a state that allows for its use are still at risk for criminal consequences. ANA actively supports patients' rights to legally and safely use marijuana and related cannabinoids for therapeutic symptom management,as well as the nurse's promotion of quality of life for patients using such therapy. Previous Position Statements The nursing profession holds that health is a universal right,which includes access to health care and education concerning the prevention of health issues(ANA,2015). ANA has supported providing safe access to therapeutic marijuana and related cannabinoids for over 20 years. In 1996,ANA's Congress on Nursing Practice supported research and education for evidence-based therapeutic uses of marijuana and related cannabinoids. In addition,the ANA House of Delegates has gone on record as supporting nurses'advocacy for patients using marijuana and other related cannabinoids for therapeutic use(ANA,2003). Supersedes American Nurses Association.(2008). Position Statement: In support of patients'safe access to therapeutic marijuana.Silver Spring, MD:author. American Nurses Association.(2004). Position Statement:Providing patients safe access to therapeutic marijuana/cannabis. Washington, DC:author. References American Nurses Association.(2015).Code of ethics for nurses with interpretive statements.Silver Spring,MD:www.nursingworld.org/Code-of-Ethics. American Nurses Association.(2003).Providing patients safe access to therapeutic marijuana/cannabis. Washington DC:Author. Drug Enforcement Agency.(2016).Drug schedules. Retrieved from http://www.dea.gov/druginfo/ds.shtml. Gonzales v.Raich 545 U.S.1(2005). Hill,K.P.(2015).Medical marijuana for treatment of chronic pain and other medical and psychiatric problems:a clinical review.JAMA,313(24),2474-2483.doi:10.1001/jama.2015.6199. Musto,D.F.(1972).The marihuana tax act of 1937.Archives of General Psychiatry,26(2),101-108.doi:10.1001/archpsyc.1972.01750200005002. Nutt,D.(2015).Illegal drugs laws:Clearing a 50-year-old obstacle to research.PLoS Biol,13(1),e1002047. doi:10.1371/journal.pbio.1002047. Pub.L.91-513,84 Stat.1236,enacted 1907-10-27,codified at 21 U.S.C.§801 et.seq. U.S.Food and Drug Administration.(2016).FDA and marijuana. Retrieved from http://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421163.htm. Whiting,P.F.,Wolff,R.F.,Deshpande,S.,DiNisio,M.,Duffy,S.,Hernandez,A.V.,Keurentjes,Lang,S.,Misso,K.,Ryder,S., Schmidlkofer,S.,Westwood,M.,&Kleijnen,J.(2015).Cannabinoids for medical use:A systematic review and meta- analysis.JAMA,313,2456-2473.doi:10.1001/jama.2015.6358. 8515 Georgia Avenue,Suite 400 Silver Spring,MD 20910 www.nursingworld.org March/April 2017 09 CANNABISNURSESMAGAZINE.COM Medical I and • Pair i ........... Using Medic- annaW 'for o i d s*"W a r i\i an Opioids Tapering in Chronic Pail The Pain and opioids Use Problem: One third of the persons who overdosed Even though the patients were often using Chronic pain has reached epidemic on prescriptions opioids were also taking the cannabis for opioid sparing.The net proportions in the past decade,with an a benzodiazepine°. There is also a effect is that these opioid dependent estimated 80 million current chronic pain documented tendency to gradually patients are suddenly without prescription sufferers in the US. There has been increase dosage of opioids over time due opioids,and may seek out illicit means of concomitant exponential growth in the use to tolerance.Also periods of abstinence obtaining opioids. Research has shown of prescription opioids for chronic pain.A from opioids,due to access or other that over time. Due to access and cost significant proportion of chronic pain issues,may lead to unexpected overdose issues,these patients often end up using patients are also being treated with when the patient resumes the previous heroin off the street.This`street heroin' benzodiazepines.Much of this increase tolerated dose 3,4. is often cut with Fentanyl®and an even has been due to more loose prescription This epidemic of opioid prescriptions more potent elephant tranquilizer,greatly guidelines for non-malignant pain,and increasing the chance of fatal unintended aggressive pharmaceutical marketing flies in the face of many meta-analyses that have found little evidence that overuse.An additional 26 people a day campaigns'.Even though there is little opioids are effective treatment for are dying for heroin overdoses4.6.As u research to support long term use of many as 80/o of these deaths were in Z chronic pain.Another study found almost opioids for chronic non-malignant pain . one million Veterans found that 71%of patients who became addicted to opioids This increased use of addictive and patients who are started on opioids and after being prescribed opioids for an 9 potentially life-threatening medications maintained on them for at least 90 days, injury or surgery7. has been associated with a four-fold will still be taking opioids three years increase in the number of deaths from later5.This suggests that medical prescription opioids between 1999 and provider prescribing practices could be a care 201123.The most recent CDC data major contributor to iatrogenic opioid H'66 Mseasestimates that 44 people a day die from dependency and adverse outcomes. sic �r P' { 4chron is prescription opioid overdose.There are °l: i �i2 over 700,000 opioids-related Chronic pain patients are commonly e . y , hospitalizations annually. As many as denied additional prescriptions for -01 pC�in${ two thirds of these deaths were in opioids due to failed urine drug testing, painful patients prescribed the opioids,who were most often from THC obtained illicitly. not using drugs illicitly3. 10 March/Apri12017 C ANNARI SNURSESMAGAZINE.COM There has been a public and political Treating C h o n i c Pain outcry to change the situation quickly Centrally-mediated pain,includes and effectively.The efforts over the past With Medical Cannabis: several forms of paresthesias,burning few years have failed to significantly and numbness.Also,fibromyalgia is at reverse the above statistics.The Medical cannabis impacts nocioception and least partially a centrally-mediated pain addition of medical cannabis,as an spasticity in the central nervous system,and condition. Some research suggests that adjunct medication may be a significant inflammatory related pain through peripheral fibromyalgia may represent a part of the solution.Cannabis has been actions.Cannabis can be used topically for cannabinoid deficiency syndrome13. shown to have efficacy in opioid acute musculoskeletal injury,but in general The American Academy of Neurology sparing,as an alternative analgesic,for most of the benefits of medical cannabis are reviewed the available literature and mood elevation and to reducing opioid for chronic pain conditions. "based on the highest quality evidence" withdrawal and craving. considering"safety and effectiveness" determined that CBD alone can help Unfortunately,as it is with using medical lessen centrally-mediated pain14. The CDC has recently released a report] cannabis with most conditions,there has entitled"Prescribing opioids for been very little high quality research due to Chronic Pain,"that recommended"In the fact that it is a Schedule I drug. A survey of 457 Canadian fibromyalgia general,do not prescribe opioids as the However,that has been changing quickly in Patients showed that 13%of them were first-line treatment for chronic pain." the past few years and there are some high effectively using adjunctive cannabis to This guideline excluded palliative or quality studies and Randomized Clinical control the pain.The Canadian end-of-life care. It also recommended, Trials(RCTs)to support use of cannabis for Fibromyalgia Treatment Guideline states "avoid concurrent opioid and certain chronic pain conditions. that cannabis should be considered for benzodiazepine use whenever possible." fibromyalgia patients with sleep Benzodiazepines,like opioids,are One study showed that low-dose(1.29% disturbances 15. respiratory depressants.They work tetrahydrocannabinol THC vaporized synergistically,opioids at receptors in y (o )) P The regions of the brain that have to do the medulla oblongata and cannabis resulted in 30r reduction in pain in with nocioception have high levels of patients already being treated with benzodiazepines as CNS depressants. CB 1 receptors as as Mu-opioid P P The FDA has recently added a black conventional FDA approved medications. receptors(MORp). Studies have shown v The low-dose was as effective as the that opioids and cannabinoids work box warning to address this9. medium-dose 3.53%THC 11.Not all studies P ( ) synergistically.Astudy of tumor pain in have been promising.A study of intractable mouse models showed that CB 1,C132In addition a more recent study added a cancer pain showed no significant pain new issue to the prescribed opioid P P agonists had comparable efficacy to epidemic.It showed dramatic increases reduction with CBD only -. morphine16 in emergency room visits for unintentional overdoses of opioids in Several high quality RCTs are underway to young children,and intentional use of examine the efficacy of cannabinoids with family member's opioids in Chronic Regional Pain Syndrome,post- adolescents 10. herpetic neuralgia,spinal cord injury and MS. wr March/Aprfl 2017 11 CANNAB ISNURSESMAGAZINE.CO M Neuropathic pain is becoming grade cannabis,with balanced ratios discontinue opioids altogether in increasingly common as a sequelae of of CBD to THC,has a far superior lieu of cannabis and other non- type II diabetes.Unfortunately,there adverse effect profile compared to opioid medications21. are very few choices for neuropathic other medications.Also, cannabis pain.Two RCTs of neuropathic pain positively impacts inflammation,and Cannabis,can also be used to in HIV patients showed that inhaled spasm which often accompany discontinue opioids for pain control. cannabis decreased pain by 30% chronic pain$. Cannabis has innate analgesic and compared to placebo".A study of anxiolytic effects as well as beneficial intractable neuropathic pain in Decreasing the dose of opioids,via effects on opioid craving,and on the patients with MS,brachial plexus opioid sparing,leads to fewer accidental severity of opioid withdrawal-related injury,limb amputation and spinal overdoses,and less adverse effects such nausea and muscle aches. cord injury found that CBD was as intractable constipation. A recently superior to placebo,without side- released analysis of the literature from A study of people using cannabis to effects. the National Cannabis Industry taper off opioids showed that the Association(NCIH)discussed some common side-effects of Migraines represent a combination promising observational and chronicopioid use:constipation, myofascial and neuropathic pain.A population-based findings supporting depression,and nausea were review of several studies showed that the use of cannabis as an adjunct to significantly reduced with cannabinoid medications can have opioids and for tapering off opioids20. concomitant use of cannabis22. positive therapeutic effects on pain, nausea and vomiting18. The primary objective of adding cannabinoid medication to chronic tz �_— ,� 101, Medical cannabis can have significant o ioid therapy is to reduce morbidity ;. -- p pY t}' l . =---medieal�tiee[ment therapeutic benefit for inflammatory and mortality associated with opioids, ulchf— �;;, �pT►SD pain and swelling. C132 receptors are and improve function.This should be - present in large number on mast cells. done,while also preventing �y Stimulation of these receptors results development of significant adverse C� in decreased release of histamine, effects such as euphoria, serotonin and other pro- psychosis,or cannabis inflammatory neurotransmitters19. dependency.The initial goal of opioid sparing,is to use Medical Cannabis as an cannabinoids safely to de- Adjunct Medication: crease the frequency of use and dose of fast acting opioids L Medical cannabis can be used as an for breakthrough pain.The 1 adjunct medication for opioid next goal is to gradually and 1 sparing. Currently NSAID, safely reduce the dose and antidepressant,anticonvulsant,and frequency of both slow and topical analgesic preparations are fast acting opioids for the being used in conjunction with baseline pain. opioids,to reduce the amount of The goal of the initial phase opioid necessary for adequate pain of opioid sparing is to have control.Opioid sparing,implies,that the opioid patient learn to f a lesser dose of opioid can be used to appreciate the ability to l get the same effect,through obtain symptom relief synergistic effects of non-opioid without any opioid,using the - medications. adjuncts of cannabis and • . 0 Unlike the other options for opioid other non-opioid medications initially. The sparing,medical cannabis also has positive impact on mood,impropatient can then take part or ving all the usual opioid dose if anxiety,usually treated with necessary. Over time,studies benzodiazepines,that is commonly have shown,that a significant associated with chronic pain percentage of syndromes.In addition,medical patients will spontaneously 12 March/April2017 C A NNA BISN U RSESMAGAZI NE.COM A tLlre Order Online Nurt-, urse® Now! .iyefl..nr. n 1 / 1 Patches "TDDS offer pharmacological advantages over the oral route and improved patient acceptability and compliance. They have been an important area What is a Transdermal Patch? of pharmaceutical research and development over the last few decades." A transdermal patch is a medicated -Oxford journals Medicine& adhesive patch that is placed on the skin Health to deliver a specific dose of medication through the skin and into the bloodstream. Often,this promotes 4 Different Varieties: healing to an injured area of the body. How does a Transdermal Patch work? Night Time Formllln,.(40 mg C) As the layers of skin absorb medication from transdermal patches (trans meaning Crafted from high quality cannabis oil produced from Indica type varieties.May used as a sleep aid,for mind and muscle relaxation, through and dermal referring to the skin), pain relief,or mood enhancement. the medication is absorbed via the blood vessels into the bloodstream. From there, W- P the blood carries medication D . 0 through the circulatory system and through a patient's body. Crafted from high quality cannabis oil produced from Sativa type varieties.May be used for mood enhancement,pain relief,and Where do you apply a other symptoms alleviated by cannabinoid therapy. Transdermal Patch? - low Choose a spot on your upper body or ; ' 20/20 mg T upper arms to apply your patch. Do not apply the patch to your arms below the Crafted from high quality cannabis oil produced from Hybrid type elbows,to your legs below the knees,or to varieties and blended with high potency Hemp CBD to create a 1:1 ratio skin folds. Apply the patch to clean, dry, of 20mg CBD and 20mg THC,totaling 40mg per patch. hairless skin that is not irritated, scarred, burned,broken, or calloused. Choose a CBD Patch (igAIYl' :, M& different area each day. .42 Can be worn for up to 24-48 hours. Crafted from high potency Hemp CBD and formulated to deliver a hefty 40mg dose of CBD.A rich source of antioxidant and neuroprotectant properties,Hemp CBD supports the eCB system and assists in obtaining and maintaining systemic wellness. Rooted in ancient plant wisdom and All transdermal expanded upon through science, patches include an Nature Nurse products support the adhesive removercisLl L U 1,C endocannabinoid(eCB)system in and alcohol swab- U rs� balancing the mind,body,and spirit. a• Source: rhe Hc:ilc,,,ch,t https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700785 www.NatureNurseHealth.com *Availabile Onlin Qualified Dispensa Therapeutic Effects Cannabis and Mu-Opioids Rece tors: Dronabinol, has been FDA approved of Cannabis: p since 1985. It was originally placed in Cannabis has therapeutic effects on Mu-opioids receptors (MOPr) are also Schedule II of the Controlled Substano pain via the Endocannabinoid G protein-coupled receptors. They are Act. But,based on the clinical experic System(eCS). See Appendix I to read the site of action of innate opioids and and lack of expected issues with adver more abut the eCS. Cannabis works of opioid medications.Opioid medica- effects and only mild to moderate phy via the CB1 and CB2 receptors, and tions reduce pain by binding to and dependency syndromes,it was reschec by modulating the effects of opioids stimulating mu-opioids receptors in to Schedule III in 1999. It has not bee at MOPr. THC is a partial agonist of the central nervous system,leading to a reviewed by the FDA for use in pain,l both CB 1 and CB2 receptors and has decreased perception of pain via has been shown to increase analgesia beneficial effects on nociceptive pain, inhibition of ascending pain pathways among patients taking opioids for chr, and neuropathic pain via CBI that start in the spinal cord. non-malignant pains. receptors,and inflammation, spasticity and myofascial pain via CB2 MOPr are heavily expressed on Nabiximols,which goes under the receptor onism23. respiratory neurons in the brainstem. P � proprietary name of Sativex®is a wh Potent mu-opioid agonists therefore, plant extract in phase III trials in the i There are over a hundred phyto- can cause respiratory depression,the It was approved in Canada in 2005 fo cannabinoids in cannabis sativa. most common cause of opioid central neuropathic pain and intractab Only,THC and cannabidiol(CBD) overdose death. There are essentially spasticity in multiple sclerosis,and in have been studied extensively$.THC no cannabinoid receptors in the Canada 2007 for intractable cancer pa has been shown to have 20 times the brainstem,which is the primary reason It is made up of extracts from two stn anti-inflammatory potency of aspirin, that no overdose deaths have ever been of cannabis sativa that result in a 1:1 and twice that of hydrocortisone in associated with cannabis use. of THC to CBD. Numerous randomi; neuropathic pain13. However,unlike clinical trials(RCTs)have demonstra aspirin,THC does not NSAIDs and as Both THC and CBD are allosteric P s ioid ors o modulators mu-opioids receptors. safety and efficacy of Sativex®in cet demonstrate cyclo-oxygenase(COX) P P and peripheral neuropathic pain, inhibition 24. COX-1 and COX-2 This results in indirect amplification rheumatoid arthritis and cancer pain. inhibition are associated with the of the effects of opioids at the mu- phase III trials of Sativex®showed a gastrointestinal and cardiovascular opioids binding site.This effect is o g associated with observed synergistic statistically significant 30%or better adverse effects associated withimprovement in their pain score comf NSAIDs24. effects of cannabis and opioid medications. with placebo. There was an average o 43%improvement with Sativex®. T CBD,has minimal agonism on eCS studies used an average of 22-32mg/d receptors,but increases the amount of the naturally occurring Cannabinoid of THC and 20-30mg/day of CBD in; endocannabinoid,anandamide Pharmaceuticals: oromucosal spray . (AEA). CBD inhibits fatty acid amidohydrolase(FAAH),which is the Dronabinol,which goes under the Phase III trials of Sativex®showed a hydrolytic enzyme of AEA. CBD proprietary name of Marinol',is a mean improvement in diabetic neurol primarily impacts CB2 receptors synthetic analogue of THC. It is pain,and one third of the patients ach which are present on immune system different from plant-derived THC and 50% improvement. But the placebo g cells in the brain and body,resulting is a full agonist of cannabinoid also had an unexpectedly large respot in anti-inflammatory effects. receptors,unlike plant-derived THC and the study did not reach statistical which is a partial agonist. Dronabinol significance 26. Medical cannabis is not the only way has been studied as amono-molecule to use the eCS to relieve pain.The terpene,beta-carophyllene,found in drug,and not as part of a whole plant extract.Whole plant extracts have been large quantities in many strains of shown to have reduced adverse effects cannabis sativa,as well as many other due to the antagonistic effects of CBD food spices,is a selective agonist of on THC adverse effects,and through •.•.•,fes ,.....,.. CB2,positively modulating the`Entourage Effect'of CBD,minor inflammation,neuropathic pain, cannabinoids,and terpenes. ijK anxiety and spasticity16 At.,�(� - 14 March/Apri12017 CANN ABISNUBSESMAGAZINE.COM INTRODUCING IMPACT NETWORK, A 5016 PUBLIC CHARITY DEDICATED TO CANNABIS RESEARCH, EDUCATION AND ADVOCACY. RESEARCH AND SCIENCE ARE AT THE CORE OF EVERYTHING WE DO. �� i EDUCATION 0 NETWORK :. 0 00'1�"'F00 RESEARC D IMPACT= Improving Marijuana Policy and L AO Al Accelerating Cannabinoid Therapeutics OA Now recruiting Members and Committee Chairs on Cannabis & Specific Medical Conditions including but not limited to: Alcoholism, Alzheimer's, Arthritis, Depression, LEARN MORE Endometriosis, Lupus, Migraine, Menopause, Parkinson's, Prostate Cancer, Sleep Apnea, SUPPORT OUR WORK Stroke, and Traumatic Brain Injury (TBI). @ IMPACTCANNABIS.ORG ® M IMPACT Network :: Denver, CO :: info@impactcannabis.org Similar results would be expected from Other Opioid Sparing Safety of extracts available at the thousands of Medications: Medical Cannabis: medical cannabis dispensaries around the country.While Sativex*is not FDA Acetaminophen,is one of the most Medical cannabis has been used in approved yet,these other extracts are commonly used over-the-counter pain Western medicine for almost two currentlyavailable. The fact is, medications.Unlike NSAIDs and hundred years for a wide variety of Sativiex'is just another version of a 1:1 aspirin,which are COX inhibitors, conditions.At the turn of the 20th CBD to THC whole plant extract of acetaminophen has no gastrointestinal century there were over 2000`patent' cannabis sativa. Similar whole plant adverse effects or untoward cardiorenal medications containing cannabis sati extracts of 1:1 CBD to THC,that are effects28,29. It is a common opioid extract,and it was the second most of high quality,laboratory tested,and sparing ingredient combined with common ingredient in prescription contaminant free are available in opioids in several common prescrip-tion medications8. e dozens of states with medical cannabis medications.The previous 500mg dose 1 laws.These extracts sell at a fraction of of acetaminophen in these combination Cannabinoid medications are- gens the cost of Sativex'. In addition,there tablets,was reduced to 325mg in 2014 to much safer,with fewer adverse-effect are a variety of ratios,2:1, 18:1 CBD to reduce the chance of hepatotoxicity and a much broader therapeutic wing THC extracts in a various dosages from taking many tablets a day. than opioids or NSAIDs.In addition; available,unlike Sativex'which only with medical doses of CBD/THC comes in one formulation28. RCTs of Acetaminophen's mechanism of action balanced cannabis the occurrence of Sativex'have shown minimal issues has been elusive in the one hundred temporary psychosis,euphoria, with drug-drug interactions or impact years that it has been in use.However, dependency syndromes,or withdraw on cytochrome P450 enzymes,when over the past decade several studies are rare,self-limiting and of short used as an adjunct with opioid have confirmed its mechanism of action durationso medications. as a prodrug.The metabolite,para- The concept of cannabis as a"gatewa aminophenol is actually a CBI selective drug"has been debunked by the Nati Studies have shown that cannabis cannabinoid.It produces analgesia Academies of Medicine in 199930.To dependency syndromes are a sequelae through the indirect agonism of CBI contrary,studies from Holland sugge of long term,frequent use of high receptors in the brain.Para- that legal cannabis use actually decor doses of cannabis with hi THC,laminophenol is also an inhibitor of � ow the likelihood of trying cocaine and CBD ratios.This is the type of AEA uptake,leading to increased levels amphetamines31 cannabis most often associated with of this endocannabinoid and increased recreational use.CBD alone is not cannabinoid receptor agonism30. A recent one year long prospective cc associated with euphoria,psychosis or para-aminophenol is also an agonist of study from Canada32 evaluated the sa dependency syndromes. The 1:1 CBD TRPV 1 receptors,also known as the of herbal cannabis use for chronic no to THC ratio in Sativex' and micro- cancer pain in 215 patients.The stud capsacin receptor.Acetaminophen has were usin u to very lac doses of THC compared to participants g p ry analgesic effects through this pathway recreational doses are probably the as well. TRPV1 is involved with amounts of 312mg THC a day in inh, reason that no withdrawal symptoms or edible cannabis.There were no providing to nociceptive sensation of or dependency syndromes have been heat and pain31. increases in serious adverse effects. associated with up to one year use of However,there were increased rates Sativex'.Similarly,cannabis that is Capsacin,is a common ingredient of mild to moderate adverse effects.The higher in CBD than THC,either in topical analgesic preparations.It is also authors concluded,"when used by extracts,or smoked or vaporized a TRPV 1 agonist,and works by patients with experience of cannabis would not be expected to be associated prolonged topical application leading to as part of a monitored treatment pro3 with dependency syndromes,or the alleviation of pain via desensitization of over one year,appears to have a adverse effects associated with high TRPV 1 mediated release of reasonable safety profile." THC to CBD ratio cannabis22. inflammatory molecules following Although there are no fatalities assoc noxious stimuli. with overdosing on cannabis,problei Beta carophyllene,a terpene,present in with decreased co-ordination have be high amounts in some strains of associated with numerous cases of"d cannabis sativa.Beta-carophyllene is a by accident."33 CB2 agonist,and greatly increases the synergistic Entourage Effect for chronic pain and inflammation16 r . 16 March/Apri12017 CANNA BISNURSESMAGAZINE.COM Chronic Pain and In 2010,a study by Dr. Donald Abrams Another study found that states with medical Medical Cannabis Use: examined the use of inhaled cannabis vapor, cannabis had 28-35%reduction in opioid Among the over 1 '/z million patients in three times a day for five days,in 24 pain addiction admissions,and 16-31%reduction patients using either morphine or in overdose deaths40. chronic pain is by far the most common the US who use medical cannabis legally, oxycodone".The findings included a 33% reduction in pain with in the cannabis and condition for which medical cannabis is A recently published analysis of Medicare recommended.Most studies suggest that morphine patients,and a drop in pain from PartD drug sales from 2010-2013 showed 44%to 21%by day five in the cannabis and 85-94%of medical cannabis patients are markedly lower prescribing of"pain killer" tY using it for pain,g. These figures may oxycodone patients. and"anxiety"medications in the 17 states that be blurred b the fact that"chronic pain" have medical cannabis laws.There were 1826 Y p A systemic review and meta-analysis of is a subjective condition,and easier to cannabinoids for medical use completed in fewer doses of pain medications,and 562 prove than other Qualifying Conditions in fewer doses of anxiety medications per fY g 2015 arrived at the conclusion that there was states with medical cannabis laws. moderate-quality evidence to support the use medical provider in those states41.An Therefore,people may be feigning a of cannabinoids for the treatment of chronic unpublished draft of a follow up paper on chronic pain condition,solely to bypass neuropathic or cancer pain;using smoked Medicaid drug sales showed even stronger prohibition against the recreational use of THC or nabiximols'22.These findings also findings. cannabis. However,this same suggest that lower total doses of opioids can phenomenon occurs regularly with opioid be used when the patient is using cannabis, UsingMedical Cannabis and benzodiazepine prescriptions. thereby further reducing the chance of adverse effects and overdoses of opioids."There is a in Clinical Practice: A study of Canadian pain clinics showed that 10-15%of the patients were using lot of data suggesting P if you air hi h otencY medical cannabis as well as other pain cannabinoids with opioids you get an„ P The biggest problem with getting medical enhanced effect. professionals to add medical cannabis to the medications.Two large-scale population- based studies in Australia and the UK list of drugs for chronic pain, is that it that the showed that about one third of people A small study of patients using long acting medication'is either plant material,plant using cannabis for medical purposes were opioids,showed that concomitant use of tinctures or extracts,or edibles.Most using it for arthritis pain,often without vaporized cannabis was associated with clinicians have verylittle experience with mm medical provider supervision$. Eighty recommending additional decreases in measured aP levels'n.Another study m CBD used in or dosing a medication in this percent of medical cannabis users reported format. In addition,the quality,consistency, substituting cannabis for prescribed combination with morphine in mice showed 3s potency and presence of contaminants is medications,especially among patients synergistic effects on nociceptive pain . highly variable with these mostly unregulated with pain-related conditions2. A study of 24 hospitalized patients using products42.The medication is obtained at a dispensary and not a qualified pharmacy and The University of California Center for morphine at oxycodone for chronic pain the health insurance does not pay for the showed that three daily doses of vaporized Medicinal Cannabis Research(CMCR), medication,which averages$100-200 a released a report in 201034. It reviewed the cannabis,measurably improved pain control month or more. findings of a decade of randomized, by 33-44%. The euphoria associated with the doubled-blind,placebo-controlled clinical vaporized cannabis became less noticeable within three to five daysbut the anti- nociceptive There are also the health concerns associated trials of inhaled cannabis.It concluded that , with smoking plant material.GW medical cannabis should be a"first line nociceptive effects persisted Pharmaceuticals has attempted to address all treatment"for chronic neuropathic pain.A A survey of 542 patients took opioids and of these issues,producing a whole plant meta-analysis of 79 studies from 2015 o medication,that meets the stringent found a 30 percent reduction of pain with cannabis together. 39/o reduced their opioid dosage and 39%stopped opioids altogether". requirements of FDA approval.Their use of cannabinoids compared to placebos. pharmaceuticals,Sativex®and Epidolex®, The concluded"We now have reasonable will be available in retail pharmacies,not evidence that cannabis is a promising Observations from States dispensaries. However,previous experience treatment in selected pain syndromes." with Medical Cannabis Laws: with Sativex®,that is available in over 20 countries by prescription for over 6 years. A 2016 University of Michigan study was published of 244 patients using medical We can learn much from the epidemiologic Research suggests that the high cost of the cannabis as an adjunct to control chronic data that has come out of the states with product has limited access43 pain 22.They found 64 percent reduction in medical cannabis laws. the use of opioids.They also noted fewer Cannabis saliva is a species of plant that has side-effects from opioids and 45 A well conducted survey during the period two medically active sub-species,cannabis percent improvement of quality of life 1999-2010 showed a 25%reduction in the saliva saliva,and cannabis saliva indica.The since adding medical cannabis to their rate of lethal opioid overdose in those states sativa strains historically have been associated treatment.Cannabis has also been shown that enacted medical cannabis laws.The with high levels of CBD and low levels of to decrease development of tolerance to effect strengthened over time from 1999 to THC and the indica strains high levels of THC opioids or severity of withdrawa131,36 2010,to 34%reductionby 20107. and low levels of CBD. March/April 2017 17 CANNA B I SN U BSESMAGAZI NE.COM n Over the past few decades there has How to Use Medical Cannabis ingested cannabis,after 4-5 days at this been significant cross-breeding and for Opioid Sparing: dose, the patient can increase the dose hybridization,resulting a hundreds of by 50%. Again,evaluate this dose for new strains often with names associated The goal of opioid sparing,is to decrease the amount of opioid being used,while 4-5 days,before considering increasing with the euphoric or relaxing effects. p g the dose.This is part of the slow titration maintaining the same level of pain control. of dosing with which most patients will Medical providers do not need to be The motivation for opioid sparing includes quickly become comfortable. aware of strains of cannabis.The reducing potential for life-threatening important therapeutic aspects of overdoses,decreasing the development of THC is usually limited to l Omg per dose cannabis,at this time,are the amount tolerance and escalation of opioid dosing and up to 4 doses a day.More than l Omg of each of THC and CBD.For whole plant reducing serious adverse effects associated THC per dose is associated with getting material the amount is provided as a with long term use of high dose opioids. euphoria or temporary adverse effects.Ir percent,for example if cannabis flower addition,use of high levels of THC can is 12%THC and 5%CBD.This means With these goals in mind,clinicians can add result in down-regulation of cannabinoid that the 12%of dry weight of the plant medical cannabis to the treatment regimen. receptors and promote tolerance to the material is THC oil,and 5%is CBD oil. The therapeutic plan includes titrating a dose cannabis medication. It also means that this cannabis has a of cannabis prior to each opioid dose.When a CBD:THC ratio of 12:5(or about 2:1). fast acting opioid is used,the patient will use Once the patient is taking IOmg of THC This information is provided by the fast acting smoked,vaporized cannabis,or a per dose,then only the amount of CBD dispensary,and should be documented tincture sublingually.When a slow release per dose will increase.A typical scenaric in a laboratory test result from an opioid is used,the patient will use ingested is that the patient is taking 10mg each of independent,state or ISO certified cannabis,such as an edible,swallowed 1:1 CBD to THC in an ingested cannabis laboratory.Appendix endix Il has a tincture or extract,as these are slow release medication,in the morning and at bedtime for chronic am.If this is not discussion of how to calculate doses of medications. P smoked cannabis. giving sufficient pain control throughout The educated patient will have been taught to the day,the patient can increase the For vaping fluids,extracts,tinctures, "start low,and go slow."For a vaporized or frequency up to four times a day.Then edibles and dermal applications,the smoked cannabis,the patient will take the increase the amount of CBD in the label provides the number of recommended dose,then wait 20 minutes. product,for example increase to 25mg milligrams of THC,CBD,some other The cannabis will reach peak plasma CBD and I Omg THC per dose. cannabinoids and often terpenes,per concentrations in the blood in 9-23 minutes. milliliter or per serving.Many of these If pain control is not sufficient,the patient Another choice is to add a low THC/higl ingested manufactured products are will then take a second dose,again waiting 20 CBD vaporizer used regularly made by small manufacturers and may minutes to decide to either try a third dose of throughout the day.CBD is very safe, have issues with quality,consistency, cannabis,before taking the fast acting opioid. and used alone has measurable impact or and contamination with pesticides, If the patient has measurable improvement in pain and inflammation.Adding over a molds,and heavy metals.A recent pain levels from the cannabis alone,but not 50mg(20 vaporized inhalations)of extra study of Colorado dispensaries found sufficient,then he may try taking half of the CBD a day via this route is not 85%had inaccurate doses,23%had usual dose of the fast acting opioid uncommon. more and 60%had less THC than medication.This is due to the expected stated on the label46.Recently enacted synergistic effects of the cannabinoids at the Once pain reduction has been established state laws should improve this MORp. with the use of cannabis,the use of situation.A good dispensary will have opioid pain medications can gradually be the labels confirmed by independent, The process is similar for ingested,or slow reduced,keeping in mind the potential high quality laboratories. release cannabis medications.These are used for opioid withdrawal and the need for Most clinicians are not familiar with to spare the use of slow release opioids.The an established protocol for weaning. helpingpatients calculate the dose of patient will take the dose recommended by p the medical provider.The patient will need to Start at a low dose of cannabis,where their medication.Most good wait 60 minutes,because of the slow release the benefit for pain relief occurs,and dispensaries will have staff members and first-pass effect.The mean peak plasma where the euphoric or dysphoric effects trained how to teach the patient to concentration time of 60-120 minutes and of cannabis are less likely to occur. Start calculatee t the correct dose. therapeutic efficacy can last up to 6 hours. low and titrate up slowly. For chronic The metabolite of THC, 11-OH-THC,is 40% pain is 2.5mg of THC and CBD(1:1 more potent than THC,therefore,no second ratio)at morning and bedtime is a ingested dose is taken.If after an hour there is recommended starting dose.If the dose 4W not sufficient pain relief,then the patient can is ingested via an edible,or swallowed decide to take either half the usual dose of tincture,it will take about 60 minutes to slow release opiate,or the full dose. If there start having effects,but should have was insufficient pain control with that dose of pain-relieving effects for up to six hours. r 18 March/Apri12017 CANNABISNU RS ESMAG A ZINE.COM Vaporized or inhaled cannabis can be Appendix I: used for quick onset to treat Tapering Off or Discontinuing Endocannabinoid System: breakthroughpain. Chronic Opioids: P Usually two The Endocannabinoid System(eCS)has inhalations(4-5mg)of smoked of Patients have historically been tapered off been present in all vertebrate life for the vaporized cannabis is taken,and wait at opioid medications at a certain past 600 million years. Receptors for least 20 minutes to determine if predetermined rate that ranges from 10%to the eCS are the most common additional inhalations are appropriate. 50%per month.The medical provider, neurotransmitter receptor in the brain based on training,experience and recent and the second most common in the Because of the desire to impact the research should discuss the taper rate,and body.The eCS is the main fat soluble nociceptive centers in the CNS, expected quit date,usually from 2 to 10 neurotransmitter in the body.Unlike neuropathic pain and inflammatory months in the future.The medical provider dopamine,GABA,acetylcholine, component of the pain,both CBD and will need to re-establish the Pain Contract serotonin,which are water soluble THC are recommended.In order to with the patient,with the addition of neurotransmitters.The eCS is reduce the chance of euphoria,and cannabis,and educate the patient on the responsible for homeostasis of a wide other adverse effects associated with proper use,dosing,safe storage,and variety of other system in the brain and THC alone,it is recommended that a awareness of adverse effects.The medical body,in general the eCS is responsible ratio of CBD:THC of 1:1 be used provider usually monitors the progress of for retrograde slowing down a system initially.This ratio works for most the tapering with regular visits and review when it gets over stimulated from patients. of a Pain diary. dozens of other neurotransmitters.The eCS works on following broad areas of There is no comparison chart of THC/ Discontinuing Opioids: bodily functioning including, CBD to Morphine Equivalent Dose nocioception centrally and peripherally, (MED).Because of the previously Totally stopping opioids is another inflammation,reward behavior and discussed issues with the potency,and potential goal for medical cannabis.In spasticity. In the brain the eCS reduces consistency of cannabis doses,it is this scenario,the goal is to replace anxiety through effects in the limbic and important to start well below the opioids with medical cannabis.Prior to paralimbic brain areas,which are rich in expected therapeutic dose and attempting this goal,the patient should endocannabinoid receptors. gradually titrating the dose upwards. have satisfactorily gained the skills, The dose can be titrated up every 4-5 experience and education necessary to The eCS has at least two receptors days until measurable reductions in use medical cannabis for opioid sparing (CB 1,and C132),two ligands, pain are noted.Usually the dose is purposes.After they have been able to anadamide(AEA)and 2- increased in 2.5mg increments, to 5mg, halt escalation of opioid doses,and often Arachidonoylglycerol(2-AG)and two 7.5mg,then IOmg. reduce opioid doses,they may be enzymes that breakdown the ligands interested in entirely substituting opioids intracellularly,FAAH and Cannabinoid medications have an and/or benzodiazepines with medical monoacylglycerol lipase(MAGL). inverse U-shaped dose-response curve. cannabis. Anecdotally,many patient who Because of this it the initial doses may use medical cannabis for opioid sparing, THC was discovered by Dr.Rafael have no effect.Once a dose is reached may attempt to taper off opioids and Mecholum at the University of with therapeutic effects,the dose benzodiazepines on their own,because of TelAviv in the 1964. The eCS with its should be titrated up more slowly until the pleasant mood elevation,relief from associated ligands was not discovered there is a maximum effect.As the dose constipation,and reduction of several until 1990. Significant new aspects of increases past the maximum therapeutic opioid adverse-effects.However,any the eCS continue to be discovered. effect,tolerance may develop due to tapering needs to be done in conjunction down-regulation of"flooded" with the treating clinician to avoid The eCS produces the ligands,AEA cannabinoid receptors. withdrawal or other adverse sequelae. and 2-AG on-demand in the post- synaptic membrane.This occurs in Doses of THC above I Omg in 1:1 response to excess of other cannabis can be associated with Unlike most medications,the patient will neurotransmitter stimuli.The ligands euphoria.Higher doses can result in often feel comfortable adjusting the are produced in microseconds and temporary psychosis,anxiety, dosing of the cannabis medication,this P �P Y ' patient centered titration is unique to released into the synaptic cleft to attach ere dysphoria,and agitation,especially if to pre-synaptic endocannabinoid there is only a low ratio of CBD to medical cannabis,but in general is a very receptors.This results in shutting down counteract these adverse effects of safe and effective way to reduce calcium channels,and a decrease in the THC. dangerous opioids and benzodiazepines release of other neurotransmitters.The and obtain long term consistent pain and ligand is then transported inside the cell associated symptom relief via specialized proteins,and degraded by FAAH or MAGL.So these naturally occurring ligands have very short-lived effects. .March/April 2017 19 CA NNABISN URSESMAG A Z I NE.COM When plant-based cannabinoids, the CNS.But are also present in the In general,when it comes to dosing phytocannabinoids,such as THC and lung,liver,skin and several other areas medical cannabis the main concern is CBD are released into the blood stream of the body. getting approximately the correct dose of via inhalation,ingestion or dermal The CB2 receptors are found predomin- THC.All of the adverse effects,euphoria application,they are rapidly distributed antly on immune system cells in the and issues with dependency are throughout the body and transported associated with THC. CBD on the across the blood-brain barrier to attach to brain and body,as well as reproductive cells and in the liver and spleen. C132contrary,is non-euphoric,is not CB I and C132 receptors. receptors are temporarily up-regulated associated with dependency and has only at sites of trauma,where they are some mild calming(anxiolytic)effects at The affinity and number of cannabinoid usually not present,leading to increased the doses recommended for pain receptors varies considerably in differentsensitivity to the anti-inflammatory management.The therapeutic window of brain centers and organ systems.It is for effects of CBD. CBD is very large up to 100's this reason that small doses of milligrams per dose. cannabinoids can have therapeutic effects, If a receptor is overstimulated,or without the adverse effects of euphoria, 'flooded'with ligands,as can occur with Appendix III: anxiety or psychosis.The correct dosing too much phytocannabinoid and ratio of CBD:THC are vital to medication,this results in a down- Chronic Cannabis Users: maximizing therapeutic effects and regulation of the receptors,and can lead Patients who have already been minimizing adverse effects. to the development of tolerance. chronically using cannabis,often for recreational purposes,will need to have Phytocannabinoids work therapeutically Appendix II: their cannabinoid receptors by mimicking the effects of the naturally Calcuating the Dose of reprogrammed prior to starting occurring endocannabinoids.Since they Inhaled Cannabis: treatment. are mimicking fat soluble It is important that the medical provider neurotransmitters,they work very The goal is to up-regulate the number of understand the basics of dosing inhaled tors in these`veteran' similarly to the way gabapentin mimics medical cannabis. If plant material is cannabinoid receptors GABA.In fact,there are many ° o patients,because they have been down- similarities CBD and 0.5/o THC,which is the regulated b frequent,high doses of similarities to gabapentin,the therapeutic cannabis used for childhood epilepsy, y q g window is very wide and adverse effects ° cannabinoids.Patients with prior regular then 18/o of the dried plant material is are short-lived and non-fatal. CBD oil. The average amount of plant use of cannabis,should be advised to discontinue all cannabis for three days. Unlike the naturally occurring ligands, material in an average`joint'has been Then start at a low dose of 1.25mg of THC the micro-dose inhaler the phytocannabinoids are not estimated as se inhaler Omg. Research for and CBD for three days.Then the patient doses of cannabinoids fo metabolized by FAAH and MAGL.In o provide tiny can increase to the full recommended dose fact,part of the efficacy of the r medical use,calculated the average`joint' to be before evaluating efficacy of the dose and phytocannabinoids may be due to their medication.This period of time with less competing with intracellular fatty acid 400mg of plant material in a 1 al rolling cannabinoid stimulation results in up- transport proteins(FATP)so that paper. Since 18 f 0 the material is CBD regulation of cannabinoid receptors and naturally occurring ligands are oil,then mil of 400 of C x.Sin unproved response to cannabinoid doses. metabolized more slowly and have a equals 72 milligrams of CBD.Since half more longer lasting effect. of the oils are incinerated by the process of combustion,a patient smoking an The phytocannabinoids are only partial entire joint would be expected to get 36 agonists of the endocannabinoid milligram of CBD. When cannabis oil opposed to as opp receptors,but have a much longer half- or extract is vaporized, - �• being smoked,there is no combustion so • :� life than the rapidly disappearing ►a� a the patient gets mostly vaporized oil. • - endocannabinoids. The dose will vary considerably by the brand,and concentration of the 6 �,& Up and Down Regulation and medication.The package insert for these Tolerance: products should provide information on CB 1 and C132 are GPR55 membrane the available dose of THC and CBD in receptors.The number ofcannabinoid the product.As it is with edibles,the receptors on cell membranes varies labels on these locally manufactured considerably in different areas of the extracts,and tinctures can be quite brain.The numbers of receptors changes inaccurate.The dispensary should also in response to up-and down-regulation. have independent laboratory analysis of The CB 1 receptors are found mostly on the products. neurons in certain brain centers and r' 20 March/Aprfl 2017 CA NNABISNUBSESMAGAZI NE.COM F 1.Morbidity and Mortality Weekly Report(MMWR),March 2016,CDC Guidelines 22.Ruhaak LR,ct al.Evaluation of the cyclooxygenase inhibiting effects of six for Prescribing Opioids for Chronic Pain-United States,2016. major cannabinoids isolated form Cannabis sativa.Biol Pharm Bull. 2.(2)Injury Prevention and Control:Opioids Overdose.Centers for Disease Control 2011;34(5):774-8. and Prevention.Oct 3,2016. 23.Narang S,Gibson D,Wasan AD,et al.Efficacy of dronabinol as an adjuvant 3.Rudd RA,Aleshire N,Zibbell JE,et al.Increases in Drug and Opioids Overdose treatment for chronic pain patients on opioids therapy.J Pain 2008 Deaths-United States,2000-2014.MMWR 64(50);1378-82. 2016. Maz;9(3):254 264 4.Chen LH,Hede aard H,Warner M.Drug-poisoning death involving opioids 24.Positive results from clinical study of Sativex in cancer pain published in peer g analgesic:United States.1999-2011.NCHS data brief,no 166,Hyattsville,MD: review journal,Nov 2009. National Center for Health Statistics.2014. 25.Results of Sativex Phase M Neuropathic Pain Trials Demonstrate Benefits for 5.American Academy of Pain Medicine(AAPM)30th Annual Meeting.Abstract HISh Need Treatment-Resistant Patients,Jan 2007. 120.Presented March 7,2014. 26.Wbiting PF,et al.Cannabinoid for Medical Use,A Systematic Review and 6.Chen LH,Hede acrd H,Warner M. Meta-analysis.JAMA.2015:313(24):2456-2473. g Quickstat:Rates of death from drug poisoning and drug poisoning involving opioids analgesics-Units States,1999-2013.MMWR 64(01):32.2015. 27.Deer TR,Leong S,Gordin V.Treatment of Chronic Pain by Medical Approaches:the American Academy of Pain Medicine,textbook on patient 7.Bachbuber MA,Saloner B,Cunningham CO,et al.Medical cannabis laws and management.2015 p.189-190. opioids analgesic overdose mortality in the United States,1999-2010.JAMA Intem Med 2014 Oct;174(10):1668-1673 29.Schultz S,DeSilva M,Gu TT,et ta.Effects of the Analgesic Acetaminophen (Paracetamol)and its para-Aminophenol Metabolite on Viability of Mouse- 8.FDA Drug Safety Communication:FDA warms about serious risks and death when Cultured Cortical Neurons.Basic and Clin Pharm and Toxicology;110:141-144 combining opioids pain or cough medicines with benzodiazepines;requires its strongest warning.http://www.fda.gov/Drugs/DrugSafety/ucm5l8473.htm 30.6 Fall-ni nt Ferrari ):Ottani A et al.Paracetamol:new vistas of an old drug. 2006 Fall-Winter;l2(3-4):250.75 9.Tadros A,Layman SM,Davis SM,et al. Emergency Department Visits by Pediatric Patients for poisoning by prescription opioids.Am J Drug Alcohol-Abuse. 31.Joy J. Marijuana and Medicine:Assessing the Science Base.The National 2016 Sep;42(5):550.555. Academies Press 1999. 10.Wilsey B,et al.Low Dose Vaporized Cannabis Significantly Improves 32.MacCoun RJ.What can we learn from the Dutch Cannabis Coffee shop Neuropathic Pain.J.Pain,2013 Feb 14(2):136-148 experience?Addiction 106(11)1899-1910(2011) 11.Johnson R,et al.Multicenter,double-blind,randomized,placebo-controlled, 33.Ware MA,Wang T,Shapiro S,et al.Cannabis for the Management of Pain: parallel-group study of the efficacy,safety,and tolerability of THC:CBD extract and Assessment of the Safety Study(COMPASS), JH Pain 2015 Dec;16(12):1233-42 THC extract in patient with intractable cancer-related pain. 34.Prevalence of Marijuana Involvement in Fatal Crashes:Washington, 12.Russo,E.B.(2008,February).Cannabinoids in the management of difficult to 2010.2014.American Automobile Association report May 2016. treat pain.Therapeutics and Clinical Risk Management,4(1),245-259. 13.www.aan.com/Guidelines/home/GetGuidelineContent/650 35.Grant I,et al.Report to the legislature of the state of California presenting findings pursuant to SB847 which created the CMCR and provided state fimding. 14.Ste.-Marie PA,et al.Herbal cannabis use in patients labels as fibromyalgia is 2010. associated with negative psychosocial parameters.Arthritis Care Res 2012 June 21. 36.Boehnke KF,Litinas E,Clauw DJ.Medical Cannabis Use is Associated with 15.Klauke AL,Racz I,Pradier B,et al.The cannabinoid CB2 receptor-selective Decreased Opioid Medication Use in a Retrospective Cross-Sectional Survey of phytocannabinoid beta-caryophyllene exerts analgesic effects in mouse models of Patient with Chronic Pain.J Pain. 2016 Jun;17(6):739-744 inflammatory and neuropathic pain.EurNeuropsychopharmacol. 2014 Apr;24(4):608-20 37.Lucas P.Cannabis as an adjunct to or substitute for opioids in the treatment of chronic pain.J Psychoactive Drugs.2012 Apr-Jun;44(2):125-33 16.Abrams DI,et al.Cannabis in painful HIV-associated sensory neuropathy-A randominzed placebo-controlled trial.Neurology 2007 Feb;68(7):515-521 38.Abrams D,et al.Cannabinoid-Opioids Interaction in Chronic Pain.Clinical Pharmacology and Therapeutics 90(6)844851 17.Baron,E.P.(2015,June).Comprehensive Review of Medicinal Marijuana, Cannabinoids,and Therapeutic Implications in Medicine and Headache:What a Long 39.Neelakantan H,Tallarida RJ,Reichenbach ZW,Tuma RF,Ward SJ,Walker Strange Trip It's Been.Headache,55(6),885-916. EA.Distinct interactions of cannabidiol and morphine in three nociceptive behavioral models in mice.BehavPharmacol.2014 Dec 5. 18.Stott CG,Guy GW,Wright S,et al.The effects of cannabis extracts Tetranabinex and Nabidolex on human cyclo-oxygenase(COX)activity.International Cannabinoid 40•The Cannabis and Opioids Survey.Healer.com Oct 4,245. Research Society.2005 Jun Clearwater,FL. 41.Brittany B,et al.Opioid substitution and antagonist therapy trials exclude the 19.Cannabis:A Promising Option for the Opioids Crisis.NCIH,October 2016. common addiction patient:a systemic review and analysis of eligibility criteria. Trial.2015;16:475 20.Kay L,Holtzman S.Substituting marijuana for prescription drugs,alcohol and other substances among medical marijuana patients:The impact of contextual factors. 42.Bradford and Bradford,Health Affairs Jul 2016. 2015 Drug and Alcohol Review 43.Ryan Vandrey,PhD,et al Cannabinoid Dose and Label Accuracy in Edible 21.Haroutouian S,et al.The Effect of Medicinal Cannabis on Pain and Quality-of- Medical Cannabis Products.JAMA.2015;313(24):2491-2493 Life Outcomes in Chronic Pain:A Prospective Open-Label Study. Clin J Pain.2016 Dec;32(12):1036-1 44."Sativex rejected by healthcare provider".Lincolnshire.20 June 2011. Retrieved 20 June 2011. March/April 2017 CANNABISNUBSESMAGAZINE.COM 21 Bio:Anita Willard Briscoe MS APRN-BC • ROADMAP CHANGE IN YOUR COMMUNITY �l TA. B:\ Anita Willard Briscoe, is from New Mexico, and has been a Nurse for 4 By: Anita Willard Briscoe, MS, APRN-BC years. She has been a psychiatric nurse for 24 years, and a psychiatric "Update on Petition Letter on Adding Opiate Dependence as nurse practitioner for 12 years. She Qualifying Condition for Medical Cannabis" has her BSN, her Masters of Scienc As of today,February 22,2017, the petition letter has not yet been signed by our Secreta in Community and School Health of Health. There are currently 3 bills in New Mexico's ongoing legislature that address i Education, and her Masters of legalization of cannabis, increasing plant count, increasing medicine limits per patients, Science in Psychiatric Nursing fro legalizing hemp, and regulating and taxing cannabis. University of New Mexico. She The Secretary may be waiting to see what the legislature, which concludes the end of Ma currently has her own private does with these cannabis bills, and whether they pass. Our Governor is very unfriendly practice in Albuquerque where she toward cannabis and has vowed publicly to veto any bills presented to her.However, to refers her patients to the New Mexi credit, our cannabis program has grown to over 36,000 patients under her leadership. Department of health Medical Cannabis Program, and is active in £ A ROADMAP OF HOW TO CREATE CHANGE IN YOUR COMMUNIT getting Opiate Dependence approv How can nurses create a sea change in the way cannabis is used as medicine? Here's hoi as a qualifying condition for medic did it: I saw that there was a great need out there among my cannabis patients who were cannabis. certified for cannabis under another condition: They needed help quitting or cutting dow on their opiate use. Often,these patients were heroin addicts,or were pain patients,using MW heavy doses of opiates and wanted to get off. Qualifying Conditions You must have your research in hand before you want to effect any change. Even thougl Oriainal Conditions Conditions Adm ■ Cancer ■ Painful peripheral neuropathy we are in an anti-science climate,public officials respect the work of robust research,will ■ Glaucoma ■ Intractable nausea/vomiting which no one can argue. ■ HN/AIDS - Severe anorexia/cachexia • Multiple Sclerosis • Hepatitis C Infection currendy I started doing online research. PubMed and The American Cannabis Nurses Association ■ Epilepsy `ece'""9 annw'ru/`'ean7ent are mostly where I started,and now Cannabis Nurses Magazine. They have a compendit ■ Spinal Cord Damage with ■ Crohn's disease Intractable spasticity • Past-traumatic Stress Disorder of articles on robust clinical research that is being done around the world on 1.)cannabis ■ Patients in hospice care • Amyotrophic Lateral Sclerosis - and pain;2.)cannabis and opiate use,as well as 3)cannabis and symptoms of opiate ■ Severe Chronic Pain withdrawal and maintenance of sobriety. Evaluating the bibliography of each article is • Autoimmune mediated _ what helped me compile a 21-page bibliography for my research.I would choose relevan articles from that bibliography,choose relevant articles from the bibliographies of the w'•0VANunn Nw UNd subsequent articles,and so on.When done online,nurses can just click on the link in ead bibliography,and it will take you right to the articles. I then compiled the abstracts of ea relevant article and came up with my bibliography.I also placed a summary comment afl What you as a Nurse can d each citation. in your state. If you as a nurse want to change something in your neighborhood,your hometown,your state,look carefully at the problem,gather data,and focus narrowly on what it is you wai to change. I did mine on Opiate Dependence;I could have done"substance abuse"or u "opiates and alcohol,"but these were too broad and cumbersome. 22 March/April2017 CANNA BI SNUBSESMA GA ZI NE.COM Once you've defined the problem that The Misdiagonosis of Cannabis Dependency Under the DSM-5 could be successfully addressed with the Diagnosis Cannabis use Disorder. use of cannabis,find out who is able to change the laws,and approach them According to High Times,March 8,2016,these 11 "symptoms"are criteria for diagnosing with your idea. Have your research this disorder,along with my comments(in italics),which are professional opinions.This ready,printed up,and documented evaluation only pertains to cannabis patients. perfectly,no misspellings,APA style. Have it available electronically. 1. Taking the substance in larger amounts or for longer than the you meant to.This would Approach the lawmakers professionally, normally happen in patients with severe conditions that need high concentrations of and follow to the letter the rules for Cannabinoids such as THC/CBD. It is normal to build tolerance,and tolerance can be presenting your petition. Convince your addressed by changing strains,or taking a`tolerance break.' 2 Wanting to cut down or stop using the substance but not managing to.This is a sign of officials see how severe the addiction.Cannabis has been demonstrated to be much less addictive than other drugs. community's problem is with recent, 3. Spending a lot of time getting,using or recovering from use of the substance.See#2. solid data. (New Mexico has one of the Medical cannabis patients(hopefully)are fortunately not put in this position. highest heroin overdose deaths in the 4. Cravings and urges to use the substance.Again,this is a sign of addiction. If a"craving" country—was my example.) exists among cannabis patients,it could mean their symptoms have returned and need to be treated with medicine. People use cannabis to self-medicate their symptoms. 5. Not managing to do what you should at work,home or school,because of substance use. Be persistent,and don't take no for an This can indeed occur;cannabis can cause impairment. answer. Many state officials are either 6. Continuing to use,even when it causes problems in relationships. Sometimes the patients' hostile to, or are uneducated about friends/family/co-workers need more education on why cannabis is working for the patient. cannabis.Try to find one that is 7. Giving up important social,occupational or recreational activities because of substance sympathetic.Present to them the use. I would argue that in the case of cannabis patients,just the opposite occurs:the patients advantages of using cannabis for your are once again able to perform life activities because they feel so much better. chosen problem,especially the financial 8. Using substances again and again,even when it puts you in danger. Research has demonstrated that cannabis is much less dangerous than alcohol,heroin,cocaine,etc. advantages. For example,how much is 9. Continuing to use,even when you know you have a physical or psychological problem it costing your state to treat overdoses? that could have been caused or made worse by the substance. See#8.Research has shown How much is it costing to imprison that patients that are truly in need of cannabis improve physically and psychologically(PTSD cannabis users?How can legalizing is a good example). cannabis provide financial incentive for 10. Needing more of the substance to get the effect you want(tolerance)This can indeed happen with cannabis. See item# 1. your state(via taxes and job growth)and how can problems be solved.Look to 11. Development of withdrawal symptoms,which can be relieved by taking more of the substance."Withdrawal symptoms"in cannabis patients simply means that their original Colorado for their success stories,as symptoms have returned for which the cannabis treated(ex:nightmares in PTSD).Because well the extensive research they have these symptoms return,of course the patient is going to"crave"their medicine. This is done such as addressing the common different than craving,for example,heroin,in which there are"cues to use,"such as seeing fear that their youth will start abusing certain people,being in a certain neighborhood,or the classic withdrawal symptoms we see cannabis(proven to be untrue.) among heroin addicts and alcohol addicts that require immediate medical attention. For patients who are legally using medical cannabis in the states which allow them,the term "dependency"is an inaccuracy. If you were diabetic,are you not"dependent,but not ^p^^ addicted"to insulin? If you have a thyroid deficiency,are you not"dependent,but not Ule&ome addicted"to thyroid supplement? You see my point? These criteria were set in place in order to"treat"cannabis users,while ignoring that there are millions of people who successfully —to use cannabis as medicine. NEWMEXICO The National Institutes of Health(NIH)uses these criteria to"research"the"problem"of Land of Enchantment cannabis use in our country. The job of the NIH is to prove how"harmful"cannabis is. Fortunately,an abundance of research is now available to debunk a lot of this.New,exciting research is coming out every day from all over the globe that is proving how wonderful a medicine cannabis really is. Tap into that research. Make a difference in your community! And now for the letter to the Department of Health we as Nurses can model from... March/Apri12017 23 C ANNA BI SNUASESM A GAZINE.COM PETITION TO THE NM MEDICAL ADVISORY BOARD TO THE NEW MEXICO MEDICAL CANNABIS PROGRAM TO ADD OPIATE DEPENDENCE AS A QUALIFYING CONDITION Anita Briscoe,MS,APRN-BC Madame/Chair,Members of the Medical Cannabis Program Medical Advisory Committee, My name is,Anita Willard Briscoe,and I am a native New Mexican from Espanola,living in Albuquerque. I have been a nurse for 40 years, a psychiatric nurse practitioner for 12 years. I have been referring patients to the cannabis program for 7 years. Over these years,I have observed that about 25%of my patients have stated independently that they were able to kick opiates with cannabis. They state it calms down their cravings,relaxes their craving anxiety and is helping them to stayoff opiates. if they are in pain,cannabis is helping relieve their pain,often to the point drat they don't need opiates any more. I beganresearchingthe medical literature more deeply to determine what it is about cannabis that's helping. What research is discovering is that THC and CBD occupy the Mu Opioid Receptors,the same places that opioids work. I also started counting,and asking my three cannabis-referring colleagues if they're observing the same thing,and they too are seeing that the patients have been able to kick opiates with cannabis.Together,we have approximately 400 patients who have been successful quitting opiates,using cannabis. I am here today to petition you to add opioid dependence to the list of qualifying conditions for medical cannabis. I have included four separate bodies of research,cannabis withdrawal,detox and maintenance,safety,and harm reduction,the economics of `how cannabis has reduced prescription costs,and cannabis and pain relief. I have attached the research I conducted. Each citation has a brief quote from each abstract of the studies that have been conducted both in • United States,and internationally.Twenty-one pages of articles from p"igious peer-reviewed medical journals and popular media which include: 2S ,i • Seven articles tort Journal of the American Medical Association • American Journal of Public Health • Harm Reduction Journal • Journal of Drug and Alcohol Dependence • Journal of Pain • Journal of Clinical Psychopharmacology • Neuropsychopharmacology • Clinical Trials.gov • Addiction Biology - • American 7ouraal of Addiction • NIH/NIDA cz • Scientific American • TIME 1Vlgazine • National Bureau of Economic Research - • National Institute of Drug Abuse(NIDA) • • Health Affairs I have also included letters of support from Steve Jenison MD,former Chair,Medical Advisory Committee,Bruce Trigg MD,International Public Health Consultant,and medication assisted treatment provider for the ECHO Program,and Clinica De Salud,Rep.Debbie Armstrong, and Sen.Jerry Ortiz y Pino. Also included is a letter written by Sen Elizabeth Warren to the CDC,directing them to begin studying the use of; cannabis for the treatment of opiate dependence. The cover page to the bibliography is a graphic reminder of how very serious and debilitating this disease is to our State,as well as how our opiate overdose and abuse problem has been increasing over the last 13 years. Indeed,since the imprisonment of EI Chapo this year,the Mexican drug cartels have dramatically lowered the price of heroin and are adding the even more deadly Fentanyl to it,or are selling pure Fentanyl.We are seeing skyrocketing overdose deaths as a result. I have focused some of my research on pain,and even though pain is already an approved condition,expanding the program to include opiate__ dependence is the next smart,logical step. After all,pain is usually the reason patients start getting addicted to opiates. You probably have heard the story: They start out with some pain pills for a condition such as a sports injury,and they get hooked.They then probably get cut o0 by their prescriber,and have to get pills off the street,which are very expensive. It is easier and cheaper to get heroin. r 24 March/Apri12017 CANNARISNURSESMAGALINE.COM I am writing this petition from my heart: I love my patients and feel very protective of them. The fact that people cannot get cannabis for their opiate addiction is a travesty.Just imagine if they had access to cannabis and were able to kick their habit,how our state would change for the better.Crime would go down,health care costs would diminish,overdose deaths would fall,and it would help our economy to flourish. (Imprisonment for cannabis use cost the state$33 million last year.) Without the familial crisis of opiate dependence,New Mexico's children would also be safer,families would be more stable. As I mentioned,I'm from Espanola,the town with the dubious title"The Heroin Capital." I've seen firsthand how heroin has destroyed, decayed and desiccated my beloved home town.The patients that come to see me now that are from Northern New Mexico describe a very dangerous environment in their communities with heroin.Indeed,when I was helping a physician prescribe Suboxone to my patient from Espanola,he was murdered for his Suboxone. Patients are very motivated to get off of heroin,but getting into medication assisted treatment is very difficult. One of my patients from Clovis has to drive to Albuquerque every week to get her Suboxone.There is a shortage of medication assisted treatment providers. I wish to stress that I am aware that medication assisted treatment(Methadone and Suboxone)is the standard of care,and I am not looking to replace it with cannabis. But the research shows that cannabis works well as a complimentary treatment. Having access to cannabis would be a great help to our patients. Also,referring for cannabis is a harm reduction intervention that can help to link people with medication assisted treatment,harm reduction(syringe exchange and naloxone especially),mental health care services and medical care(such as treatment for hepatitis Q. This move would also be a rich opportunity to begin doing research in New Mexico,particularly prospective studies on opiate use,overdose and death reduction. You may ask,why add Opiate Dependence as a qualifying condition? Here are some answers. 1. The patients are using cannabis to treat their dependence anyway. { f 2. It has been proven by medical research to work. 3. Arresting and i}pgrisoning them for using cannabis to stop using opiates is expensive for NM. . # 4. Medication assisted treatment is difficult to get into,sometimes with very long waiting periods to get into the program,as well as having to drive long distances. 5. Finally,we owe this to our patients. A treatment modality that is within close reach is unattainable because it's illegal. Research views medical cannabis as legitimate harm reduction. Using this model,cannallig is much less dangerous to the patient and his/her community than the heEoin and Fentanyl that is now on the streets and is often more readily accessiHTtr. Our state's cannabis program has often been a model that other states are following as they legalize medical cannabis. We are a leader in this Wit! Let's continue to lead and be innovative,and use solutions that work. You may be aware that Maine attempted to add opiate dependence to their list of qualifying conditions this summer,and failed,due to"lack of evidence". I am here to tell you that the bibliography I have developed shows beyond a shadow of a doubt that there is an abundance of robust research on the topic.New Mexico can and should lead the way in taking advantage of this opportunity to give opiate dependent patients access to medical marijuana. I encourage the Medical Advisory Board to review this petition for inclusion of Opiate Dependence to the current list of qualifying conditions for the Medical Cannabis Program. The risks would surely be outweighed by the possibility improving lives or even saving just one life. We have an opportunity to explore and lead the nation in researching what could be a compassionate, and revolutionary treatment for addiction. In concluding,I ask that you as the Medical Advisory Board consider adding Opiate Dependence as a qualifying condition. I know there are forces out there such as the big pharma,the alcohol lobby,and the private prison lobby,as well as other strong anti-cannabis forces in this state that want to hold back progress for treatment. My colleagues,myself,and all our patients ask that you DO NOT buckle under these forces and do the right thing by allowing opiate dependence to be on the list of qualifying conditions for use of medical cannabis. Thank you very much, Anita Briscoe,MS,APRN-BC March/Apri12017 25 C A NNAB ISN URS ESMAGAZINE.COM BIBLIOGRAPHY Study:Long term cannabis use mitigates pain,reduces opioid use Cannabidiol for the treatment of cannabis withdrawal syndrome:a Martinelli,A NORML http://thejointblog.com case report Crippa,JA et al J Clin Pharm Ther,Apr 2013 Amygdala activity contributes to the dissociative effect of cannabis on Adolescent exposure to chronic delta 9 THC blocks opiate dependence in pain perception Lee MC,Ploner M,Wiech K.Bingel U,Wanigasekera V, maternally deprived rats Morel,L et al Neuropsychopharmacology,2009 Brooks J,Menon DK,Tracey I.Pain.2013 JanI;154(1):124-34.doi: 10.1016/j.pain.2012.09.017.PMID:23273106[PubMed-indexed for MEDLINE] Impact of cannabis use during stabilization on methadone maintenance treatment Scavone,JL et al Am J Addict,Jul 2013 America's Opiate Crisis: How Medical Cannabis Can Help New study finds cannabis reduces the symptoms of opiate withdrawal By Dr.Dustin Sulak on July 25,2016 http://thejointblog.com July,2013 Dr.Dustin Sulak on a neglected treatment for opioid addiction: medical cannabis Cannabidiol as an intervention for addictive behaviors:a systematic https://www.projectcbd.org/article/americas-opiate-crisis-how-medical- review of the evidence Prud'homme,M et al Subst Abuse May,2015 cannabis-can-help Science recognizes cannabis reduces withdrawal symptoms,but state Medical Cannabis Use Is Associated with Decreased Opiate laws still don't http://theweedblog June,2012 Medication Use in a Retrospective Cross-sectional Survey of Patients with Chronic Pain Boehnke,KF Opioid addiction being treated with medical marijuana in Massachusetts J Pain.March 2016 http:///www.jpain.org/article/ http://www.drugfree.org/news-service Jul,201 Acute and short-term effects of CBD on cue-induced craving in drug- Weed can alleviate withdrawal symptoms with opiate addicts abstinent heroin-dependent humans Hurd.Y et al http://www.thefix.com Sep.2014 https://clinicalMals.govAugust,2016 Endocannabinoid signaling system and brain reward:emphasis Top three benefits of cannabis for opiate dependence https:;/sensiseeds.com Jul,201 on dopamine Gardner.EL Pharmacol Biochem Behay.June,2005 Anxiolvitc effect of Cannabidiol derivatives in the elevated plus-maze Advocates push to let patients use marijuana to treat opiate addiction Guimaraes,FS,Mechoulam,R et al Gen Pharmacol,Jan, 1994 The Portland Press Herald Apr.2016 Results of this study confirm previous findings with CBD and indicate that its derivative HU-219 may possess a similar anxiolytic-like profile. Early phase in the development of Cannabidiol as a treatment for addiction: opioid relapse takes initial center stage Cannabidiol is an allosteric modulator at mu-and delta-opioid Hurd.Y Neurotherapeutics Oct,2015 receptors Naunyn Schmiedebergs Arch Pharmacol,Feb,2006 Kathmann M,et al Is weed the secret to beating opiate addiction' Cannabidiol inhibits the reward-facilitating effect of morphine: Mitchell,T et al involvement of 5-HT1A receptors in the dorsal raphe nucleus The Daily Beast Sep,2014 Katsidone.V.et al Addict Biol,March 2013 http://www.thedailybeast.com/articles/2014 The Substance Abuse and Mental Health Services Administration(SAMSHA) Differential effect of cannabinol and Cannabidiol on THC-induced describes the side effects of marijuana as sleepiness,trouble concentrating,and responses during abstinence in morphine-dependent rats decreased social inhibitions. These seem mild in comparison to the harsh side Hine,B et al Res ComunChemPatholPharmacol, 1975 effects of replacement medications. Effect of some cannabinoids on naloxone-precipitated abstinence in ECONOMICS morphine-dependent mice Bhargava,HN Psychopharmacology(Berl)Sep, 1976 Medical marijuana laws reduce prescription medication use in Medicare Part D Bradford,A et al Cannabidiol,a nonpsychotropic component of cannabis,inhibits cue- Health Affairs,Jul,2016 induced heroin seeking and normalizes discrete mesolimbic neuronal The use of prescription drugs for which marijuana could serve as a clinical disturbances Ren,Y et al J Neurosci,Nov,2009 alternative fell significantly,once a medical marijuana law was implemented. 26 March/April 2017 CANN A RI SNURSESMAGAZINEXOM BIBLIOGRAPHY SAFETY AND HARM REDUCTION Cannabis as a substitute for alcohol and other drugs:A dispensary-based survc A safer alternative:Cannabis substitution as harm reduction of substitution effect in Canadian medical cannabis patients Lau N,Sales P,Averill S,Murphy F,Sato SO,Murphy S.Drug Lucas,P et al Addiction Res Theory,2013 Alcohol Rev.2015 Nov;34(6):654-9.doi: 10.1111/dar.12275.Epub 2015 Apr 28.PMID:25919477[PubMed-indexed for MEDLINE] Substituting cannabis for prescription drugs,alcohol and other substances among medical cannabis patients:The impact of contextual factors Lucas, Is cannabis use associated with less opioid use among people who P et al Drug and Alcohol Review,May,2016 inject drugs? Kral AH,Wenger L,Novak SP,Chu D,Corsi KF,Coffa D,Shapiro Confirming big pharma fears,study suggests medical marijuana laws B,Bluthenthal RN.Drug Alcohol Depend.2015 Aug 1;153:236-41. decrease opioid use McCauley,L doi: 10.10 1 6/j.drugalcdep.2015.05.014.Epub 2015 May 22. PMID:26051162[PubMed-indexed for MEDLINE] Study: Medical cannabis access associated with reduced opioid abuse Medical cannabis laws and opioid analgesic overdose mortality http://normi.org/news/2015/07/16 in the United States, 1999-2010 Bachhuber MA,Saloner B,Cunningham CO,Barry CL.JAMA Legal marijuana linked to fewer opioid prescriptions Intern Med.2014 Oct;174(10):1668-73.doi: 10.1001/ Sifferlin,A jamainternmed.2014.4005. Erratum in:JAMA Intern Med.2014 Health Medicine,Jul,2016 Nov;174(11):1875.PMID:25154332[PubMed-indexed for MEDLINE Could medical cannabis break the painkiller epidemic? Hsu,J, Medical cannabis laws and opioid analgesic overdose mortality Scientific American,Sep,2016 in the United States,1999-2010 Bachhuber MA,Saloner B,Cunningham CO,Barry CL.JAMA Opioid addiction being treated with medical marijuana in Massachusetts Intern Med.2014 Oct;174(10):1668-73.doi: 10.1001/ Join Together Staff jamainternmed.2014.4005.Nov;174(11):1875.PMID:25154332 Partnership for Drug-Free Kids,Aug,2016 [PubMed-indexed for MEDLINE] Study: Cannabis improves outcomes in opioid-dependent subjects Use of prescription pain medications among medical cannabis undergoing treatment Armentano,P patients:comparisons of pain levels,functioning,and patterns of http://thejointblog.com/ Dec,2015 alcohol and other drug use Perron BE,Bohnert K,Perone AK,Bonn-Miller MO,Ilgen M.J The great health experiment Stud Alcohol Drugs.2015 May;76(3):406-13.PMID:25978826 Barcott,B et al [PubMed-indexed for MEDLINE] TIME MAGAZINE,Aug,2016 Use of a synthetic cannabinoid in a correctional population for State medical marijuana laws and the prevalence of opioids detected among posttraumatic stress disorder-related insomnia and nightmares, fatally injured drivers chronic pain,harm reduction,and other indications: Kim,J et al a retrospective evaluation Cameron C,Watson D,Robinson J.J American Journal of Public Health,Sep,2016 ClinPsychopharmacol.2014 Oct;34(5):559-64.dol: 10.1097/ JCP.0000000000000180.PMID:24987795[PubMed-indexed for Do medical marijuana laws reduce addictions and deaths related to pain killers MEDLINE] National Bureau of Economic Research,Jul,2015 Powell,D et al Medical Cannabis Use Is Associated with Decreased Opiate Lower opioid overdose death rates associated with state medical marijuana Medication Use in a Retrospective Cross-Sectional Survey of laws JAMA,Aug,2014 Patients with Chronic Pain Boehnke KF,Litinas E,Clauw DJ.J Pain.2016 Jun;17(6):739-44. How cannabis can be used for safe and effective opioid drug withdrawal doi: 10.10 1 6/j.jpain.2016.03.002.Epub 2016 Mar 19.PMID: Fassa,P Health Impact News,Aug 2016 27001005 [PubMed-in process] Could opiates actually becausing chronic pain?[Italics mine] Prescribing medical cannabis in Canada:Are we being too Granowicz,J cautious? Lake S,Kerr T,Montaner J.Can J Public Health.2015 Apr https://www.marijuanatimes.org Jun,2016 30;106(5):e328-30.doi: 10.1 7269/cjph.106.4926.PMID:26451996 Study links medical marijuana dispensaries to reduced mortality from [PubMed-indexed for MEDLINE] opioid overdose Sarlin,E et al Cannabis as a substitute for alcohol and other drugs Is cannabis better for chronic pain than opioids? Reiman,AHarm Reduction Journal Dec,2009 https://www.leafly.com/news/bealth/cannabis-for-chronic-pain-vs-opioids March/April 2017 27 CANNARISNURSESMAGAZINE.COM New Jersey Department of Health Panel to Consider Petitions Adding Qualifying Conditions to the State's Medicinal Marijuana Program By: Ken Wolski, RN,MPA Multiple Sclerosis Seizure disorder, including epilepsy Post-Traumatic Stress Disorder(PTSD) , X Warm o Terminal Cancer Rpm— j NeWersey' END— �� --��-- IPuttin tie pieces to etker to ire roue our 6ealtkiy .� h � The New Jersey Department of Health(DOH)accepted 45 Medical Marijuana Act(CUMMA)was signed by petitions from the general public to add qualifying Governor Jon Corzine.Governor Chris Christie,who conditions to the state's Medicinal Marijuana Program took office shortly after the law was signed,complained (MMP)in the month of August 2016.Most of these that he would not have signed this bill into law. petitions were for conditions that are characterized by Marijuana advocates and state legislators have said that chronic pain,the most common reason medical marijuana Governor Christie delayed and obstructed the full is used in the United States. implementation of the CUMMA. For example,the Members of the Coalition for Medical Marijuana-New CUMMA empowered the DOH to add qualifying Jersey(CMMNJ),a non-profit educational organization, conditions at any time,but this is the first action taken submitted the following petitions:Neuropathic Pain, by the DOH to do so,seven years later. Migraine Headaches,Osteoarthritis,Anxiety,Autism,and Currently in New Jersey,only five conditions allow Opioid Use Disorder. unqualified access to marijuana therapy:amyotrophic The DOH appointed a panel of eight healthcare professionals lateral sclerosis;multiple sclerosis;muscular dystrophy; to evaluate the petitions.The panel,consisting of five terminal cancer;inflammatory bowel disease;and any physicians,two pharmacists,and one registered nurse,is terminal illness.Four conditions qualify for marijuana if expected to conduct a public hearing on the petitions in early conventional treatment has failed: seizure disorders; 2017.This panel will make recommendations to the intractable skeletal muscular spasticity;glaucoma;and Commissioner of the DOH who will have the final say on post traumatic stress disorder(PTSD).Patients with adding conditions that qualify for marijuana therapy in the HIV/AIDS and cancer may qualify if the condition or state. its treatment causes chronic pain,nausea or vomiting,or the wasting syndrome. The actual petitions under consideration,with some information redacted and which are only identified by The original version of the CUMMA,passed by the numbers on the DOH website,can be found at:http:// New Jersey Senate in 2009,included Chronic Pain www.nj.gov/health/medicalmarijuana/review-panel/ (from any cause)as a qualifying condition for petitions20l6.shtml marijuana therapy.However,when the bill later went to the New Jersey Assembly,Chronic Pain was removed A complete list of the conditions under consideration,with the as a qualifying condition except in the cases of cancer identifying DOH numbers,can be found on the CMMNJ or HIV/AIDS.Sources at the statehouse said that this website at:http://cmmnj.blogspot.com/2017/01/petitions- was a political expedient to move the bill along.The to-nj-doh-panel.html decision was not based on scientific or medical CMMNJ was instrumental in getting a medical marijuana bill research. introduced into the state legislature in January 2005.In January 2010,New Jersey became the 14th state to pass a medical marijuana law when the Compassionate Use 28 Jiarch/April 2017 C A N N A D I S N U[S ES M AG A Z I N E.C O M In fact,there is no valid scientific or medical reason to limit In addition,Waltz's petition documents the suffering caused by the marijuana therapy for pain management to only two diseases-- three FDA-approved drugs used to treat Opioid Use Disorder— cancer and HIV/AIDS,as is currently the case in the state's methadone,naltrexone,and buprenorphine(suboxone).These drugs MMP.Marijuana is effective pain management for any disease, can cause serious side effects,drug interactions,and even death. injury or medical condition that causes chronic pain.Marijuana therapy is significantly safer than narcotics.There is a 25 percent The peer-reviewed articles published in scientific journals that are reduction in opiate overdose deaths in states that have robust noted in Waltz's Petition show remarkable evidence for marijuana's medicaljuw�juana programs. efficacy in alleviating the suffering caused by Opiate Use Disorder: PTSD was added as a qualifying condition by an act of the . In patients with chronic pain,cannabis use was associated with 64% legislature that was signed by the Governor in September 2016. lower opioid use,a better quality of life,and fewer medication side CMMNJ waged a multi-year effort to add this condition because effects and fewer medications used; 22 U.S. Veterans were committing suicide every day,largely . States with medical cannabis laws had a 24.8%lower mean annual because PTSD is so poorly managed by traditional pharmaceuticals.CMMNJ submitted a formal Request for opioid overdose mortality rate compared with states without medical Rulemaking through the DOH regulatory process in 2014 to add cannabis laws; PTSD as a qualifying condition,but the DOH rejected this •When used in conjunction with opiates,cannabinoids lead to a greater request. CMMNJ continued its educational efforts about cumulative relief of pain,resulting in a reduction in the use of opiates marijuana therapy for PTSD with New Jersey Legislators and a (and associated side-effects); bill was introduced in September 2014.CMMNJ identified •There is a statistical association between recent cannabis use and Veterans who were willing to testify to legislative committees lower frequency of non-medical opioid use among people who inject about marijuana's usefulness in managing the symptoms of drugs; PTSD.Two years later,the bill became law.PTSD,the first •Medical cannabis patients have been engaging in substitution by condition added to the state's MMP,was also the fust mental or using cannabis as an alternative to alcohol,prescription,and illicit emotional condition that qualified for marijuana therapy in the drugs; state. .Cannabis is a safer alternative(than opioids)with broad applicability ,w The petitions accepted for review by the DOH in August 2016 for palliative care;and, display extensive research,persuasive scholarship and passionate •National overall reductions in Medicare program and enrollee testimony. For example,CMMNJ Board member Vanessa spending when states implemented medical marijuana laws were Waltz,submitted the petition to include Opioid Use Disorder estimated to be$165.2 million per year in 2013. (MMP-063)and this petition alone is 80 pages long. Waltz's petition identifies: Add to this the compelling testimony from eight patients in New Jersey's MMP,and two other members of the community,along with a •The problem(DSM–V"Opioid Use Disorder"and ICD-10" physician who recommends marijuana in the MMP,an RN expert in Opiate Related Disorders"); the field,and a Director of one of the state's Alternative Treatment •The scope of the problem(16,651 deaths due to overdose on Centers,and it is difficult to imagine bow the DOH could do anything prescription opioids and 3,036 deaths due to overdose on heroin but approve this petition. in the U.S. in 2010 according to the World Health Organization, with over 5,000 opiate overdose deaths in New Jersey in the last However,it may not be so simple.It is the Commissioner of the DOH decade); who will make the final determination in this matter,after the panel of •The ineffective attempts to manage the problem(an in-patient healthcare professionals makes their recommendations. In New Jersey, rehabilitation center in New Jersey estimates that 33%of addicts the commissioners of all the executive branch departments,like the in the state are denied access to treatment resources and that DOH,are appointed,and may be removed from office at any time by 45,000 state residents were turned away from treatment facilities the Governor.Governor Christie still insists that marijuana is a due to high costs);and, dangerous gateway drug,despite scientific and even common sense •The hope that marijuana brings to the issue. evidence to the contrary.Governor Christie also insists,through his Office of the Attorney General(OAG),that marijuana remain a Marijuana brings more than hope.Waltz's petition documents Schedule I drug on a statewide level. scientific studies published in peer-reviewed journals,the compelling testimony of patients who have struggled with opiate addiction,and testimony from healthcare experts that attest to the effectiveness of marijuana in mitigating Opiate Use Disorder. New Jersey,a state in the midst of a worsening opiate epidemic, PTSD Veterans can ill afford to ignore this evidence.Even when mortality is not testifying at the the outcome,the morbidity associated with intravenous drug use NJ DOH in August is an important concern among New Jersey's 128,000 heroin 2016 with CMMNJ. Photo Credit Submission addicts.Hepatitis C infections may occur in up to 90%of people Ken Wol d,RN,MPA who inject drugs,and HN infections can be as high as 60% among heroin users who do not have access to Needle Exchange Programs. March/April 2017 29 CANNA R I SNU R SE SMA G AZIN E.COM R_ This means that the NJ OAG believes that frn marijuana has no accepted medical uses in the The entire Opiate Use Disorder(MMP—063)petition can be found at: U.S.,even while the NJ DOH debates exactly what additional medical uses marijuana should http://www.nj.gov/health/medicalmarijuana/documents/petitions/MMP-063.pdf have in New Jersey(!) Selected references from this petition include: In 2014,the Board of Directors of CMMNJ 1.Medical Cannabis Use Is Associated With Decreased Opiate Medication endorsed legalization of marijuana.There are Use in aRetrospective Cross-Sectional Survey of Patients With Chronic hundreds of thousands of people in New Jersey Pain.Boehnke,Kevin F.et al.The Journal of Pain,Volume 17,Issue 6,739 who would benefit from marijuana therapy.After —744•Source: all,if you live in the Garden State,you have a one Abstract—http://www.jpain.org/article/S 1526-5900(16)00567-8/abstract in three chance of having a cancer diagnosis at Full Text—http://www.jpain.org/article/S1526-5900(16)00567-8/fulltext some point in your life.You have a one in three References—http://www.jpain.org/article/S 1526-5900(16)00567-8/references chance of having chronic pain--pain that lasts six 2.Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the Unil months or more.We all die,and marijuana helps States: with some of the common problem associated 1999-2010 Bachhuber MA,Saloner B,Cunningham CO,Barry CL.JAMA Intern M with terminal illnesses like no other drug. 2014;174(10):1668-1673.doi:10.1001/jamaintemmed.2014.4005. Source:http://archinte jamanetwork.com/article.aspx?articleid=1898878#Abstract This is why CMMNJ joined with New Jersey 3.Cannabis as an Adjunct to or Substitute for Opiates in the Treatment of Chro United for Marijuana Reform(njumr.org)and Pain: Lucas,Philippe.Journal of Psychoactive Drugs 08 Jun 2012;44(2):125-133. endorsed legalization of marijuana in New Jersey. Source:https://www.researchgate.net/ Along with undoing the harms to society that are publication/230652616_Cannabis_as an_Adjunct_to_or_Substitute_for_Opiates_in_ caused by prohibition,legalization is the most _T reatment_of_Chronic_Pain efficient and effective way to get the therapeutic 4.Is Cannabis use associated with less opioid use among people who inject drugi benefits of marijuana to the vast number of Kral AH,Wenger L,Novak SP,Chu D,Corsi KF,Coffa D,Shapiro B,Blumenthal patients who can benefit from it.Legalization is Drug Alcohol Depend,2015 Aug 1;153:236-41.doi: 10.10 1 6/j.drugalcdep.2015.05.0 the best way to get the right medicine to the most Epub 2015 May 22. people. Source:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509857/ 5.Cannabis as a substitute for alcohol and other drugs.Reiman A.Harm Reduction Ken Wolski,RN,MPA Journal:2009;6:35.doi:10.1186/1477-7517-6-35. Executive Director Source:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2795734/ Coalition for Medical Marijuana--New Jersey, Inc. 6.Cannabis in palliative medicine: Improving care and reducing opioid-related 219 Woodside Ave. morbidity: Carter GT,Flanagan AM,Earleywine M,Abrams DI,Aggarwal SK, Trenton,NJ 08618 Grinspoon L.American Journal of Hospice and Palliative Medicine.2011 www.cmmnj.org Aug;28(5):297-303.doi: 10.1177/1049909111402318.Epub 2011 Mar 28. kenwolski@gmail.com Source:https://www.researchgate.net/ publication/50891411_Cannabis_in_Palliative_Medicine_Improving_Care_ Follow CMMNJ on Facebook,Friends of the and_Reducing_Opioid-Related_in Coalition for Medical Marijuana-NJ,at:https:// 7.Medical Marijuana Laws Reduce Prescription Medication Use in www.facebook.com/groups/62462971150/?ref-ts Medicare Part D. Bradford AC,Bradford WD. Health Affairs 35,no.7(2016):1230-1236 January 31,2017 10.1377/doi:hlthaff.2015.1661 Source:http://www.ouramazingworld.org/uploads/4/3/8/6/43860587/bradford2Ol6.pdf CMMNJ,a 501(cx3)public charity,is a non-profit educational organization. Ken Wolski,RN,MPA t i 30 March/April2017 CANNA 61SN URSESMAGAZI N E.COM CANNABIS Cannabis Science Conference 2017 SCIENCE • CONFERENCE Portland, Oregon What to Expect Two Days of Technical Oral and Poster Presentations Keynote Speeakers Expanded Canna Boot Camp& Cannabis Education Network Courses&Event Plenary Symposium Meet Medical Professionals and Cannabias Testing Lab Experts On-Site CME Accredition Opportunities to Establish your Brand is Cannabis Markets Parallel Medical&Scientific Technical Sessions Large Exhibit Hall GROW WITH US in 2017 at the Oregon Convention Center in Downtown Portland,OR,August 28th-30th!This year we will have 60,000 square feet of exhibit hall space and 50,000 square feet of meeting space for technical presentations.We hope that you willjoin us for this historic event.Don't miss out on our 2017 Canna Boot Camp! This is our full-day workshop that covers everything from Cultivation,Extraction, Sample Prep,Analytical Testing,Edibles Manufacturing and more! This event sold out VERY quickly in 2016.We also welcome Cannabis Education Network to our team providing a full-day of Pre-Courses&Event focusing on Cannabis Health&Wellness through the National Nursing Experts.Go to:www.C.mnabisEducationNetwork.com for Details and Registration. Cannabis Science Conference is the world's largest cannabis science expo. Our conference pulls together cannabis industry experts,instrument manufacturers, testing labs, research scientists, medical practitioners,policy makers and interested novices. Our annual event is aimed at improving cannabis science.Join us in Portland, Oregon,for an exciting conference with keynotes, presentations, round table discussions and exhibits.At our inaugural event we hosted over 750 attendees from all over the world! Please contact Josh at (443) 623-2282 or josh djcanna.com before sending in payment. Please make check payable to: JCANNA Inc. (EIN#81-0992186) and mail to 4006 Logan Court,Pasadena, MD 21122. SAVE THE DATE ! PATIENTS OUT OF TIME presents: The El a ve n th ow National Clinical Berkeley, CO n f-e r Ce O i'I California Can obis S ay 18-207 X017 Therapeutic www.PatientsOutof 'tme.org www.MedicalCa.nnabis.com � 1 a Nurses Must Advocate for Patient Access to Cannabis to Stem the Opioid Epidemic Bv: Mary Lynn Mathre, RN, MSN, CARN Pain is the most common reason people To address this growing opioid epidemic seek health care. Common treatment Cannabis has been used for millennia the CDC issued guidelines for prescribing and various records note its use as an for moderate to severe acute and opioids for chronic pain(https:// chronic pain has generally included www.cdc.gov/mmwr/volumes/65/rr/ analgesic,muscle relaxant,anti- opioids. While many patients may rr6501e1.htm). Healthcare practitioners are inflammatory and useful in the suffer from an opioid use disorder that management of pain,especially chronic strongly encouraged to use these guidelines neuropathic am. Cannabis is a plant started with experimentation with illicit P P P for managing their patients with non-cancer that contains more than 400 constituents opioids or heroin,most patients with an related chronic pain. opioid use disorder started with including cannabinoids(such as THC prescribed opioids. For the past two and CBD),as well as terpenes and While cannabis remains in Schedule I flavonoids. These cannabinoids and decades,pain has been identified as the (forbidden category)of the Controlled 5th vital sign and efforts to assess for some of the terpenes have been found and treat pain has become a standard of Substances,countless patients are seeking possess analgesic,anti-inflammatory, cannabis information or a safe supply of the and muscle relaxant properties. When practice in health care. Pharmaceutical medicine based on word of mouth from other P P manufacturers of opioids encourage the used as a whole plant herbal medicine, patients. While we now have 28 states with there is synergy among these use of their products and minimize the medical"marijuana"laws,each law varies addictive potential when used to constituents that produce a more from state to state,but all include barriers to effective and gentle effect than if sin manage pain. Over prescribing and g � P� patient access,including ignorant,indifferent constituents from the plant are used. lack of close follow-up soon led to or intimidated health care providers. Asa P physical dependence on opioids,poor nurse,what do you know about the cannabis pain management,and a tolerance to the In a 1914 Blumgarten pharmacology plant or cannabis/cannabinoid products? text for nurses,it states in bold that effects requiring patients to seek higher What do you know about the use of cannabis and higher doses. cannabis relieves pain and induces for pain management. How does it work. Is sleep." Modern research on the it safe? Is it legal? Why should I care? interaction between opioids and THC Currently the CDC has estimated 91 These are questions that nurses are expected P opioid overdoses per day in the U.S. shows a synergistic effect and when to be able to answer. We are the most usin cannabis as an adjunct to (https://www.cdc.gov/drugoverdose/ trusted group of professionals,we are the g epidemic/index.html).This is a prescribed opioids,the development of largest health care discipline at 3.6 million tolerance too opioids is decreased complex problem with various P RNs strong,and we spend the most time Cichewicz,et al. 1999, contributing factors and all potential with patients. This is an ethical treatments should be explored. Cichewicz&McCarthey,2003). responsibility as a patient advocate. 32 March/April 2017 CA N N A B I S N U R S E S M A G A Z I N E.C O M 9 But the more compelling rationale for the While that simply shows an association,it References: clinical use of cannabis for pain is a striking finding that supports the management is the discovery and anecdotal reports. increasing understanding of the Endocannabinoid System(eCS). The Cannabis inappropriately remains in Abrams,D1,Coney P,Shade SB,Kelly ME, primary role of the ECS is to protect us Schedule I(the forbidden category)of the Benowitz from stressors and help keep us in Controlled Substances despite the clear interaction balance.This system plays an important evidence that it does not meet the criteria Pharmacology& role in decreasing the harm from an for such placement:not safe for medical injury,aiding in the healing process,as use,no currently accepted medical use in well as decreasing the perception of pain. treatment in the United States,and highly MA,Saloner addictive. There has never been an _ CO 1 Cannabis is remarkably a nontoxic overdose from cannabis. Opioids such as cannabis and opiid analgesic overdose botanical medicine. That's not to say it is oxycontin,dilaudid,morphine or fentanyl mortality in the United States, 1999-2010. completely safe,but it is clearly less are in Schedule II—highly addictive,but JAMA Internal Medicine. addictive and less toxic than opioids. recognized as being safe to use as When cannabis is used as an adjunct pain prescribed and having medical value. As Blumgarten, medication,many patients are able to noted above,there are now 91 opioid Nurses. The MacMillan Company:NY. decrease their opioid dose or eliminate overdoses per day. The prohibition of the ''' 1 1 opioids completely. Cannabis clinicians cannabis plant is a literally a crime,when Medical are seeing this trend with their chronic one realizes that the use of cannabis in decreased '' pain patients and this has been validated chronic pain patients can not only provide retrospective cross-sectional with a study of patients in an Israeli better management of chronic pain and an with chronicpain. Journal of Pain. nursing home(Weisberg&Sikorin,2015). increased quality of life,but it can 17(8):739-744. significantly decrease the amount of With the passage of medical cannabis opioids a person uses and save lives. Cichewicz DL,Martin ZL,Smith FL,et al. state laws,patients are speaking more ... .Enhancement of mu opioid openly about their use and clinicians and As nurses,we cannot tum our backs on antinociception researchers are seeing results. In 2011 these patients. We need to educate our tetrahydrocannabinol: Donald Abrams,M.D.conducted a study colleagues and patients about the use of and receptor identification. on 21 patients who were on sustained cannabis for the management of chronic PharmacolExpTher, 289:859-67. release oxycodone or morphine and they pain. We need to talk with our legislators added vaporized cannabis to the patients' and urge them to decrease roadblocks on Cichewicz DL,McCarthy EA.2003. treatment protocols,they found a lower the state level and end the prohibition of Antinociceptive plasma level of the opioids,but a cannabis on the federal level. Cannabis tetrahydrocannabinol and opioids after oral statistically significant reduction in pain. should be removed completely from the administration. A 6 month follow-up study of 176 Controlled Substances listing and patients ' patients using cannabis for pain should be allowed to grow this wonderful management found improved pain natural plant. Once the cannabis plant is ' management and functional outcomes recognized as a medicinal herb,quality &Davidson E.(2016)The effect of medicinal along with a 44%reduction in the use of control measures can and should be applied cannabis on pain and quality-of-life outcomes opioids(Haroutounian,et al.,2016). A to cannabis products using guidelines set in chronicprospective retrospective survey of 244 chronic pain by the herbal medicine experts. study.Clinical Journal of Pain. patients at a cannabis dispensary in 32(12):1036-10, 3. Michigan found a 64%lower opioid use, an increased quality of life,and fewer . medication side effects along with fewerMedical - Nurse- medications used by these patients once led Approach. Presented y 23,2015 at they began using cannabis for painThe ConferenceNinth National Clinical • management(Boehnke et al.,2016). CannabisTherapeutics Bachhuber and others looked at states' death certificate data from 1999-2010 comparing the medical cannabis states to states without laws allowing the medicinal use of the plant.They found a 24.8%decreased mortality rate from opioids in the 23 medical cannabis states compared to the other states and that there was a progressive decrease in the states that had a cannabis law in effect for longer periods of time(2014). March/Apri12017 33 CA N NABIS N U RSESMAGAZ I N E.COM r 1 beAt Patrick cad' 1 ud g.,rea. t '*ty food CORNED BEEF AND CABBAGE INGREDIENTS 3 pounds corned beef brisket with spice packet ti 10 small red potatoes 5 carrots,peeled and julienned 1 large head cabbage,cut into small wedges CHEF HERB whose nickname is Mota, which is Spanish for marijuana, DIRECTIONS knows the benefits of medical marijuana and has decided to incorporate his two Place corned beef in large pot or Dutch oven and cover passions:cooking for people's pleasure and creating gourmet medicinal food.In the with water. Add the spice packet that came with the corned Basics, Chef Herb teaches us how to create THC butter and oil that can be used in beef. Cover pot and bring to a boil, then reduce to a simmer. countless recipes from party food hors'dourves to sweet desserts. Simmer approximately 50 minutes per pound or until tender. This month of March Chef Herb will have another birthday. If you would Add whole potatoes and carrots,and cook until the vegetables like to send him birthday wishes you can contact him at his web site are almost tender. Add cabbage and cook for 15 more WWW.CDOKWITHHERB.COM or email him at cookwithherb@gmail.com. minutes.Remove meat and let rest 15 minutes. If you are interested in learning more about cooking with cannabis or want to order Place vegetables in a bowl and cover. Add as much broth (cooking liquid reserved in the Dutch oven or large pot) as his great DVD series call:310.462.1649 you want. Slice meat across the grain. wasp % 1 � 1 +rli all 34 March/Apri12017 CA NN A RI SNL'RSESMAGA Z IN E.COM CREAMY COLCANNON garlic. Spread each slice of bread with some of the butter. Arrange 6 slices, THC butter side down, in a 9 by 13-inch INGREDIENTS 1 baking dish. pound cabbage In a medium bowl, combine the shredded cheese, chopped 1 pound potatoes chives,Worcestershire sauce,salt and pepper. Evenly sprinkle 2leeks the cheese over the bread in the baking dish. Top with the 1 cup milk remaining bread, THC butter side up.In a medium bowl,beat m the eggs,half and half,milk and chicken broth. Pour over the salt and pepper taste bread. Cover tightly and refrigerate overnight. 1 pinch ground mace Preheat the oven to 350 degrees F. Uncover the fondue and 1/2 cup THC butter bake it for 1 hour, or until the top is lightly browned and the inside is fairly firm. COOKING INSTRUCTIONS Remove the fondue from the oven. Let it rest for 10 minutes. In a large saucepan, boil cabbage until tender; remove and Cut into 8 or 10 wedges. chop or blend well. Set aside and keep warm. Boil potatoes until tender.Remove from heat and drain. KICK ASS IRISH BREAD PUDDING Chop leeks,green parts as well as white,and simmer them in just enough milk to cover,until they are soft. Season and mash potatoes well.Stir in cooked leeks and milk, INGREDIENTS salt a pepper to taste,and mace. Blend in the kale or cabbage 2 cups granulated sugar and heat until the whole is a pale green fluff.Make a well in 5 large beaten eggs the center and pour in the melted THC butter.Mix well. 2 cups milk 2 teaspoons pure vanilla extract IRISH FONDUE CASSEROLE 3 cups cubed Italian bread,allow to stale overnight in a bowl 1 cup packed light brown sugar INGREDEINTS 1/4 cup(1/2 stick)THC butter,softened 12 slices firm white bread 1 cup chopped pecans 1/2 cup THC unsalted butter,softened For the sauce: 3/4 teaspoon dry mustard 1 cup granulated sugar 1 clove garlic,finely chopped 1/2 cup (1 stick)THC butter,melted 1/2 pound(2 cups)shredded Swiss cheese 1 egg,beaten 2 teaspoons chopped fresh chives 2 teaspoons pure vanilla extract 1 teaspoon Worcestershire sauce 1/4 cup brandy Salt and pepper to taste DIRECTIONS 4 eggs Preheat the oven to 350 degrees F. Grease a 13 by 9 by 2-inch 1-1/2 cups half and half pan.Mix together granulated sugar,eggs,and milk in a bowl; 2/3 cup milk add vanilla. Pour over cubed bread and let sit for 10 minutes. 1/2 cup chicken broth In another bowl, mix and crumble together brown sugar,THC butter,and pecans. COOKING INSTRUCTIONS Pour bread mixture into prepared pan. Sprinkle brown sugar Cut the crusts off the bread slices. mixture over the top and bake for 35 to 45 minutes, or until In a small bowl, stir together the THC butter, mustard and set.Remove from oven. - March/Apri12017 35 CANNABISNURSESMAGAZINE.COM FOR THE SAUCE 1/2 teaspoon salt Mix together the granulated sugar,butter,egg,and vanilla in 1/2 teaspoon baking soda a saucepan over medium heat.Stir together until the sugar 1/2 teaspoon vanilla extract is melted.Add the brandy,stirring well.Pour over bread pudding.Serve warm or cold. PREPARATION Preheat oven to 250°. In a large roasting pan combine the popcorn and nuts. Place in the oven while preparing glaze. IRISH SODA BREAD In a medium saucepan combine brown sugar, corn syrup, THC butter, and salt. Bring to a full boil over medium heat, INGREDIENTS stirring constantly, then continue to boil for 4 minutes 3 cups all-purpose flour without stirring. Remove from heat; stir in baking soda and 1 tablespoon baking powder vanilla,then pour over the warm popcorn and nuts,tossing to 1/3 cup white sugar coat well. Bake another 60 minutes, stirring freqently, about 1 teaspoon salt every 10 minutes. Cool and break apart. Store in an airtight 1 teaspoon baking soda container. 1 egg,lightly beaten 2 cups buttermilk EGGS BENEDICT HERB SUPREME 1/4 cup THC butter,melted Three recipes in one, think of the Eggs Benedict recipe as DIRECTIONS toast and ham topped with a poached egg recipe,topped with Preheat oven to 325 degrees F. Grease a 9 x 5 inch loaf pan. a hollandaise sauce recipe. Combine flour,baking powder,sugar,salt and baking soda. 4 English muffins,split,toasted and buttered or 8 crumpets Blend egg and Buttermilk together,and add all at once to the 8 1/4-inch slices ham,warmed and cut to fit flour mixture. 8 poached eggs Mix just until moistened.Stir in melted THC butter.Pour into 1 1/4 cups(about) Hollandaise Sauce prepared baking pan. Bake for 65 to 70 minutes or unit a toothpick inserted into POACHED EGG RECIPE center of loaf. Comes out clean. Cool on wire rack and wrap Water in foil over night for best flavor 1 tablespoon salt 2 tablespoons vinegar(any variety) 8 eggs Full � Bring 2-3 inches of water almost to a boil in a large saute pan. Add the salt and vinegar. One at a time, crack the eggs into a cup and then slip the eggs, one at a time, into the barely THC CARMEL CORN simmering water.Reduce the heat,if need be,to maintain that low simmer. INGREDIENTS Cook just until the whites are set and the yolks are glazed but 3 quarts popped popcorn still very soft,about 3 minutes.(Wait until the eggs are set to dislodge any that may have stuck to the bottom of the pan.) 3 cups dry roasted mixed nuts,unsalted Using a slotted spoon, transfer the poached eggs onto a dish 1 cup brown sugar,firmly packed towel to drain. Trim the edges of any streamers so they're 1/2 cup light or dark corn syrup nice and tidy. (If the eggs get too cold,slip them back into the 1/2 cup THC butter simmering water for a few seconds and drain again.) !• i � , 4W. CWit ! ; A 36 March/April 2017 CANNA B I SN C RSESM A G A Z I NE.COM MAKE-AHEAD DIRECTIONS Cook as above but remove the eggs from the water after 2 EASY CRAB CAKES minutes.Immediately place them in ice water to prevent them 2 Pounds lump crab meat -- from cooking further. Cover and refrigerate the eggs and 2 tablespoons THC olive oil and/or THC butter water for up to 12 hours. To reheat,slip them into simmering 1/2 cup green onions,minced water for about 30 seconds. 1/4 cup red bell pepper,diced HOLLANDAISE SAUCE RECIPE 2 eggs be tenresh garlic,minced 4 egg yolks 1/2 cup THC mayonnaise 4 tablespoons fresh lemon juice 1 tablespoon Dijon mustard 1 tablespoon water 1/3 cup fresh parsley,minced 1/8 teaspoon salt,or to taste Salt and ground black pepper to taste 1/8 teaspoon ground white pepper,or to taste 2 1/4 cups toasted bread crumbs(more or less) 1 pinch of cayenne pepper 4 tablespoons THC butter and/or THC olive oil 1 cup THC melted butter Combine the egg yolks, lemon juice, and water in a small, HOW TO MAKE CRAB CAKES THAT DON'T heavy saucepan. Whisk the mixture constantly over very low FALL APART heat until thickened. Immediately remove the pan from the Fust, thoroughly pick the crabmeat over for shell fragments heat but continue whisking for 1 minute.Add the salt,pepper, and set aside. and cayenne.Cool slightly. Saute the green onions, bell pepper, and garlic in THC olive Scrape the mixture into a blender.With the motor running at oil and THC butter.Cool. medium-high speed,add the melted(but not hot)THC butter In a large bowl, combine the crab meat, sauteed mixture, in a slow,steady stream until it is well-incorporated.Taste and beaten eggs, mayonnaise, mustard, parsley, salt, pepper, and adjust the seasonings,if necessary. 1/4 cup of bread crumbs. To keep warm,place the Hollandaise Sauce in a bowl over(but Pour the remaining(2 cups)bread crumbs onto a plate.Line a not touching)hot water,stirring occasionally,or simply place baking sheet with wax paper or plastic wrap. the blender container in warm(not hot)water. Form the crab cake mixture into 1/2-inch thick patties,8 large NOW PUT IT TOGETHER or 12-16 small ones. Press both sides of the patties into the bread crumbs, and HOW TO MAKE EGGS BENEDICT placethem on the baking sheet. Cover with plastic wrap and refrigerate for 3 to 6 hours,until firm. Start by preparing the Hollandaise Sauce.Keep it warm. In a large, non-stick saute pan, brown the patties in THC Start the water for the eggs. Warm the ham slices, and toast olive oil and/or THC butter over medium-high heat, about and butter the muffins or crumpets.Keep them warm in a 4 minutes each side.Drain on paper toweling. warm oven. Serve with lemon wedges or tartar sauce. Makes 8 large or Finish preparing the Poached Eggs. 12-16 small crab cakes. To assemble,place a slice of ham atop an English muffin half or crumpet,place a poached egg on the ham,and spoon a little Hollandaise Sauce over the top.Serve immediately. Makes 8 servings F L11 now i s March/April2017 37 CANNABISNURSESMAGAZINE.COM " HMM DID YOU KNOW " Online Cannabis TV NETWORK Launching Soon ! PROBLEM: Cannabis is the fastest growing SOLUTION: industry in the US yet there's hardly 7 anywhere for new companies to advertise OUR PREMIER CANNABIS Tr NETWORK . and for potential consumers to find the LAUNCHING SOON! information Learn about why and how Cannabis works synergistically with our bodies.0ur first to market series to air will be " Nurse Talk" hosted by Nurse Heather Manus and Cannabis Nurses Magazine's very own Nurse Juhlzie Monteiro! We will learn about our endocannabinoid system, receptors, and the many components of the Cannabis plant H M M Our Intention Is To DID YOU KNOW Take Cannabis YOUR PREMIER CANNABIS Education and ONLINE TV NETWORK THAT WILL FEATURE Brands Global ! PROFESSIONALLY PRODUCED VIDEO SERIES , Dedicated in loving memory of COMMERCIALS , DIGITAL "Aunt Kathy" AK+,..w MEDIA , TELEVISION VENTURES COMMERCIAL CAMPAIGNS , LIVE STREAMING , qd2o INTEGRATED MARKETING AND MORE WITH UNPRECEDENTED DidY�u� OPPORTUNITIES ! 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'Multiple Market "Knowledge IS Power LIVE" wilt be pre- Discounts Available recorded with a LIVE studio audience HM W s info@420MEDIA.US featuring interviews, celebrity DWYOU appearances, sponsored segments, and K 110 W • or call field trips across the globe showcasing (425) 420-0585 innovative products, events, profiles and more all with the intention of understanding our plant Cannabis. . . - NURSE TALK Welcom to Nurse Talk! In this Issue,we were able to get an interview with CBD Living Water which is the innovator of Nano CBD Products. The name says water but we found out that they have a full range of products, including CBD Gummies, Nano CBD Chocolate Bars, Nano CBD Sleep Aid, Nano CBD Roll on Topical for pain relief and many more. Below is their interview.We hope you enjoy it: How would you describe your Company? What are the Goals and Vision for your Company? CBD Living is the Innovator of Nano CBD products Our goals are to continue to be in the forefront of innovative what's your Specialty? CBD Products. We work daily side by side with our scientists to CBD Living is in the forefront of CBD productsby utilizing make our products the best they can be along with continuously Nano Technol to 'Nano' our CBD which allows the CBD to working on New Products under CBD Living and we're doing it for the right reasons! become immediately Bio-Available in the body. When consuming CBD in other ways beside Nano CBD, the body Where do you see your Company in Five Years? looses up towards 90%of the CBD through the Digestive system. We hope to be Worldwide and a Household Brand When we use Nano CBD technology, we break it down to 1 What do you hope to accomplish in the MMJ Industry? millionth its original size allowing it to be absorbed directly into the body's cells at the cellular level giving the body immediate CBD Living hopes to accomplish in the MMJ industry and bio-availability.Our first product was CBD Living Water but WE outside the MMJ industry, to be able to provide our consumers AREN'T JUST A WATER COMPANYANYMORE!We have a full the BEST CBD products with the most BioAvailability and bring range of products from Full Spectrum Nano CBD Gummies, awareness to everybody of the benefits of CBD and, we hope to continue to help many others with our products as we do now. Nano CBD Chocolate Bars, Nano CBD Sleep Aid, Nano CBD Roll on Topical for pain relief, and Nano CBD Gel Caps and many more exciting products to come in 2017. 00, What do you offer Consumers/Clients that others don't? 00 10 We offer CBD Products with Nano CBD and Full Spectrum 0 Nano CBD which gives the consumer the best Bio- 1x Available CBD products on the Market. to 01 How and why did your Company start up? >a CBD Living Started with a Team of Scientist and a vision to create 110t a product that would give consumers a CBD product that would 'o" far surpass anything on the market and'Viola"CBD Living WaterQ O was created,not only giving the consumer the best bio-availability �� b to CBD but with other nutrients such as d-ribose,Coq 10,Mythel �� LIVIK t tl' B12 and maximum hydration. WATO i With the changing landscape of MMJ and Recreational Cannabis,what do you see as the biggest challenges to your ` _. progress as a Company? The changing landscape of MMJwill only yhel our company an) LIVING \ grow as Consumers learn more about the benefits of CBD and all of the current states that do not have MMJ or Recreation WATER IN Cannabis acceptance as of yet_ CBD Living can still provide our CBD products to these states which are 100%legal in all states. r, NANO AMPLIFIED What words of advice would you offer anyone seeking to ` ©E V E R A G i enter the world of Cannabis Business? ` Do it for the right reasons! �, M.. II 40 March/April2017 GANNARISNURSESMAGAZINE.GOM NOTJUSTAWATER COMPANYANYMORE . ML LIVING WATER 9 njti C, A Y oil LIVING WATER AMPLIFIE CBS � 11 Ll V l'SL r I Fw14,xVING . 7NNW s A • �I L: NIGH E a] LIVING GEL A. TRYALL OURAWARD WINNING PRODUCTS 800-940-3660 1 CBDLIVINGWATER.COP Li TM UNHAZE THE BLAZE The Cannabis Safety Net TM AN ALL-NATURAL EMERGENCY SUPPLEMENT INTENDED TO EASE THE SIDE EFFECTS OF CANNABIS OVER CONSUMPTION . UNDOOTM is an innovative, patent-pending formula that supports the body's natural ability to counteract the euphoric effects of THC-rich Cannabis. Formulated with a proprietary blend of all natural ingredients, UNDOOTM contains no Cannabis, no caffeine and no sugar. It is designed to effectively and quickly help your body manage the "high" associated with THC-consumption. Sign up to complete the #UNDOOChallenge Use codel UNDOOCN for special pre-order pricing! Learn more at www.UNDOO.com Interested in wholesale pre-orders or becoming an affiliate partner? Contact support@undoo.com O10�- Apps for Health-Care Professionals Smartphone apps and web-based tools are increasingly important resources for health-care practitioners. Check out these great tools and put a wealth of health-care information in your pocket. p01 NURSING CENTRAL O G EPONYMS Nursing Central is the complete mobile solution for M A browse-able and searchable app that provides nursing produced by Unbound Medicine.The app short descriptions of more than 1,700 obscure includes disease,drug and test information for nurses. medical eponyms. http://goo.g"glb http://goo.glBKPOH 02 LIPPINCOTT NURSING ® 07 NETTER'S ANATOMY FLASH CARDS DRUG HANDBOOKS Keep over 300 outstanding anatomical flash cards on This app provides up-to-date drug information on your device.This app enables you to carry the popular your device,including contraindications,nursing Atlas of Human Anatomy(4th edition) and its detailed considerations,patient teaching and integration of anatomical illustrations on your phone or tablet. the nursing process. http://goo.gl/jr9Th http://goo.gi/em9E 1 O8 CNOR EXAM PREP 07 MANAGEMENT GUIDELINES The Competency and Credentialing Institute, FOR NUSING PRACTITIONERS the governing body of the Certified Nurse Operating g WORKING WITH ADULTS Room (CNOR)credentialing program,has created The app is a best-practice guide for health-care the CNOR exam prep app to help perioperative professionals who work with adult patients. Other nurses prepare for the CNOR exam.The app helps apps in the series provide guidelines for working individuals assess their exam readiness and develop specifically with women,with children,with older critical thinking skills;it also provides tips for success, adults or in family practices. reviews knowledge related to the CNOR exam and can http://goo.gl/o2hC6 enhance test-taking confidence. http://goo.gl/nlDMo O4 JOURNAL WATCH This tool from the Massachusetts Medical Society 09 EPOCRATES Rx notifies you about new papers published on topics O The app includes a drug guide,formulary information of your choice. and a drug interaction checker.This product also http://goo.gl/dxbrd includes continual,free updates and medical news. Additionally,the app works on your device when you 0 S 3M PREP are offline,so you can look up information without a 30 This app provides a detailed rationale for selecting wireless connection. surgical prep solutions.You can view how to http://goo.gUfgchG correctly apply solutions while listening to a detailed set of instructions. 10 MACEWAN LIB http://goo.gl/QGwsY The MacEwan University Library app simplifies searches for books and articles.It allows you to place a hold on library catalogue items,renew items,download full-text resources and perform many other tasks. http://goo.gYYAUQe March/Apri12017 43 CA NNARI SNURSESMAGAZINE.COM Resources Recommended Books Marijuana and The Health Effects MARIJUANA Medicine:Hemp for of Cannabis and Health: The Health Effects Cannabinoids: AND of • .. and MEDICINF The medical use of marijuana is .• • • Significant changes have surrounded by a cloud of social, taken place in the policy political, and religious landscape surrounding controversy, which obscures the ►. cannabis legalization, facts that should be considered in production,and use.During the debate. the past 20 years,25 states and the District of Columb' This book summarizes what we have legalized cannabis an know about marijuana from or cannabidiol(a compone evidence-based medicine--the of cannabis)for medical ® harm it may do and the relief it conditions or retail sales at may bring to patients.The book the state level and 4 states helps the reader understand not only what science has to say about have legalized both the medical marijuana but also the logic behind the scientific conclusions. medical and recreational use of cannabis.These landmark changes in policy have impacted cannabis use patterns and perceived levels of risk. The Little Black Book of Marijuana As Medicine? Marijuana: The } Some people suffer from - Essential Guide chronic,debilitating disorders to the World of for which no conventional Cannabis treatment brings relief.Can marijuana ease their symptoms? This concise guide to Would it be breaking the law to cannabis delves into pot tum to marijuana as a culture and history,from medication? Herodotus to the hippies and beyond. J 91 There are few sources of It also covers the essentials objective,scientifically sound of using,cultivating,and advice for people in this cooking with weed;identifying pot varieties;and understanding legal and health issues. sitation.Most books about marijuana and medicine attempt to Handy and to the point,The Little Black Book of Marijuana promote the views of advocates or opponents.To fill the gap gives you"the dope"on pot,from possible side effects and between these extremes,authors Alison Mack and Janet Joy have risks to medical uses and their efficacy.Learn about cannabis extracted critical fmdings from a recent Institute of Medicine study history and the issues around its legalization. on this important issue,interpreting them for a general audience. 44 March/Apri12017 CANNABISNU RS ESM AGA ZI N E.CO M Job Op Perm & Travel Cannabis Nurse Job Board has over 2,000 nursing job opportunities in all nursing specialties. �. Get started... High paying travel nursing positions all over the country EMERALD HEALTH SERVICES Emerald currently provides travel nurses to hundreds of hospitals and currently is offering assignments in every major specialty (ICU, L&D, r ER OR,TELE PACU, PICU,NICU, and PEDS). Ithsia Contact Emerald at any time at 1-800-917-5055,or respond to this message via E-mail or you can also visit us on the web at: Apply Today! www.emeraldhs.com 1- 877-447-3376 x709 1 . ei � lrnydk FAVORITE TRAVELER Nightingale,a nationally recognized leader in travel Needs' healthcare professionals,has Immediate and Exclusive needs for all Nursing Specialties with excellent pay. ICU,CVICU,LDR,MS,Tele,Neuro ICU,ER,LDR,& OR RNs! If you are available for consideration,please reply to this email and a recruiting specialist will contact you as soon as possible. Give us a call at 800-755-1411 Call us immediately: 800-591-7860 or for additional information! scan the QR code Don't forget to ask about our Referral Bonus! To complete a full application,please 0+46 scan the QR code March/April 2017 45 CANNABISNURSESMAGAZINE.COM • Nursing 2017 oil March 2017 Conferences Cannabis Health,Wellness& Industry Overview Event-Cannabis Education Network(CEN) March 2nd,2017 from 6PM-8:30PM I Wellington,FL � http://www.CannabisEducationNetwork.com Take No Apri12017 Conferences Colorado Pre-Conference Courses& Event: Cannabis Health&Wellness-Cannabis Education Network(CEN) Course:April 27th,2017 from LOAM-4PM I Event: 6PM-8:30PM I Pueblo,CO http://www.CannabisEducationNetwork.com 1 st Annual Institute of Cannabis Research Conference-Panel: Cannabis Wellness Takes Center Stage April 28th-30th,2017 1 Pueblo,CO http://www.csupueblo.edu/]CR/2017 May 2017 Conferences 11 th National Clinical Conference on Cannabis Therapeutics Patients Out of Time—Cannabis: Protecting Patients and Reducing Harm May 18th-20th,2017 1 Berkley,CA http://www.medicalca n nab is.com/2017-national-clinical-conference-on-can nabis-therapeu tics/ June 2017 Conferences AHNA's 37th Annual Conference-Workshop: Endocannabinoid Connections(June 10th 10:30AM-12Noon) June 5-10th,2017 I Rancho Mirage,CA www.ahna.org/conference August 2017 Conferences Pre-Conference Courses& Event: Cannabis Health&Wellness-Cannabis Education Network(CEN) -� August 28th,2017 1 Portland,OR www.CannabisEducationNetwork.com Cannabis Science Conference 2017 August 28th-30th,2017 1 Portland,OR wwww.CannabisScienceConference.com October 2017 Conferences Cannabis Nurses Magazine 2-Year Anniversary&Awards Ceremony I October 7th,2017 Cannabis Health&Wellness Courses&Eventl October 6th,2017 October 6-7th,2017 1 Las Vegas,NV www.CannabisEducationNetwork.com I www.CannabisNursesMagazine.com if you know of other Conferences available that are based on Cannabis Therapeutics that you wish to be listed in future issues please email us at: editor@cannabisnursesmagazine.com 46 March/ApM 2017 CANN A RI SNU RSESMAGAZINE.COM GPNNge April 27th, 2017 Pueblo, CO �S Rawlings Library InfoZone Theater T 100 E. Abriendo Ave. Pueblo, CO 81004 l tiFrWo�� LEADING INDUSTRY EDUCATION Educational Achievement Award 2016 Heather Manus, Cannabis Nurses Magazine Lisa LeFevre RT(R), MBA Heather Manus, RN Julie Monteiro RN, BSK Pre-Conference Course & Event! 1 st Annual Institute of Cannabis Research Conference - National Cannabis Nurses Lectures "Cannabis for Healing & Wellness" "Meet the Professionals" Educational Course Cannabis Event 10:00am - 4:00pm 6:00- 8:30pm Featuring: Heather Manus, RN Lisa LeFevre Produced and facilitated by: RT(R), MBA Julie Monteiro RN, BSK Stonefield National (Lisa LeFevre) Agenda: Meet and Speak with 12 Professionals: • The Endocannabinoid System (eCS) • Cannabis Educators • Methods of Administration • Scientists • Terpenes & Aromatherapy • MDs • Touch Therapy • Nurses • Wellness Perspective • Growers • Ending Prohibition- Our Ethnobiological Right • Converters (MIPS) • Dispensaries Bonus! 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