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YourPatientTakesMedicalMarijuana?EvidenceBasedResearchinActionJennyRaybin,MSN,RN,CPNPAssociateProfessorofPediatrics

(MollyHemenway,DNP,DNP,CPNPSeniorInstructorofPediatrics)

UniversityofColoradoSchoolofMedicineChildren’sHospitalColorado

SpeakerDisclosure

• JennyRaybinhasnoindustryrelationshipstodisclose.

• JennyRaybinwilldiscussoff-labeluse.

Areyouhearingthiseverywhereyouturn?

http://people.com/movies/ricki-lake-marijuana-cancer-treatment/

Introduction• Over6,000childrenareregisteredusersofmarijuanain

Colorado(about8,000inCalifornia)• Manypediatriconcologypatientsreportmedicalmarijuana

(MMJ)use.• ClinicaltrialsinadultshaveexaminedMMJforcancer-related

symptoms.• Newresearch

• MMJinanticancertherapy• MMJreceptorsontumorcells• PotentialroleforMMJasanimmunomodulator

• FewpediatriconcologystudieshaveevaluatedMMJ.

Objectives

HistoryLegality:ColoradoandCalifornia—beststatesever!DefinitionsandProductInformationEvidenceinSelectedConditionswithCaseStudiesHowHospitalsRespondResearchNursingimplications

History

1970:ClassifiedasSchedule1substance1988:DEAjudgerecommendedMJbereclassifiedasscheduledII(overruled)1985:FDAapproveddronabinol(Marinol)

1996:CaliforniapassesacttolegalizeMMJ

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WhereisMedicalMarijuanaLegal?

MedicalMarijuanaLegalizedRecreationalMarijuanaLegalizedNoLawsLegalizingMarijuana

AsofNovember11,2016.Source:http://www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html

ColoradoSpecificLegality ColoradoSpecificLegality

MarijuanainColoradoRetailhasincreasedandMedicalhasdecreased

since2016

NumberofLicensedRetailMarijuanaBusinessesasof

May 1,2018

Stores 528Cultivations 741

ProductManufacturers 286

TestingFacilities 12

NumberofLicensedMedicalMarijuanaBusinessesasof

May1,2018

Centers 497Cultivations 734

ProductManufacturers 253

TestingFacilities 14

CaliforniaLegality

• SimilartoColorado• Seriousmedicalcondition(referstoADA):

acquiredimmunedeficiencysyndrome(AIDS);anorexia;arthritis;cachexia(wastingsyndrome);cancer;chronicpain;glaucoma;migraine;persistentmusclespasms(i.e.,spasmsassociatedwithmultiplesclerosis);seizures(i.e.,epilepticseizures);severenausea;anyotherchronicorpersistentmedicalcondition

• Proofofresidency• ID• MDrecommendation• Fees

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CaliforniaMedicalMarijuanaCardNumbers

• Currenttotal:99,843• Peakyearwas2009-10with12,659• Trendingdownwithabout6,000/yr and2017-18

having5,435

https://www.cdph.ca.gov/Programs/CHSI/Pages/MMP-Card-Data.aspxUpdated4/3/18

Definitions

MMJ:medicinalmarijuanaCannabis:synonymouswithmarijuana

—C.sativa,C.indica,C.ruderalis

Cannabinoids:chemicalcompoundsthatinteractwithcannabinoidreceptorsinthebody.Therearemorethan100cannabinoidsderivedfromcannabis.

Endocannabinoids:endogenousagonistsofCB1&CB2receptors—Anandamide,2-Archidonoylglycerol(2-AG)

Definitions

∆9THC:tetrahydrocannabinol(agonistofCB1)

—Principalpsychoactivecannabinoid—hasthemostmedicalclaims

CBD:Cannabidiol(lowaffinityforCB1andCB2,5HT1Aagonist)

—Minimalpsychoactiveeffects—Hasthemostmedicalpromise—Inhibitsbreakdownofanandamide

CannabinoidReceptors

Products

Pharmaceuticalproducts

Smokedcannabisflower(joint,pipe,blunt)

Vaporizedgroundleaf

Vaporizedconcentratedoil(shatter/wax)

Dabbedconcentrate

Ediblebakedgoods,candies,chocolates

Oraltincturesandoils

Cannabisinfusedtopicalcreams,lotions,oils

Transdermalpatches

Cannabinoid-BasedMedications

• SyntheticTHCderivatives(FDAapproved)• dronabinol(Marinol®,Syndros®)- scheduleIII• nabilone(Cesamet®)- scheduleII• BindtoCB1receptorswithhighaffinityandefficacy,onset

ofaction30-90min

• Epidiolex®- (investigational/expandedaccessprogram),concentratedCBDoil(>98%CBD)

• Nabiximols(Sativex®)oromucosalspray(notavailableintheUS)—THC/CBD(1:1)combinationcannabisextract,onsetofaction30-150min

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PKofproducts

Inhaled:Tmax:3-10min,Duration:1-4hours,t1/2:~19hours

Oral/Mucosal:Tmax:1-3hours,Duration:4-10hours

Transdermal:Tmax:1.4hours,Duration:48hours,t1/2:~7days

THCDose-RelatedEffects

Lowdose:<7mginconsistenteffects

IntermediateDose:7-18mgreliablepharmacologiceffectsIncreasedheartrateDecreasedbloodpressureLowerocularpressure;reddeningofeyes

IntensifiedvisualandauditoryperceptionDecreasedattention,Cognitiveperformance– impairedonsequentialtaskswithmultiplestepsMoodeffects– euphoria;laughter,anxietyDrymouthBloodGlucoseDrop- “munchies”Reducednauseaandvomiting(anti-emeticaction)

HighDose: >18mg->undesirablepharmacologiceffectsNausea/VomitingDelusions,HallucinationsParanoia,AnxietyConfusionDepersonalization

TheEvidence MMJforPain:Felix

• 16yearoldwiththalamicanaplasticPXA• Treatedwithsurgery,radiation,andchemotherapy• Headachepainwasthemostdifficulttocontrol• Receivednervepainmeds,opioids,Botoxinjection• Thalamicpainsyndrome• MMJwasthemosteffective• Difficultywithcross-discipline

management

Page: 84 of 160Page: 84 of 160 IM: 84 SE: 15IM: 84 SE: 15Compressed 7:1Compressed 7:1

ChronicPainIn2014- 94%onColoradoMedicalCardholdersreportedseverepainasamedicalcondition

Survey-baseddatainMichiganshowed64%reductioninopioidusewithcannabisinpainpatients5systematicreviewsalldemonstratethatcannabinoidshaveamodesteffectonpain

Whitingetal2015-

28randomizedtrialsinpatientswithpain(chronicneuropathymostcommon)

22evaluatedplant-derived(nabiximols,plants,oralmucosaspray,oralTHC)8trials(nabiximolandplant-derived)showedMMJincreasedoddsforpainimprovementby40%vscontrol(placeboinmosttrials)Notenoughpowertotestfordifferencesbetweenpainconditions

ConclusionforChronicPain

MajorityofthestudiesweredoneoutsideoftheU.S.onnabiximols

TheU.S.studiesweredoneonflowersvaporizedorsmokedprovidedbyNIDA

2015- over500,000unitsofediblessoldinColoradoalone,whichdoesnotincludetopicalformssold

ThereisevidencecannabisisbeneficialforchronicpaininADULTSbutthereisapaucityofdataofdosagesandroutes

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WhyareyoumovingtoColorado?

• Annie,9yo withmultiplyrecurrent,metastaticretinoblastoma

• Initiallytreatedoutofstate• MovedtoColoradoforMMJ• Admittedforsymptoms• Whoistheprimaryteam?• Palliativecare• Supportsystem

Page: 59 of 156Page: 59 of 156 IM: 59 SE: 801IM: 59 SE: 801

CancerSystematicReview- Rochaet.al2014

35studiesontheantitumoreffectsofcannabinoidsingliomas.Only1studyinhumans,16invivosamplesAllofthestudiesinthisreview,exceptone,showedthatcannabinoidsarecapableofselectivelykillingtumorcellsIncontrasttoitspro-apoptoticandantitumoreffectinvarioustypesoftumors,cannabinoidsprotectnormalcellsfromapoptosisOneofthepossibleexplanationsforthisparadoxicalbehavioringliacellsmaybe

secondarytodifferentcapacitiesoftumorandnon-tumorcellstosynthesizeceramideinresponsetocannabinoids

Guzmanetal2006- 9patientswithGBMwhofailedsurgeryandXRT(60Gy)Medianage55AdministeredTHCaliquotsdailystarting3-6dayspost-opDecreasedcellproliferationoninvivosamples

Conclusion

Insufficientevidencetosupportorrefute

MMJTreatsCancer

• Olivia,7yo withdiffuseglioma ofthemidbrain• TP53mutation(Li-Fraumeni)• Receivingchemotherapy• GivenMMJdaily• Increasingdosestotreatandpreventcancer• HighCBDandlowTHC

MMJforNauseaControl:Maggie

• 5yo girldiagnosedwithaverageriskmedulloblastoma

• MMJonlyfornauseamanagement• Goodsymptomcontrol• Alsorefusedchemotherapy…

Chemotherapy-InducedNauseaandVomiting

Whitingetal2015- 5compounds

28trials(mostpriorto1984)- 8placebo,20comparators,2combotrialsAvgnumbersofptsshowedgreaterbenefitwithcannabinoidsthanwithplaceboNotallwerestatisticallysignificant

CochraneReview2015- nabiloneanddronabinol

23trials- placebo,cross-over,parallelMixedfindingsinplacebo(noneworsewithcannabinoids)NodifferencecomparedtoprochlorperazineModerateevidenceshowingpreferenceforcannabinoids

Only3trialswithchildren- nabiloneanddronabinol

Comparedtoprochlorperazine,metoclopramide,domperidoneOnetrial,THCat10mg/m2ondayofchemowassuperiortoprochlorperazineAnothertrialfoundnodifference

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Conclusion

ConclusiveEvidencethatoralcannabinoidareeffectiveanti-emeticsforchemo-inducednauseaandvomiting

Lackofdataregardingplantcannabis,cannabidiol

Background—MMJforSupportiveCare

Darla,11yo girl,highriskPNET• (nowcalledSTNeuroblastoma)• Severemalnutrition/weightloss• “MMJreallyworks!”• “Tastesterrible”

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Cancer-AssociatedCachexia

Strasseretal.2006- PhaseIIIRCT

Advancedcancerandweight-loss>5%over6monthrandomizedtoTHC+cannabidiol,THC,orplaceboBIDfor6weeksITTanalysisyieldednodifference

Jatoietal.2002- RCT

Advancedcancerand5lbweightlossover2monthrandomizedtodronabinolormegaceorcomboMegacewassuperior(75to49%,combo66%)

Cognition

2studies(Bluhmet.alandElMarrounet.al)examinedcognitivedevelopmentat36and60monthstothoseexposedtoTHC- nodifferencefound

Weakeffectonshorttermmemory

Goldschmidtetal.2012 - worsereadingscoresatage14onWechslerAchievementTest

Non-exposedchildren94score,thoseexposedtomorethanonejointperday87.8

Threeotherstudiesshowednodifferenceincognitiveormotordevelopment

OtherHealthEffects

MVI:20143.2%16-25yearoldsreporteddrivingwhileintoxicatedwithcannabis

SystematicreviewbyRogerbergin2016lookingatover230,000patientsshoweda20-30%higheroddsofMVCwithcannabisuse

Overdose: publicopinionitisa“safer”alternative

Severalcasereportsofingestionbyyoungchildrenleadingtorespiratoryfailureandcoma

Wangetalin201681casesinColorado- 44%obsinED,22admittedtoinptorICU,2requiredrespiratorysupport

OnecasereportofanadolescentdyinginpartsecondarytoediblesinColorado

MMJMedicalConcerns• Infectionrisk

• Baselineimmunosuppressionwithcancertreatment• ImmunecellshaveCB2receptors• Additiveeffectonimmunefunction?• Unclear“clean”procedures

• Prepareproductsfromplantsource• Potentialcontamination• Bacterialpathogens• Fungalpathogens

• Autoclave!

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Aspergillus

Severalcasereportsregardingimmunocompromisedandcompetentpatientswithevidenceofaspergillosis

CannabiscanharborAspergillusspores

Case-controlstudyin1998byWallaceetal.inHIVpatientsshowednosignificantassociationbetweencannabisuseandaspergillosis

Only19patients

Consensusguidelinesuggestcannabisavoidanceinimmunocompromisedhosts

DrugInteractions

Inhibitorsof2C9,2C19and3A4mayincreasethepharmacologiceffectanddurationofTHC

—Macrolides(exceptazithromycin),oralcontraceptives,CBD,paroxetine,fluoxetine,sorafenib,cyclosporine,plussomeprotonpumpinhibitors,calciumchannelblockers&azoleantifungals

Inducersof2C9,2C19and3A4maydecreasethepharmacologiceffectanddurationofTHC

—Carbamazepine,rifampin,phenytoin,ritonavir,StJohnsWort,phenobarbital

CBDisastronginhibitorof3A4and2D6

—Mayincreaseeffectofcalciumchannelblockers,antihistamines,cyclosporine,busulfan,etoposide,tacrolimus,sirolimus &sildenafil

THCisaninducerof1A2

—Maydecreaseeffectoftheophylline,clozapine,chlorpromazine,cyclobenzaprine,dacarbazine

HOWDOHOSPITALSANDPROVIDERSRESPOND?

Recentstudyinpediatriconcology

• 288pediatriconcologyproviders• 32-itemsurvey• Multidiscproviders• 3centers(Boston,Chicago,

Seattle)• Providerswhoareeligibleto

certifywereactuallymorecautious

• Ananth P,MaC,Al-Sayegh H,etal.Providerperspectivesonuseofmedicalmarijuanainchildrenwithcancer.Pediatrics.2018;141(1):e20170559.Availableat:http://pediatrics.aappublications.org/content/141/1/e20170559.

HowourinstitutionhasaddressedMMJ

Thewidespreadavailabilityanduseofmarijuana-derivedproductsinColoradohascreatednewchallengesforourhospital.Asarefresher,ourCHCOMedicalMarijuana:PatientUsepolicyprovidesforacknowledgment(notendorsement!)ofmedicalmarijuanaproductsbyinpatients/families,whoarerequiredtosigntheCHCOMedicalMarijuanaReleaseandWaiverofLiabilityforminordertousetheproduct.Iamattachingahandoutwhichexplainsthestep-actionwherebyourinpatientteamscanacknowledgetheuseofmedicalmarijuanaproductssothatitwillappearunderthepatient’sMedicationList.SinceourhospitalpolicywasapprovedinMarchof2016,wehaverecognizedaneedtoprovideguidancetofamiliesandcareteamsinunderstandingstate/federallawandexpertiseinpotentialpharmacologicinteractionsofuseoftheseproducts. Tosupportourcareteamsinimplementationofourhospitalpolicyandourfamiliesinadvancingtheirunderstandingofmarijuana-derivedproducts,IampleasedtoannouncetheinitiationofourChildren’sHospitalColoradoinpatientCannabinoidEducationService,whichwillbeginnextMonday,July25th.ThisinpatientconsultativeservicewillbeateamapproachthatincludesaCHCOclinicalpharmacistandsocialworkerandwillbeavailableM-Fr8am-5pm.Uponrequestbythepatient’sprimaryservice,theteamwillmeetwiththeadmittedpatient/family,assessforanypotentialdrug:druginteractionsinvolvingthemedicalmarijuanaproduct,assessforanypatientsafetyconcerns,provideeducationtofamiliesaboutpertinentstatutesandtheCOmedicalmarijuanaregistry,andexplainthethatfamiliesmustsignifusingmedicalmarijuanaproductswithinourfacility.Theconsultteamwillthenmeetwiththeprimaryservicetodiscussfindingsandanyrecommendationsaswellasdocumenttheirfindingsinaconsultativenote.

CHCOCannabinoidEducationService

• ConsultantTeam:clinicalpharmacistandsocialworker• Role:

• Assessfordrug:druginteractionswithMMJproduct• Evaluateforanysafetyconcerns• ProvideeducationregardingpertinentstatutesandtheColoradoMedical

Registry• ComplywithhospitalrequirementofsigningMMJpolicywhileinpatient• Discussfindingswithprimarymedicalteam

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LocalPolicyMedicalMarijuana-Providers

S/B:Thepolicy“Marijuana:PatientUseofMedicalMarijuana”wasreleasedMonday7,2016.Thispolicyoutlinestheprocessforacknowledgementofpatientuseofmedicalmarijuanaandallowsfordocumentationofmedicalmarijuanauseonthepatient’sMAR.Thisprocesswillbeusedbyproviders,pharmacistsandnurses.Toprovideeducationregardingthispolicy,thisdocumenthascompileddetailsofprocedurescontainedinthepolicy,theEPICworkflowforenteringinthemarijuanaacknowledgement,andreferenceinformationavailableonmarijuanause.WhatProvidersNeedtoKnow:

• TheuseofmedicalmarijuanawhilereceivinginpatientcareatCHCOisatthediscretionofthepatient’sprimaryservice.

• Thispolicyacknowledgespatientuse.However,CHCOanditsstaffdonotendorseorrecommenduseofmedicalmarijuanaproducts.

• IntheabsenceofamedicalmarijuanaregistrationcardthefamilywillbeprovidedinformationonhowtoparticipateintheCOmedicalmarijuanaregistry.

• Patients/caregiverswhohavecompletedtheCHCOReleaseandWaiverofLiabilityFormmaybeallowedtousemedicalmarijuanaproducts(oralortopicaldosageformsonly;nosmokingorthroughavaporizer).

o AspartoftheReleaseandWaiverofLiabilityprocess,alicensedphysicianand/orhealthcareproviderwhoisamemberoftheCHCOmedicalstaffmustadvisethepatient/familyofthepossiblerisksandbenefitsoftheuseofmedicalmarijuana.

• AfterCompletionofthewaiver,theproviderwillentertheacknowledgementintothepatientsEpic™profile(Describedintheworkflowbelow)forpharmacytoassessforknowndrug/drugordrug/diseaseinteractionspriortoapprovaloftheacknowledgement.

o NOTE:Forpatientsutilizingmultipledosageformsofmarijuanaproducts(e.g.oilsplusedibles)onlyONEacknowledgementneedstobeenteredintothepatient’sprofile.

• Withtheacknowledgementofmedicalmarijuanauseineffect,thefamilywillassumeallresponsibilityassociatedwithmedicalmarijuanastorageandadministration.

LocalWorkflowProviderWorkflow:

1. TheCHCOproviderscanaccesstheacknowledgementutilizingtheordersactivity

2. IntheorderssectionofEpic™,theproviderwillenteranacknowledgementofthepatient’sself-

administrationoftheproduct.a. NOTE:Thisacknowledgementcanbeaccessedbytyping‘medicalmarijuana,’

‘marijuana,’‘acknowledgement,’or‘cannabinoid’(oranypartofthosenames).

3. Oncetheacknowledgementisselected,theproviderwillberequiredtoanswerprompts

addressingthefollowingissues:a. Theacknowledgementwillincludetheprovider’saffirmationstatement:“Ihavebeen

informedaboutthispatient’s(orfamily’s)desiretoself-administermedicalmarijuanaproductswhileundermycare.Iacknowledgethispatient’s(orfamily’s)choice.”

i. NOTE:Bydocumentingthisnotetheproviderismerelycommunicatingacknowledgementtoanotherteammember,notnecessarilyindicatinghe/sheisrecommendingorendorsingtheuseoftheseproducts.

b. AdditionallytheproviderisrequiredtoacknowledgethattheCHCOreleaseandwaiverofliabilityagreementhasbeensigned

4. Uponcompletionoftheacknowledgementorder,thenurseandpharmacistwillbenotifiedper

usualEpic™workflow.

MMJConsultServiceCannabinoidEducationConsultService

• Toassistourinpatientteams,apharmacist/socialworkerteamcanmeetwithpatientsandfamiliesuponrequestbythepatient’sprimaryservice

• Thegoalsofthisservicearetoassessforpotentialinteractionsbetweenmedicalmarijuanaproductsandanyothermedicationsthepatientistaking,toassessforanysafetyriskstothepatient,andtoprovideeducationtofamiliesaboutpertinentstate/federallegislationandtheCOmedicalmarijuanaregistry,whereappropriate.

• Theconsultteamcanalsoprovideeducationtofamiliesaboutthehospital’smedicalmarijuanareleaseandwaiverofliability.

• Torequestaconsult,CANNABINOIDEDUCATIONTEAMcanbesearchedforasaninpatientorder–seescreenshotbelow:

BarriersToResearch

SeveralstepsinobtainingapprovalforScheduleIcontrolled-substanceincludingFDA,DEA,andstateapproval

LastattemptatchangingtoScheduleIIfailedin2016

Untilrecently,onlyonesiteprovidedMMJforapprovedresearch(UniversityofMississippi)

NoFDAapprovalformajorityofcompoundsconsumedrecreationally

MedicalMarijuanaAct- inhousesub-committeecurrently

MMJStudyinColorado

• ProspectiveobservationalstudyofMMJonthequalityoflife(QOL)inpediatricbraintumorpatients

• Laboratoryassessmentsofwhitebloodcellfunction• FundedbytheColoradoDepartmentofHealth• Nursesarethefrontlinefordiscussionswithpatientsabout

MMJandmustbeawareoftheemergingfieldofMMJinpediatriccancer.

ExternalWebsiteStudyInformation

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StudyDesignOverview

• Prospectiveobservationalcohortstudyevaluatingthequalityoflife(QOL)ofchildrenwithCNStumorsandtheirfamilieswhochoosetoself-medicatewithMMJproducts

• Gatherinformationregardingpotentialclinicalefficacy,impactonimmunefunction,cannabinoidpharmacokineticsinchildren,andpotentialtoxicities/complications

StudyDesignOverview

• PediatricQualityofLifeInventory(PedsQL™)cancer,braintumorandfamilyimpactmodulesattimeofenrollment(priortocannabinoidtherapy)andatserialtimepointsduringcannabinoiduse

• Patientswillserveasowncontroltolimitpotentialconfoundingfactorsrelatedtotypeoftumor,treatmentregimen

• Serialblooddrawswillbeperformedtoassessimmunefunctionandcannabinoidlevels

MMJStudyOutcomeMeasures

• PrimaryoutcomeismeasurementofoverallQOLscoresinchildrenwithCNStumorsasassessedbythevalidatedPedsQL™braintumor(PedsQL™-BT)module

• SecondaryoutcomesincludechangesinspecificsubscoresofPedsQL™cancerandbraintumormodulesandtotalscoresforPedsQL™familyimpactmodule

MMJStudyInclusion/ExclusionCriteria

• InclusionCriteria• Age>2yearsand< 18yearsatthetimeofstudyenrollment• Patientsmusthaveadiagnosisofcentralnervoussystem(brainorspinal)

tumor• PatientsmustbeONEofthefollowing:

• Undergoingdisease-directedtherapy,palliativetherapy,ortransferringtocareunderthePediatricNeuro-OncologyphysiciansatCHCO

• Interestinmarijuanausehasbeendiscussedbythepatientorparents.

• ExclusionCriteria• Patientbegantherapywithcannabinoidsmorethan72hourspriortothetime

ofconsent.

MMJStudyDesign

• CHCO-developeddiarywillbeadministeredtogatherdataregardingmarijuana/cannabinoidusepractices• Producttype/strain• Methodofdelivery(i.e.,edible/oil/inhaled)• Perceivedsideeffects• Financialimpactonthefamily(togatherdataregardingout-of-pocketcostsforthisalternative

therapy)• Diarieswillalsorecordnausea,painandappetitemedicationsrequired

• Clinicaldatawillalsobecollected,includingage,gender,tumortype,diseasestatus,chemotherapytreatment,radiationtherapy,andcomplications(includinginfections)

• Datacollectionisatstudyentry,3,6,and9monthtimepoints

MMJBiologicCorrelativeStudies

• Immunefunctionatserialtimepoints• T-cell(ForemanLaboratory)• Neutrophil(AmbrusoLaboratory)

• Cannabinoidbloodlevelsatserialtimepoints• AssociationwithhigherCBD/THC/metaboliteswithchangesin

PedsQL™assessments?• Contributetoscienceinabiggerway!

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MMJSubstudyinPalliativeCare

• Tobedoneincollaborationwithhospices• UsedmethodsdevelopedbyCHCONeuro-Oncologyteam

usingunexpectedadmissionandstructuredinterviewswithparentsafterdeathtoassessqualityofterminalcare(HaveconsiderableamountofpriordataforpatientsnotonMMJ)

• AssessimpactofMJusageontheneedforIVmedicationssuchasversedandopioids.

NursesRoleinMMJ:Legality

• Wheredoesthepatientreside?• Whatageisthepatient?• Consequencesforusingillegally• Howtoobtaina“RedCard”• MedicalMarijuanaClinics• Dispensaries(Recreationalvs.Medical)

NursesRoleinMMJ:Education

• Learnaboutyourstate’sregulations• DepartmentofHealthWebsite• CannabisEducation

• Web-basedseminars• Universityoffered

• Visitaclinicanddispensary• Learnthelingo

NursesRoleinMMJ:PatientEducation

• Talkaboutit!• Askiftheyareusingany

MMJproducts• Dosing---lowandslow• Strains• Products• Safety• SideEffects• Interactionswithother

allopathictherapies

Challenges

• Financial• Clinicfee• Medicalmarijuanacard• Product

• SocialSupport• ClinicalStaff• FriendsandFamily

• Barriers• Travel• Camps• SchoolAdministration

What’snext??

• AbilitytoresearchMMJwiththesamestrengthofresearchwecandowithothermedications

• NationalregulationsforMMJ• Standardizationofproducts• Cleanerprocessingoftheproduct• Education• Collaborationbetweendisciplines

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