Tara Fowler BSc.Kin. RRT CHT MHS
Tina Yan HBSc RRT CHT
The federal Cannabis Act and Cannabis Regulations law came into effect on October 17, 2018. Statistics Canada estimates twenty percent of Canadian males and fourteen percent of Canadian females consumed recreational or medical cannabis in 2019. Reports of regular cannabis use from patients in both long-term and acute care institutions have also increased. With the new legal landscape, hospitals have been required to develop and update policies related to medical and recreational ca Save nnabis use for both patients and employees.
The Canadian government, regulating bodies, healthcare institutions and other independent groups have created resources for clinicians to use to guide policy, procedures, and best practices to assist with bedside care. The Canadian Society of Respiratory Therapists (CSRT) and the Respiratory Therapy Society of Ontario (RTSO) have also issued a position statement in October of 2018 outlining usage and practice recommendations for Respiratory Therapists.
The role of healthcare providers in providing care to patients using cannabis is increasingly recognized; clinicians must be aware of these implications and informed about how this therapy may influence practice in a variety of health care settings, including acute care. This article aims to provide a brief summary for Respiratory Therapists caring for patients utilizing medically prescribed or recreational cannabis.
Medical Versus Recreational Use of Cannabis
The term medical cannabis is used to describe products derived from the whole cannabis plant or its extracts, which patients take for medical reasons, after interacting with and obtaining authorization from an authorized healthcare provider. It is difficult to draw a line between medical and recreational cannabis use…the differentiation truly comes down to the intent of the individual. Patients taking cannabis for medical reasons generally use cannabinoids to alleviate symptoms while minimizing intoxication, whereas recreational users may be taking cannabis for euphoric effects (Canadian Pharmacy Association, 2017).
Medical Use of Cannabis
The Access to Cannabis for Medical Purposes Regulations (ACMPR) was the set of laws that governed medical cannabis use in Canada prior to October 2018. After cannabis legalization took effect, the ACMPR was absorbed into The Cannabis Act, although there have been no changes to the previous medical cannabis laws.
Medical cannabis can only be purchased through Licensed Producers, licensed by the Federal Government of Canada. With medical cannabis, patients are provided with a personalized treatment plan for strain selection and dosing. Pharmacological cannabinoids such as delta-9-tetrahydrocannabinol-cannabidiol and nabilone have been approved for specific indications by Health Canada, however, herbal medical cannabis has not gone through Health Canada’s drug review and approval process, nor does it have a Drug Identification Number (DIN) or Natural Product Number (NPN) (Canadian Pharmacy Association, 2017).
Due to the fact that medical cannabis use requires a medical recommendation and ongoing treatment by a medical doctor, there are no age restrictions on medical use and it is accessible to all patients who require it. Under the Cannabis Regulations, patients can access dried cannabis or equivalent amounts in non-dried form. Regulations require that healthcare providers indicate in the required medical order the daily quantity of dried cannabis, expressed in grams, that they authorize for the patient. The licensee who sells or provides cannabis in a form other than dried will determine the quantity that is equivalent to the quantity of dried cannabis recommended by the authorized prescriber (Canadian Medical Protective Association, 2019).
Through the ACMPR, patients may be granted the privilege to produce their own cannabis for medical purposes. Under the review and approval of Health Canada, ACMPR patients can calculate how much cannabis they can legally grow and store based on the requirements under their medical recommendation.
Clinical studies supporting the safety and efficacy of cannabis use for therapeutic purposes in a variety of disorders are limited, but slowly increasing in number. The Canadian Medical Association (CMA) holds a position expressing concern about the lack of clinical research, guidance and regulatory oversight for cannabis as a potential medical intervention. However, Health Canada does provide information regarding the potential uses of medical cannabis.
Table 1: Potential Therapeutic Uses of Medical Cannabis (“Information for Health Care Professionals”, 2018)
Quality of Life
|Multiple Sclerosis, Amyotrophic Lateral Sclerosis and Spinal Cord Injury||Wasting Syndrome and Loss of Appetite in AIDs, Cancer and Anorexia Nervosa Patients||Epilepsy|
|Pain (Chronic and Acute)||Arthritic and Musculoskeletal Disorders||Movement Disorder|
|Movement Disorders||Anxiety and Depression Disorders||Inflammation for IBS and Crohn’s Disease|
According to the Government of Canada, Cannabis should not be used for individuals who (Consumer Information, 2016):
- are under the age of 25
- are allergic to any cannabinoid or to smoke
- have serious liver, kidney, heart or lung
- have a personal or family history of serious
- mental disorders such as schizophrenia,
- psychosis, depression, or bipolar disorder
- are pregnant, are planning to get pregnant,
- or are breast-feeding
- are a man who wishes to start a family
- have a history of alcohol or drug abuse or
- substance dependence (p. 4)
Recreational Use of Cannabis
According to federal law under The Cannabis Act it states that the legal age of consumption in Canada is 19 years. Local and municipal laws also apply to recreational cannabis, in many cases adding restrictive municipal laws such as opting out of recreational cannabis retail stores or raising the legal age for consumption for their individual areas.
Recreational Cannabis can be purchased from online cannabis retail stores. Cannabis retail stores are required to be licensed by the province. Recreational cannabis sold through regulated government stores is purchased from Health Canada approved Licensed Producers.
In some provinces, it is legal to recreationally grow a certain number of cannabis plants per household. This is provincially regulated. The Cannabis Act states that recreational cannabis may be consumed wherever tobacco can be consumed, however many provinces have tightened these restrictions.
The Endocannabinoid System, Tetrahydrocannabinol and Cannabidiol
According to a review by Bridgeman and Abazia (2017), the two main active ingredients in cannabis include Tetrahydrocannabinol (THC) and Cannabidiol (CBD) that are chemically similar to the body’s own endocannabinoids (eCBs). This allows them to interact with the body’s cannabinoid receptors. eCBs are the messengers of the Endocannabinoid System (ECS) (Bridgeman & Abazia, 2017). The ECS has a homeostatic role, having been characterized as “eat, sleep, relax, forget, and protect” (p.181). eCB receptors are involved in the regulation of many bodily functions including brain and nervous system activity, heart rate and blood pressure, digestion, inflammation, immune system activity, perception of pain, reproduction, wake/sleep cycle, regulation of stress and emotional state (Bridgeman & Abazia, 2017).
THC works because it very closely mimics the chemical structure of the eCB known as anandamide. THC and anandamide interact with receptors known as CB1 receptors (Bridgeman & Abazia, 2017). Like THC, anandamide can also affect things like perception of pain and sense of reward, but not at the same levels of THC (Bridgeman & Abazia, 2017). Researchers have also identified a different group of receptors called CB2 receptors, with which THC interacts but anandamide does not. Most CB1 receptors are part of the central nervous system (like the brain and spinal cord); most CB2 receptors are part of the immune system (Bridgeman & Abazia, 2017). This explains why cannabis has both psychoactive and therapeutic effects.
From the Bridgeman and Abazia (2017) review, Cannabidiol (CBD) doesn’t act on CB1 or CB2 receptors, so it has many different effects than THC. CBDs are known for having a calming effect. CBD has been shown to have the potential for therapeutic use, including antiepileptic, anxiolytic, antipsychotic, anti-inflammatory, and neuroprotective effects (Bridgeman & Abazia, 2017). Researchers are still identifying which receptors CBD acts on, but they know a few of them. They know CBD interacts with a serotonin receptor called 5-HT1A, which could explain its anti-anxiety effect. They also know it interacts with receptors known as the vanilloid receptors, specifically one called TRPV1, which is known to influence the body’s perception of pain (Bridgeman & Abazia, 2017).
Medical cannabis generally has a higher CBD content and lower THC content and is used for medical or therapeutic purposes, while recreational cannabis generally has higher THC content (Bridgeman & Abazia, 2017).
Therapeutic Uses, Methods of Delivery and Dosing
According to Health Canada, there are several potential therapeutic uses for Cannabis, which include: palliative care, quality of life, chemotherapy-induced nausea and vomiting, wasting syndrome and loss of appetite in AIDS and cancer patients, and anorexia nervosa, multiple sclerosis, amyotrophic lateral sclerosis, spinal cord injury and disease, epilepsy, acute and chronic pain, arthritides and musculoskeletal disorders, and a few other diseases and symptoms (“Information for Health Care Professionals”, 2018).
The three most common methods of administration are inhalation via smoking, inhalation via vaporization, and ingestion of edible products. The method of administration can impact the onset, intensity, and duration of psychoactive effects; effects on organ systems; and the addictive potential and negative consequences associated with use.
For example, inhalation of THC causes a maximum plasma concentration within minutes and psychotropic effects within seconds to a few minutes. These effects reach their maximum after 15 to 30 minutes and taper off within two to three hours. With oral ingestion, psychotropic effects manifest within 30 to 90 minutes, reach their maximum effect after two to three hours, and last for about four to 12 hours, depending on the dose (Grotenhermen, 2003).
Currently, there are no evidence-based guidelines on precise doses or uniform dosing schedules for products such as fresh marijuana, smoked/vaporized marijuana, or cannabis oil. Dosing remains highly individualized and titrated based on the “starting low and going slow” approach, where inappropriately prescribed dosages may pose health risks associated with its use, such as psychoactive, intoxicating, and impairing effects (“Consumer Information”, 2016).
Table 2: Potential Risks of Cannabis Use (“Information for Health Care Professionals”, 2018)
|Physiological Effects||Cardiovascular effects – increase BP, HR, arrhythmias
Lung – irritate and damage airways and lung tissue
Contaminants – pesticides/herbicides, street drugs
Early pregnancy failure, birth defects
|Interactions with Other Medications||May potentiate other forms of sedatives|
|Cognitive Functioning||Decreased concentration, short-term memory and motivation|
|Mental Health Issues||Abuse/tolerance/dependence
Potentiate symptoms associated with Anxiety, Psychosis, Schizophrenia
|Public Safety||Driving impairment, workplace safety|
Understanding the Legislation and the Impact on Healthcare Providers and Institutions
The Cannabis Act provides details on how both recreational and medical cannabis can be accessed, purchased, and used. In Canada, before the legalization of cannabis, patients who had a health condition for which cannabis was indicated could, with the support of a physician or nurse practitioner, register with a Licensed Producer. They chose from a broad variety of products, including fresh and dried cannabis, seeds, extracts and oils, and topical products. Since legalization, patients can now purchase cannabis for therapeutic purposes directly from retail stores and websites without the need to register with a Licensed Producer or provide medical documentation.
Under the Cannabis Regulations, registered patients are permitted to possess an amount of medical cannabis equal to a maximum of 150 grams of dried cannabis in a public place. This is significantly higher than the amount of recreational cannabis permitted under the federal Cannabis Act, which allows individuals to possess an amount of cannabis equal to a maximum of 30 grams of dried cannabis in a public place (OHA, 2018).
Systemically, issues surrounding policy, practice, safety, and sourcing need to be addressed.
There are implications to the Occupational Health and Safety policies and procedures of a healthcare organization. The Occupational Health and Safety Act (OHSA) sets out the rights and duties of employers and workers. The employer’s duties include ensuring that workers are not impaired while working and taking every reasonable precaution to ensure that workers are protected. The worker’s duties include reporting to work fit for duty, assisting in ensuring a safe workplace and complying with safety policies. The provincial Cannabis Act prohibits cannabis use in “workplaces” within the meaning of the OHSA.
The OHA (2018) recommends hospitals develop policies regarding the possession and use of medical and recreational cannabis on hospital grounds. Hospitals may choose to take a zero-tolerance approach, permit medical cannabis only or permit both medical and recreational cannabis use. Healthcare provider organizations will be required to incorporate medical cannabis smoking and vaping into smoke-free policies. They will also need to determine the most appropriate approach for addressing medical cannabis and develop or update policies accordingly.
Healthcare providers and institutions are in an odd place where currently the sourcing, dosing and delivery method for cannabis is determined by the patient. Healthcare providers and institutions must also navigate the differences between recreational and medicinal use. Dispensing and storage concerns, including an evaluation of where and how this product should be stored; who should administer it; what pharmaceutical preparations should be permitted (e.g., smoked, vaporized, edible); and how it should be charted in the medical record represent other logistical concerns.
Hospital policies may require patients to provide documentation authorizing the use of medical cannabis and evidence/proof that it has been purchased from an authorized licensed producer. There are complicated logistics for self-administration of medicinal cannabis by the patient or caregiver; in particular, many hospitals have policies on self-administration of medicines that permit patients to use their own medications only after identification and labelling by pharmacy personnel. Healthcare providers must be able to assess the impact and interactions medical cannabis may have provided treatments, provide direction as to when to stop using switch to alternative medication, address the forms of medical cannabis permitted (e.g., pills, oils, edibles, etc.), and/or set parameters regarding where cannabis is to be used (Ontario Hospital Association, 2018).
Highlighting CSRT and RTSO (2018) Position Statement Recommendations
In 2018, the CSRT and the RTSO issued a joint position statement regarding respiratory health and cannabis use. The recommendations made were aimed at protecting the lung health of the patients Respiratory Therapists work to treat and protect.
The CSRT and RTSO made the following Usage and Practice Recommendations:
- If cannabis is to be used, it should not be smoked.
- If cannabis is to be used, harm reduction methods should be employed.
- Adolescents and young adults under the age of 25 years old should not use cannabis in any form.
- Respiratory therapists should have access to the evidence informing cannabis use for medicinal purposes and of the harmful health effects of cannabis so that they are able to appropriately educate the populations they serve.
- Respiratory therapists should screen patients for cannabis use, as is recommended for tobacco use, and be aware of cessation resources so that they can support members of the public as required.
Throughout the literature, it is recognized that more research is required for fulsome recommendations regarding medical and recreational cannabis use. RTs support Canadian patients in the safe consumption of Cannabis. Also, RTs are required to recognize and seek opportunities for education to maintain competence. With this evolving process, RTs need to recognize that the evidence and legislation for Cannabis are rapidly changing; hence as self-regulating practitioners, we need to ensure we stay current with our practices and policies.
Bridgeman, M. B., & Abazia, D. T. (2017). Medicinal cannabis: history, pharmacology, and implications for the acute care setting. Pharmacy and Therapeutics: a peer-reviewed journal for formulary management, 42(3), 180-188.
Canadian Pharmacy Association (2017). Retrieved January 2020, from https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/MedicalCannabis_FAQ_Final.pdf
Canadian Medical Protective Association (CMPA)(2019). Retrieved January 2020, from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/medical-marijuana-new-regulations-new-college-guidance-for-canadian-doctors
Cannabis Laws. (2019, March 5). Retrieved January 1, 2020, from https://www.ontario.ca/page/cannabis-laws
Consumer Information – Cannabis (Marihuana, marijuana). (2016, July). Government of Canada. Retrieved January 2020, from https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/licensed-producers/consumer-information-cannabis.html
CSRT and RTSO Joint Position Statement on Respiratory Health and Cannabis. (2018, October). Retrieved December 2019, from https://www.csrt.com/wp-content/uploads/CSRT-_RTSO_Respiratory_Health_and_Cannabis_2018.pdf
Grotenhermen, F. (2003). Pharmacokinetics and pharmacodynamics of cannabinoids. Clinical pharmacokinetics, 42(4), 327-360.
Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the Cannabinoids. (2018, October 12). Retrieved January 13, 2020, from https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids.html
Ontario Hospital Association (2018). Preparing for Cannabis: Developing and Updating Hospital Policies. Retrieved January 10, 2019, from https://www.oha.com/Legislative%20and%20Legal%20Issues%20Documents1/Preparing%20For%20Cannabis-Developing%20and%20Updating%20Hospital%20Policies%20(September%202018).pdf