cannabis at camp · 2019-05-07 · the cannabis act: controls the production, distribution, sale...
TRANSCRIPT
2019-05-07
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CANNABIS
AT
CAMP Matthew Canning NP-PHC
Disclosures Staff at Northstar Wellness Cannabis
Clinic, subsidiary of Starseed.
2019-05-07
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AIM OF PRESENTATION:
Increase knowledge around cannabis, the legislation around its use, medicinal indications, side effects.
To foster greater comfort and reduce stigma associated with use for medicinal purposes.
To facilitate greater safety at camp via discussion of hypothetical cases
OUTLINE
Cannabis Defined
History of Cannabis
Components of Cannabis and the ECS
Legislation
Medicinal Use in Adults– re: staffers
Medicinal Use in Children–re: campers
Dangers of adolescent use
Side Effects
Overdose
Case studies
Questions
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WHAT COMES TO MIND?
What is Cannabis & Where is it from?
Cannabis/Marijuana/POT/Weed:
A plant largely known for its recreational and medicinal properties
Flowers or buds hold the medicinal properties of the plant
western china
Himalayas
Kush/Indica
Middle East/Africa
Sativa
Groom et al. (2013)
Hybrid of the Two
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HISTORY LESSON
1st Medicinal use 5000 years ago in China
William O’Shaughnessy first physician to study cannabis using animal models
19th century used as tincture in Europe
1923 Prohibition and creation of the pill makes cannabis old news
1963 via chromatography CBD &THC Identified
1988 Allyn Howlet identified receptors CB1 receptor
1992 Endogenous Cannabinoid Anadamide (mimics THC), and later 2AG in 1995
1993 Discover of CB2 receptor
2001 medical cannabis legalized in Canada
2018 Legalized for recreational purposes in Canada
Hanus (2007); Mechoulam et. Al (2014) O’Shaughnessy (1843)
Evolved Perception
https://archive.attn.com/stories/2912/cannabis-kills-cancer-cells
https://www.youtube.com/watch?v=CWxgfTMLtc0
https://nationalpost.com/news/canada/ontario-residents-can-now-buy-cannabis-online-must-wait-for-retail-stores
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Components of Cannabis
CBD –Non intoxicating
THC – Intoxicating
Terpenes – provide smell and are associated with additional sensations
Flavonoids – found in plants/fruit with medicinal properties
& Many more
Fine et, al. (2014); Malfitano et, al. (2014); Panche et a., (2016)
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The Major Components of Cannabis
CBD THC
• Anti-Inflammatory/ Analgesia
• Anxiolytic
• Antiepileptic
• Possible Anti-psychotic
• Analgesic –neuropathic pain
• Sedative
• Appetite Stimulant
• Anti-emetic
(Crippa et al., 2018; Fine et la., 2014;
Masccarone et al., 2015)
Non intoxicating intoxicating
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CBD - Antianxiety
Mouhamed, Et, al. (2018); Mesamore, E.(2019); Bakas et a., (2017)
NO CB1 receptors in
cardiac/respiratory
locations of the pons
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Lowin (2015) ; Mouhamed, Et, al. (2018); Medical Cannabis Mentor (2019)
CBD Effects
Act on TRPV receptors
to reduce pro-
inflammatory peptides
(chemical messengers
Immune System
Anti- Inflammatory
Inhibit immunoregulatory
proteins ie. cytokines
At certain levels ie.
40mg may increase IOP.
CB2 Receptors:
Immune cells at tonsils, thymus, spleen, bone
marrow ad enteric nervous system in GI tract
CB1 Receptors:
CNS, GI, Adipocytes (fat cells), liver
tissue, and skeletal muscle
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How is Cannabis Administered?
Ingestion
Inhalation Transdermal
Joint
Spliff
Blunt
Bong
Pipe
Vaporizer
Oils
Edibles
Concentrates
Creams
Salves
Patches
Cannabis Mentor (2019)Hammel et al., (2016)
Pharmaceuticals/Synthetics
ACMPR
Access to Cannabis for Medical Purposes Regulations (2016)
Indications include but not limited to:
Severe refractory nausea and vomiting associated with cancer chemotherapy
Loss of appetite and body weight in cancer &HIV/AIDS
Pain & muscle spasms associated with multiple sclerosis
Chronic non-cancer pain (neuropathic)
Severe refractory cancer-associated pain Symptoms encountered in palliative or end-of-life care
Insomnia and depressed mood associated with chronic diseases
Other symptoms or conditions authorized by a health care practitioner
Possession Limits: the amount a patient may possess is limited to “30 times the daily quantity of cannabis prescribed, or a monthly maximum of 150g.”
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Current Canadian Legislation Bill c-45
The Cannabis Act: controls the production, distribution, sale and possession of
cannabis across Canada
Age Restrictions: 19 and older to buy, use, possess and grow recreational cannabis.
This is the same as the minimum age for the sale of tobacco and alcohol in Ontario. If
sold to minor (up to 14 yrs in jail)
Promotion Restrictions: products, packaging/labelling should not be appealing to
youth, no self service/vending machines, only promote in narrow circumstances where
youth don’t see
Travel Restrictions: illegal to cross Canadian international border. Use or work with
Cannabis may deem you Inadmissible to other countries. Domestic travel is ok, but
must know provincial rules.
Legislation Continued.. The RULES
The Rules for 19+
Purchase dry or oil cannabis up to 30 grams (dried equivalent) in public and can
share up to 30 grams
Can purchase from federal LP if no framework in your province
Grow from licensed seeds or seedling up to 4 plants/household
Edibles and concentrates likely legal in 2019
Possession production and distribution outside legal system = illegal
No driving under the influence – law enforecement using Drager 5000, Field
sobriety testing and blood testing
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How are patients getting Cannabis?
Licensed Providers:
Illegal Dispensaries
Medical Prescriptions Sent to LPs
Authorized
retailers must
display the
official cannabis
retail seal
Current Medicinal Use
ADULTS:
Chronic pain/neuropathic pain
Spasticity related to MS
Fibromyalgia – fibro fog, generalized pain etc
Harm Reduction
Anxiety
Migraine management
Epilepsy
Anorexia
Chronic Nausea/vomiting
Menorrhagia
Cancer Treatment (Research)
Glaucoma (debate)
Pediatrics
Epilepsy
Behavioral Issues – Autism Spectrum
Cyclic/Chronic Vomiting
Anxiety/Depression (refractory)
Chronic pain/neuropathic pain
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Contraindications: ABSOLUTE:
Pregnancy/Lactation
History of psychosis, Bipolar, Schizophrenia
Unstable cardiac conditions – ischemic heart disease & arrhythmias
NOACs - Anticoagulants –”blood thinners”
Allergy to Cannabis
RELATIVE:
<19 years of age
Trying to conceive
Hx of glaucoma with poor control
Family Hx of schizophrenia
Significant Chronic Respiratory Conditions
Adolescent Use – should be 3rd line treatment.
Severe Immunosuppression (rt inhalation) *
Brents et al., (2016);Ko, et al.(2016)
DRUG INTERACTIONS
Sedatives: Potentiation
Anti-epileptics: ^ serum levels/ potentially ^liver enzymes
Warfarin/Antiplatelets/NOACs– slowed metabolism and
increased effect
Theophylline – reduced by smoking cannabis
Other theoretical interactions
Arrelano et, al. (2017); Damkier et al. (2019; Gaston et al.,
(2017) Hartman (2015); Yamaori et al. (2012)
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Dangerous and risk of Addiction?
Cannabis a Gateway Drug?
Cannabis an Exit Drug?
Long Term Implications of Chronic Use ?
Budney et, al. (2007); Cannabis Mentor (2018);
Government of Canada (2018); Hall et al., 1999; wiese, et al. (2018)
CASE STUDIES 1
Josie is a 7 year old camper with a long standing history of
cyclic vomiting syndrome. Her symptoms have been so severe
that she has required cannabis oil (THC & CBD). Josie’s mom is
anxious about Josie going away to camp for the first time since
starting the cannabis oil. She asks the camp counselor if they are
aware of the side effects in case Josie were to experience any.
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Side Effects of Use
Dose dependent
Recreational vs. Medicinal
Generally Self limiting
Tolerance as benefit
COMPASS Study
Short Term COMPLICATIONS
Cannabis Mentor (2019) ;McCallum, et, al. (2018); Ware et al. (2015)
CANNABIS OIL STORAGE
Cool
Dark
Sealed
Locked
Dry
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CASE STUDY 2
Sara one of the campers comes to the Camp Nurse Practitioner in a panic she reports Thomas another camper snuck off to the woods, “Thomas ate a weed gummy and now he’s acting strange, im scared”. The camp counsellor finds Thomas and sees that he is exhibiting signs of cannabis overdose. How should the counsellor respond?
A) give Thomas a bag of chips
B) Call Thomas’ parents and have them take him home so he can sleep it off in his own bed and explain that he cannot return to camp due to breaking the rules
C) Call 911
Overdose
Potent psychoactive properties
Symptoms Include: cannabis side effects more pronounced
Relatively low toxicity
A case report.
CDC (2019); Government of Canada (2018); Wang et al,( 2019)
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CASE STUDY 3
Jack is a 9 yo male with a history of Lennox-Gastaut syndrome (LGS). His parents
have recently started him in conjunction with their pediatric neurologist on CBD.
The staff taking care of jack should be aware of which of the following ?
1) CBD oil should be given to Jack with a high fat content food
2) Staff should be on the look out for any signs of sedation and have a safety plan in
place as CBD can affect the serum levels of some antiseizure meds
3) All Cannabis medication should be stored in a locked cabinet to prevent
intentional or accidental ingestion
4) All the above
Gaston (2017); Zgair et al. (2016);
CASE STUDY 4 Tim is a administrative staff member of camp. He discloses to the leadership
team upon being hired that he has severe chronic neuropathic leg pain
secondary to tissue excision of cancerous tissue 3 years ago. CBD oil and dry
cannabis prescribed by Matthew the NP, is the only medication controlling his
pain. What are some factors the team should consider prior to Tim starting
work at Camp.
Should Tim Be allowed to bring his Cannabis to Camp?
A) Yes
B) No
There are several stipulations/considerations
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Considerations for Employers/Employees
Reduce stigma – foster environment that’s non punitive for home use
Safety is non negotiable, intoxication is not allowed while at work ****
No exposure to children visually or via 2nd hand smoke
Employers duty to accommodate for medical needs
Employees Duty to ensure safe work
QUESTIONS ?
Contact Information:
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