Overcoming the Barriers to Medial Professional's Understanding of Cannabis TherapyBy Janna Champagne, BSN, RN (Ret.)
As detailed in my article, Demise of Medical Cannabis in Oregon, our medical cannabis program in Oregon is failing to meet the needs of vulnerable OMMP patients, despite 24 years of legal Medical Cannabis access in our state. Medical professionals are lacking an understanding of cannabis science, which supports its therapeutic applications and harm reduction potential. Unfortunately, many barriers exist in improving receptivity of cannabis-naïve practitioners to learning about and utilizing cannabis in their practice, and the many contributors are detailed below. Federal Schedule I placement is another deterring fear factor for medical professionals, who wrongly assume that cannabis (in the form of THC) meets these criteria for justifying harsh accessibility restrictions: 1. Harmful 2. Addictive/Potential for Abuse 3. No accepted medical use (1). Then there’s the reality:
As early as 1988, we’ve had multiple federal judges rule in favor of descheduling cannabis, when presented with the above objective evidence that it doesn’t meet the criteria for Schedule I placement (7) . Yet here we are in 2022, with cannabis still under federal Schedule I restriction, effectively disallowing cannabis access for most patients in our country who might otherwise benefit. “When politics lack logic, follow the money” is the only clear rationale for this 34-year delay in patient justice. Cannabis obviously competes with pharmaceutical profits, and from my experience educating thousands of cannabis patients, it’s common for patient success in medical cannabis therapy to concurrently reduce their reliance on prior pharmaceuticals. The leading contributor to politician recipients is pharmaceutical lobbyists, constituting more than double the next leading industry of oil and gas (8) This sure could explain why cannabis is still plagued by federal level restrictions, despite 60% of the country being pro-medical cannabis use (9). Becoming a medical cannabis practitioner also requires overcoming the seemingly deliberate barriers to medical professionals service of cannabis patients. In Oregon, despite longstanding legal cannabis access for our patients, the medical and nurse licensing boards are notoriously discriminatory towards practitioners serving those who choose cannabis therapy (10). Ethical practitioners determined to serve cannabis patients must disregard the fear of possible licensure ramifications, and choose to follow their oath and serve patients without prejudice. Historically, many Oregon physicians and nurses have been subject to harassment, investigation, and even license discipline or retraction (11, 12). It’s for this very reason that I decided to retire my RN license this month (in good standing), to facilitate my ability to freely advocate without this inherent liability. Oregon licensing boards are capitalizing on their own failure to adopt guidelines for their licensees working with medical cannabis patients, forcing ethical practitioners to operate in a licensure gray area. This entails risking licensure to abide by our ethical oath to provide nondiscriminatory service to patients in need. This situation exists in Oregon despite 24 years of legal patient access to medical cannabis, representing ample opportunity for our state’s licensing boards to support practitioner’s needs. Here’s an example of the poor handling of this issue, by the Oregon State Board of Nursing (OSBN), which effectively placed a gag order on nurse education of Oregon cannabis patients in November of 2019. This decision effectively amplified the severity of the already critical educational gap experienced by our cannabis patients in Oregon. Nurses are uniquely qualified to provide patient education, and screen pharmaceuticals for possible interactions with cannabis, which represents the primary risk of cannabis therapy today. This discriminatory OSBN cannabis nurse gag order increased the likelihood that medical cannabis patients would fail to meet reasonable therapeutic goals, or potentially suffer negative effects of combined pharmaceuticals (13). This ridiculous mandate resulted in Oregon nurses being legally allowed to administer cannabis to patients, meanwhile being strictly prohibited from educating these same patients about the substance being administered. After 18 months of advocacy, OSBN adhered to forcible retraction by efforts of. My attorney Lee Berger, and the proven unlawful cannabis nurse gag order ceased in April 2021 (14). This was further supported by passage of HB3669 effective 1/1/22, which specifically protects nurses from license discipline for providing cannabis education to patients. While this may appear as progress, we are effectively back to pre-2019 conditions, where Oregon nurses are forced to operate in a gray area, absent parameters to guide their patient health education practice, thereby risking their unencumbered license status. This, despite the 2018 release of National Counsel State Board of Nursing (NCSBN) guidelines, which specify the requirements of nurses education of cannabis patients, which were presented to every state board of nursing for adoption (15). All of my attempts to educate or converse with OSBN board members on this topic since 2015 have been ignored, and deliberate ignorance and stigma are the main issue. The Oregon Medical Board is not handing this topic any better, and they have historically investigated and even rescinded cannabis physician licenses in response to their attempts to serve medical cannabis patient’s needs. It’s logical that these boards should accept some responsibility in lieu of pursuing disciplinary action, and instead examine how they are failing to support and guide the medical professionals ethical service of patients using cannabis. Oregon boards’ refusal to examine the prolific medical cannabis education and science resources, and failure to adopt scope of practice guidelines for those serving this specialty cohort of patients, is a major contributor to the current failure to serve our vulnerable medical cannabis patient population. There is no excuse for licensing board’s discrimination against, and continued disenfranchisement of, our Oregon medical cannabis patients. We are bound by medical ethics, and patient autonomy and informed consent are both compromised as a result of our licensing boards’ cognitive dissonance. Research supports the role of medical professionals to ensure cannabis patients achieve their health goals, and experience optimal therapeutic outcomes (16). It's time that we advocate for change, so that medical professionals may uphold our ethical duty to serve cannabis patients without prejudice or discrimination. References:
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In 1998, Oregon was the second state in the US to legalize access to medical cannabis, when it launched our Oregon Medical Marijuana Program (OMMP). Despite our progressive beginnings, Oregon’s current protocols are failing to treat cannabis patients in accordance with our foundational medical ethics, and failing to meet their profound needs. As a result, many consumers opt to access cannabis through Oregon’s adult use/recreational access and pay the higher fees. Considering we are a destination for many “cannabis refugees”, and a trailblazer in cannabis legalization nationally, one would expect our program to be a highly effective example for duplication in newer legal states. Instead, our current regulations and barriers to ethical treatment of cannabis patients clearly exemplifies what must be avoided in order to ensure a success medical cannabis program.
Further supporting our need to make improvements is the Americans for Safe Access 2021 State of the States report, which graded Oregon’s medical cannabis program at only 54.43% overall, awarding us 374 of 700 points possible. Most notably, Oregon scores only 50/100 in the category of patient rights and civil protections, and 45/100 for affordability (1). Considering our 24-year tenure as a legal medical cannabis state, we should be achieving stellar marks. Instead, our low score reflects that we have many issues to address should we endeavor to honor Oregon’s cannabis trailblazer beginnings, and a noble intent to serve patients in need. Unfortunately, Oregon’s opportunity to provide a duplicatable program, or be a shining example to newer cannabis-legal states is quickly dissipating. Instead, our mishandling of OMMP patients’ needs provides a precautionary tale for newer states, and guidance on what not to do. The following overview includes detailed insights on the many root contributors to our current disarray in Oregon, with the hope of targeting and improving these circumstances through the legislative process. I’m a cannabis patient who happens to be an RN (Ret.), and I became an OMMP patient in 2014, so I have a unique perspective on this issue. The following insights are based on my personal experiences as a participating OMMP patient, and a cannabis-specialty nurse pioneer, who endeavored to educate patients, provide solutions to their barriers, and follow their profound outstanding needs for nearly a decade. In order to become a legal medical cannabis patient in Oregon, one must meet specific health criteria, and have current (<90 day old) documentation providing a qualifying OMMP condition from their primary physician (2). The medical cannabis certification process often requires a separate doctor appointment not covered by insurance ($250 average), with one of many clinics signing OMMP authorizations as an exclusive offering. I experienced this exact process myself a few times, before eventually finding a Primary Care Physician that would provide my OMMP certification. Using a PCP for certification enables insurance coverage, and reduced the cost of my OMMP certification to my insurance copay. Unfortunately most PCP’s are unwilling to facilitate this process, which may present affordability issues and restrict patient’s ability to afford OMMP participation. While we have a few amazing Oregon physicians providing education to patients along with their certification for OMMP, more often this interface between OMMP doctor and patient spans less than 15 minutes, and the patient walks away with only a signature. This was consistently my experience, regardless of the physician or type of clinic used to obtain my OMMP certification, where a signature was my only takeaway. A signature alone does not constitute a prescription as is required for pharmaceuticals, which always requires a specific product, and detailed dosing, timing, and method of administration. Patients prescribed pharmaceuticals have the option to request education from their pharmacist, who can advise about possible side effects and interactions with other medications. Cannabis patient’s do not have this option, and are left seeking this information from layperson dispensary budtenders, who are not required to have any specialty education. Our current medical cannabis approach in Oregon can be likened to a doctor giving a patient a blank prescription note with a signature only, and leaving them to visit the pharmacy, guess which product might be appropriate from thousands of choices, and figure out how to use it without any medical guidance. This is not conducive to optimal cannabis therapy outcomes, nor does it provide for appropriate education regarding patient considerations and possible risk factors (4). Comparatively, if we were treating medical cannabis patients using our standard medical ethics, they would receive evidence-based education, product guidance, and a full screening for individual considerations including pharmaceutical interactions (3). Competent medical care of the cannabis patient is linked with optimal therapeutic outcomes, and reduced risk factors (4). While I know some amazing budtenders, even the best of them aren’t qualified to deliver medical guidance such as screening for pharma interactions, yet in Oregon this role defaults to them as the primary resource, thanks to the deliberate absence of reputable medical supports. The current methods in Oregon completely disregard cannabis patients’ basic needs, in full breach of our foundational medical ethics, which mandate that medical professionals disregard any prejudice in our treatment of patients (4). Instead, cannabis patients are left to make these vital decisions on their own, resulting in extended experimentation with multiple products, while facing many added barriers compromising their ability to meet the desired health goals with cannabis (3). Further driving my staunch advocacy and cannabis science education is the reality that medical professionals in Oregon will inevitably interface with patients using cannabis. Ethically this requires they have at minimum a basic understanding of cannabis, to facilitate patient autonomy (right to choose from therapy options) and informed consent (right to be fully educated on all options). Yet there is no minimum required education for them in Oregon, and consequently many don’t understand that cannabis is a viable therapeutic option. Complicating matters, neither doctors nor nurses learn the science supporting the therapeutic potential of cannabis in their formal training, even though this master regulator system was discovered in 1992 patients (5). Lack of cannabis science education spawns rampant stigma and misconceptions among our medical community, inhibiting their ability to support cannabis patients. Those practitioners who happen upon the therapeutic potential of cannabis must independently pursue medical cannabis knowledge and education. Many practitioners hear cannabis is “good for everything” and automatically write it off as a snake oil, not understanding that cannabis activates our EndoCannabinoid System, resulting in promotion of balance or homeostasis in EVERY other system in the body. Medical professionals also fail to recognize that all chronic illnesses are linked to EndoCannabinoid Deficiency, (Russo), which creates imbalances contributing to the root cause of disease. This clearly explains why cannabis may be effective for many different medical uses, as it seamlessly fills a vital nutrient deficiency linked with all illnesses (6). Practitioners who read the objective scientific education discover the rampant stigma and unwarranted restrictions on medical cannabis objectively don’t apply, and the brave advocate to overcome this major hindrance to supporting patients properly. It’s important that medical professionals understand and review the 35K + valid research articles, presenting strong evidence that cannabis is a safe and effective therapy with potential to benefit dozens of conditions, and is especially useful as a harm reduction tool. Ethical cannabis patient care includes weighing risk vs benefit of all therapeutic options, and when cannabis is objectively considered vs the risks of pharma, it’s typically the first logical choice for those suffering chronic illness. This is thanks to an unsurpassed safety profile, minimal side effects, and profound research-supported efficacy. Unfortunately there are many barriers to educating medical professionals on this topic, as detailed in my article: Mission: Educate and Advocate. It’s well past time that Oregon legislators, patients, and medical professionals advocate for medical cannabis patients and those bravely serving their profound unmet needs. This entails providing best practice guidelines to medical professionals, and allowing them to provide non-discriminatory service as dictated by medical ethics, without fear of retaliation. Lacking this progress, the ones who suffer most from stigma are underserved medical cannabis patients. References:
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