Today in the chart

Eleven states have legalized marijuana for recreational use, and some 33 have given it the green light in medical settings. Still, education about the effects of cannabis, the endocannabinoid system, and how THC interacts with other drugs is not a standard part of nursing or physician assistant school.

As laws change, you can be sure more patients will ask you about using marijuana — either recreationally or medicinally — and you have a responsibility to provide them with information that will keep them safe, says Theresa Mallick-Searle, MS, RN-BC, ANP-BC, who practices in Stanford Health Care’s division of pain medicine. Mallick-Searle recently taught a webinar through the American Association of Nurse Practitioners about cannabis. 

Here are Mallick-Searle’s top tips for addressing this topic with patients.
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Share Your Own Opinions on Cannabis Use

If you want your patients to be honest with you, then be honest with them. “If you feel this way, you can say that you don’t feel cannabis is an appropriate medication, treatment, or recreational substance for a patient,” Mallick-Searle says. Just avoid being judgmental.

When Discussing Medical Cannabis, Ask Your Patient to Seek a Medical Marijuana Card

You can have a more comprehensive conversation with your patient if they get a medical marijuana card. That’s why Mallick-Searle recommends all her patients interested in cannabis for medicinal use do so. “In many states, it’s easy to get,” she continues. “Having that card … brings the conversation into a realm where you can talk about medical utility, safety, drug-to-drug interactions, traveling considerations, treatment agreements, and goals of care.”

Talk About the Risks of Cognitive Impairment

It might seem obvious, but clinicians should stress to patients the danger of performing certain activities while under the influence of cannabis. (According to a recent AAA report, 15 million Americans who admit to driving high could use a refresher.)

The duration of the cognitive effects depends on the product’s THC levels, and the ingestion method — psycho-activity hits much more slowly after eating it. Usually, effects dissipate within six hours, according to the Ontario Medical Association.

‍Walk Through the Difference Between Orally Ingesting and Inhaling Marijuana

“Most of your patients will probably be more comfortable using edibles as an introduction to marijuana because they falsely think it’s not as severe as an inhaled product,” Mallick-Searle says. However, if you’re assessing how a patient responds to cannabis, Mallick-Searle recommends inhalation first. “With an inhaled product, you’ll get rapid blood level and psycho-activity, so you’ll know how that patient will be affected by the substance,” she says. “With orally ingested products, there’s a degree of variability in terms of when cognitive side effects hit.”

‍Explain the Addictive Properties

Existing research shows cannabinoids trigger the same reward system as alcohol, cocaine, and opioids. Stressing this similarity is especially important for individuals with a personal or family history of addiction or subclinical mental illnesses. Mallick-Searle adds that “there’s evidence of cannabis dependence,” and you should be concerned about it becoming “an addictive substance” for certain patients.

Provide Safe Purchasing Tips

With most cannabis products, especially CBD, there’s potential for contaminants, Mallick-Searle stresses. So, “it’s important to educate patients about reading labels, knowing where the base product comes from, be it cannabis or hemp, where it’s grown and how it’s manufactured before it gets to the dispensary or market,” she explains.

To start, you can recommend Consumer Reports’ resources on CBD and cannabis and tell patients to avoid inhaled products containing propylene glycol, which becomes formaldehyde when heated. Another helpful tip? CBD from hemp tends to have more contaminants than CBD from cannabis sativa, and hemp oil has no cannabinoids.

Do Not Be Judgmental and Encourage Honesty

You want your patients to feel comfortable talking to you about marijuana so that, if they choose to use it, you can empower them to do so safely. And that won’t happen unless you check your biases at the door and have an “open conversation,” Mallick-Searle explains. Consider asking them about their interest in trying marijuana and avoid making assumptions about the patient based on age, gender, or ethnicity.