May 01, 2018
On March 29, CNA hosted a one-day think tank as a followup to its mid-2017 national survey to assess nurses’ knowledge about the health effects of non-medical cannabis. In their survey responses, nurses identified several knowledge gaps in this area including use during pregnancy, the impact of use on the developing brain and health risks related to consumption methods, addiction and mental health.
In September 2017, more than 90 per cent of Canadians surveyed (by Nanos on behalf of CNA) said they support having nurses as educators on the risks and harms of non-medical cannabis use. These results suggest that, as the date for legalization approaches, nurses will be among the health-care providers expected to take a lead role in public education.
To examine how best to address the current knowledge gaps on the health and safety risks of cannabis use, 32 invited participants — representing a diversity of nursing and health-care stakeholders and individual health and legal experts from across Canada — came to CNA House for the March event.
Among the featured speakers were Theresa Tam, Canada’s chief public health officer; Mark Ware, director of clinical research on pain management at the McGill University Health Centre and former vice-chair of the federal Task Force on Cannabis Legalization and Regulation; and Lynda Balneaves, a cannabis researcher and associate professor at the University of Manitoba school of nursing. Their views on cannabis legalization and its implications for nursing served to contextualize more detailed discussions later in the day.
Tam’s presentation emphasized the government’s public health approach to the legalization of non-medical cannabis, one that centres on prevention, harm reduction and education. Noting how specific populations are at greater risk of cannabis-related harms, including youth, persons with substance use disorders, pregnant and breast-feeding women (especially with respect to the effects on the fetus), and persons with a family history of psychosis, Tam focused on youth and protecting young brains.
She pointed to some of the challenges educators will face, given what many young adults believe about cannabis; for example, that it is socially acceptable — therefore, natural and safe when compared to alcohol and tobacco. Such a casual attitude, Tam said, does not consider that we know much less about the health risks of cannabis use than we do for these other substances.
It is because of the need to influence such attitudes, she explained, that Canadians’ widely shared respect for nurses as trusted professionals is so important. Nurses will certainly be one of the best sources of accurate cannabis use information. Yet, to be heard they will need evidence-based messages that are aligned with those of other health-care providers.
Picking up on the state of cannabis research, Ware’s presentation drew attention to the complexity of the cannabis plant. It’s not just one thing, he said, noting that it contains multiple active compounds (cannabinoids), aromatic oils and antioxidant flavonoids, and we need to know about each of them. THC (tetrahydrocannabinol) and CBD (cannabidiol) are only the two most well known. While Ware estimates the state of our knowledge on cannabis to be about 30 years behind our knowledge on opioids, he thinks cannabis researchers have a good chance of avoiding the mistakes that have led to the opioid crisis.
At this stage, he said, health-care professionals must be prepared to manage competing research results as they develop valid and clear messages. There will be instances where the evidence that supports these messages will be at odds with other evidence. So, until existing research becomes decisive, Ware believes the best approach is to be willing to acknowledge divergent conclusions and areas where a consensus has not yet been established.
Balneaves focused on the health impact of having legal non-medical cannabis and its connection to nurses’ educational needs. She thinks that legalization is likely to bring greater attention to the harms of cannabis and could also result in wider use. Such escalation could lead to having more patients coming to urgent care facilities and EDs who are experiencing adverse effects from cannabis. Balneaves also expects an increase in cannabis self-medication and in the number of people seeking help for problematic use. Legalization, she added, will probably result in changing patterns of use for other substances such as alcohol, tobacco and opioids.
In all these areas, Balneaves said, nurses need information to help Canadians reduce the harms of use; for instance, when best to avoid cannabis, such as when consuming alcohol or when a person has a family history of substance use disorder or psychosis. Aside from educational needs related to harm reduction, nurses will also have a role in developing policies in the health, public, regulatory and employment sectors, she added. Examples include organizational rules on tolerance for cannabis use and workplace safety.
During panel presentations, six additional experts provided further details on the health effects of cannabis use as these relate to pediatric considerations, youth brain development, pregnancy, mental health and dependency, youth perceptions, stigma as a barrier to care, patient advocacy and driving safety.
In small-group discussions, participants then identified a range of ideas to meet educational needs, while focusing on three key goals: (1) what nurses need to know, (2) how best to get it to them and (3) what they require to communicate it to patients. For example, with respect to methods of cannabis consumption, one of the small groups said that nurses need to know the specific risks associated with each type of use. Since this particular knowledge is needed right away, it could initially be offered through toolkits, workshops and fact sheets. Over the long term, it could be communicated by means of nursing curricula, conferences and continuing professional development. To help nurses communicate the information, it should be easily understandable and based on sources without vested interests.
After strategizing on ways to overcome the barriers to nurse and client education, such as the abundance of what nurses need to learn or the challenges of getting messages through to young adults, think tank participants agreed on several overarching recommendations. The consensus on communication plans emphasized the need to standardize information, make it accessible (e.g., clearly written, in multiple formats and languages, culturally appropriate) and identify the most responsible organizations to develop and deliver it. With respect to materials to educate nurses, participants agreed that these should be tailored to learning needs, which means first examining nurses’ biases, stigmas and beliefs about cannabis. More generally, it was proposed that nurses be encouraged to use a harm reduction approach to care with all cannabis users.
Once the organizations most responsible for creating and delivering nurse education and health-care materials related to non-medical cannabis use are identified, these recommendations will serve as the basis for further direction and development.