What would I know? An informed perspective.

I began nursing in 1987. Since then I have looked after many, many people with chronic pain, cancer, drug/substance use problems (including cannabis), and mental health problems – all in rural and regional settings in Australia. I have studied nursing a lot (to Doctoral level – currently under examination) & I have practiced nursing a lot. I have published about cannabis misuse too (Wilson, 2014). I have gained a significant experience over the years, and I continue to learn about how to care for people more effectively so that they can enjoy a positive quality of life, health and well-being at whatever stage of life they are at (including the dying stage).

I know about pain from personal and carer perspectives too. I have nursed my own mother with terminal cancer. I have the personal experience of being close to friends who have had or do have cancer (some who have died). I am familiar with chronic pain in my own life. I have a personal experience of human pain on many levels, as many others will also have. I have compassion for people who experience pain, and I actively work towards fine tuning this compassion for others so that I can serve others (personally or professionally) with the care and kindness that is needed in times of pain.

This blog is not intended to be an exhaustive expose about everything I know (or about everything anyone else knows) about cannabis and/or chronic or terminal pain care. The intention is to provide an informed perspective based on my accumulation of professional and personal experiences of pain care and substance use care in rural and regional contexts. There will be those who agree with me, and those who don’t. I think it is an important time for discussions about this topic – and this blog is in part a contribution to a public conversation about cannabis and a treatment of pain. You will find lots of hyperlinked information about this topic throughout the blog – it is lengthy this time – but the topic is big too!

The key issues:

How the cannabis is used is the question? And, what component? Some components of the cannabis plant may have beneficial effects and these can be developed as carefully prepared pharmacological formulary preparations that isolate the good helpful components and remove the harmful (eg psychoactive) components to reduce the risk of harm to people. These types of products have been developed as an oral spray (Nabixol for example) targeting specific health conditions and they are stringently tested and retested in clinical trials to demonstrate therapeutic effect and to ensure that harm is minimal. This is evidence based practice in regard to prescribing, administering and dispensing any medication. The challenge here is that you can’t easily do this with crude cannabis. Crude cannabis is leaf or wax/oil substances derived from the plant. There is a gap in the analysis process at this level and the rigour is ambiguous – and you can’t remove the harmful components. The medical cannabis debate gets a bit tricky to follow her at times… but it is the use of crude cannabis that is the key issue which is currently being debated in NSW. There has not been sufficient investigation to warrant the support of changes in cannabis legislation to date – there is no evidence on which to base the practice. And it is this lack of supporting evidence that underpins a call for caution at his time. The evidence to support the pharmaceutical Nabiximol – a synthetic cannabis product as an oral spray is undergoing pharmaceutical trials – but the evidence to support wider use is not yet available (study completion Dec 2015). Thus we are a long way from having an evidence base to support medical crude cannabis. There is no medical or health basis which can support a change in legislation at this time.

• Smoking Cannabis is not a strategy for pain management. Legislation of cannabis is not warranted at this time.
• Legalizing cannabis for medical treatment places moral & ethical burdens on nurses, pharmacists and doctors who are responsible for the prescription, administration and dispensing of a drug that has insufficient evidence as a basis for practice at this time.
• Any form of legalization of cannabis will provide some traction for business entrepreneurs to apply market pressures to extend to non-medical use.
• Chronic pain nurses could do far more to reduce the burden of human pain, but they would need more funded time to do so. Trials should be conducted to ensure that all other possibilities have been exhausted first.
• The health literature clearly states that there are profound linkages between cannabis use and mental health problems, and that young people are especially vulnerable in this regard. There is strong evidence indicating that cannabis is linked to significant harm for people.
• Society has an obligation & responsibility to care for our sick people – those with chronic pain/ cancer. Administering cannabis may short-change sick and vulnerable people, if all other measures are not previously exhausted – such as expert pain nursing care.
• Funded Australian research should be the source of evidence on which to base Australian decisions about the use or not of cannabis for medical purposes. This should include a range of alternatives to cannabis use as the central strategy to manage pain. This should be a prologue to any change, without it, legislation will have no firm basis on which to proceed with legalization.
• There are no magic pills or potions to cure pain – FACT

Cannabis: a bull-in-a-china-shop to pain/cancer care

There are no easy answers to mitigate the human pain (especially related to cancer or chronic pain) on this scale, and cannabis seems like a quick fix; a tidy solution to nasty problem – but it isn’t. There is simply not enough evidence to support this practice. If the Bill before NSW parliament is approved it will place nurses, doctors and pharmacists in a dubious position of condoning and administering, prescribing and dispensing ‘medications’ that would also cause harm – a serious consideration. It will also place NSW Health in the incongruent circumstance of maintaining a register of people who are eligible to consume cannabis. Such a tacit endorsement of consumption of cannabis will have flow through impacts whereby NSW Health will have to also take responsibility for condoning the consumption of hazardous material which could cause harm to people. We as a society, and as health service providers, need to take responsibility for managing that harm. It will cost the State money to do that – money that could be channeled to establishing a stronger team of specialist pain care nurses who may be able to mitigate much of the pain that is the core issue in this debate. There are alternatives – and the ‘shiny thing’ (cannabis) that attracts popular appeal – may not be the most useful, effectiveness and economic solution (nurses) to this problem (pain and nausea).

We need to consider very carefully what we are getting ourselves into if this Bill proceeds. And to question whether there is more harm than good on offer in this Bill for the most vulnerable people, some of whom will be nearing the end of their lives. Like a bull in a china shop – using cannabis to address pain, will cause a range of other problems that are unpleasant and may detract from precious moments of well being. A high price to pay. However, a more considered and planned approach to pain management may be less disruptive and troublesome overall – for example; expanding the nursing capacity to address the problems as part of an overall strategy.

I urge voters for this Bill to consider the responsibility of voting on this matter with extreme caution. The decision and outcomes will have a range of consequences – some will be unintended… but there is still time to return the Bull to the paddock, and not let it loose where it will wreak havoc.

Popular opinion V considered rigorous evidence

We have not yet exhausted the possibilities that excellent nursing care has to offer to people at home where they are often in pain. For instance, palliative care nursing has much to offer in reducing pain and other health problems experienced by people with terminal conditions such as cancer. Perhaps our health services need more of these experts delivering care and the point of need in people’s homes? Nurses are expert in providing pain management care – but it takes time, and our health budgets don’t like that the most important pain relief work takes time to deliver.

Cannabis is a much wished for quick fix that poses more risks and harm than overall good to the wider population. I am not yet convinced that the evidence to support cannabis legislation on medical grounds is sufficient therefore I don’t support the use of cannabis for pain management. BUT I DO support more research to understand the issues better and I support and advocate for nurses to have enough time to administer the non- pharmacological strategies in their professional clinical scope more effectively. Our current legislations are sufficient for now and are flexible enough to accommodate research producing more evidence to improve pain care in the future including research about cannabis and pain.

Over the years, I have looked after many palliative people with pain, nausea, vomiting, constipation…. it is awful. The most horrible of times for people to endure… but my practice experience has shown me that there is a great deal of scope to improve what we do, rather than reaching for a quick fix that will ultimately rob people with little quantity of time, of their quality of life/time. There is a great deal of interprofessional collaboration
working towards preventing and managing pain in Australia, and a lot of positive news and community engagement. There is a strong evidence-based discourse in pain management and the expert views should not be dismissed hurriedly so as to rush through legislation changes because crowd wisdom deems it should be so, despite thin evidence.

Nurses Tips

Here are some nursing tips for coping with the nasty experiences of pain as a sample of starting points for care:

Pain tips

• Hot wheat bag
• Positioning
• Mindfulness
• Monitoring and managing anxiety
• Support for carers
• Tips from those who have been there
• Support groups
• Massage (or even a beauty facial treatment)
• Self management
• Meditation
• Keep a pain diary
• Relaxation techniques
• Distraction
• Imagery
• Pain control plan
• biofeedback
• Emotional support – caring, listening, attending too, being with…
• A good nights sleep
• Self help
• Practice happiness
• Avoid stress
• Get moving – it will help your physical and mental state!

Nausea & Vomiting tips

• Eat small amounts frequently
• Food should be warm or cold not too hot.
• Small and frequent fluids
• Crushed ice – or frozen drinks – eg soft drinks/ cola or fruit juice
• Ask for wafers instead of tables
• Ginger… tea, crystalline
• Clean your teeth – look after your oral hygiene
• Sit upright to eat – not lying in bed or slouching in a
• Managing chemo side effects
• For some – cannabis causes nausea & vomiting: Cannabinoid hyperemesis syndrome.

Constipation tips

• Toilet 10 – 20 minutes after eating
• Fibre
• Fruit
• Positioning while sitting on the toilet
• Getting enough fluids
• Some exercise might help – even short walks
• Talk to your pharmacist – they will have some over the counter products to choose from.
• Ask you pharmacist for a medication review…they will understand the implications of the ways that the medications you take interact with each other, andthey may be able to find improvements.
• Talk to a dietitian
• What is normal

Withdrawal from cannabis is not pleasant… but there is help to get through that…

For people who do use cannabis regularly to address their unresolved chronic pain problems, and find that the side effects are not helpful, there is help available to quit. Though it may not be pleasant for a few days – but that can be planned for, so that the discomfort are minimized. But, better not to start in the first place and double the woes… Here is a list of what people commonly experience in withdrawal from cannabis:

• Anger
  
• Aggression
• Irritability
• Anxiety
• Nervousness
• decreased appetite or weight loss
• restlessness
• sleep difficulties
• chills
• depressed mood
• shakiness
• sweating.

Here is a check list to help in deciding if cannabis use is problematic. And another one to determine the level of dependency. If you are a clinician reading this you might like to see the National Cannabis Prevention and Information Centre – Management of Cannabis Use Disorder and Related Issues: Clinician’s Guide to assist you in help others further. And here is a guide to a brief motivational intervention.

Cannabis and Big Business – Market Open… (kind of like the card game Billionaire!)

Muddying the waters… commercial interests: Australia’s ABC TV recently screened a Foreign Correspondent episode which highlighted the commercial influences of the cannabis industry, and which demonstrated the vulnerability of decision making about legalizing this drug. This episode revealed interviews with business people who have found a soft landing place in ‘medical’ cannabis usage and have used this platform as a springboard to campaign for decriminalization of cannabis to the whole population. The soft entry point to the market is enticing to business markets and from a business planning perspective. It is clear that there is money to be made in bucket loads… However, at what price to the wider society? What price – especially to young people who are most vulnerable to the adverse side effects of cannabis? Sometimes, with devastating mental health consequences which might take a year or two to resolve… or worse, trigger an underlying mental illness vulnerability which has lifelong implications. Surely there are lessons learnt with tobacco? Big business is a significant motivator for pressure to adopt legalization…

Cannabis has been considered for other health conditions and not been endorsed

Nabiximol oral spray (synthetic cannabis) has previously been considered by the Australian Dept of Health for the treatment of severe spasticity due to multiple sclerosis. Clinical trials were conducted and reported in the literature with outcomes that were not sufficiently generalisable to practice and with little evidence of clinical significance. That means that the proof that it was an effective treatment is minimal, and perhaps overstated. About half to two fifths of the participants in the trails reported adverse effects of using Nabixmol included gastro intestinal problems such as nausea, nervous system disorders and psychiatric disorders. Finally, the outcome was that in terms of comparative safety, Nabixmol appeared to be inferior to standard care. Had the submission to PBS scheme in Australia been successful, the estimated cost per year would have been $10-$30 million.

What if?

• $10-$30 million was diverted to establishing a specialist Pain Care Nurse scheme throughout Australia? Not unlike McGrath Foundation Breast Care Nurses. What if a Charity was able to partner with health service to build a sustainable future for Pain Care Nurses to address this significant health problem in Australia…? What if…?
• We can make what we have work better? What if?
• We don’t need new legislation that will open window and loop holes that don’t need opening just now… what if?
• We wait for good quality evidence to inform our practices… what if?

A different view

There will be people who don’t like my view. I don’t mind a range of views – that is a good thing. I am continuing to listen, learn, think and consider this topic – but I don’t want to be swayed by crowd wisdom if there is not convincing evidence to support a change of this magnitude. I hope that we (society) can find new and innovative ways resource and deploy much more compassionate care to people with extreme and enduring pain. Careful consideration is warranted, the stakes are high at a population health scale. Caution is warranted at this stage.

I hope that this blog contributes to more innovative thinking by others about this topic. The tips and ideas contained in the blog are not specific health advice, but are general in nature – most of the links are freely available on the Web – use at your own discretion and check with a health professional if you are unsure.

References and further reading & viewing

Recent media about this topic:

http://www.abc.net.au/local/stories/2014/05/29/4014607.htm?&section=news

http://www.abc.net.au/local/stories/2014/05/27/4013099.htm?site=newengland

http://www.abc.net.au/local/audio/2013/05/22/3765113.htm?site=newengland

Wilson, R. L. (2014). Mental health and substance use. In N. Proctor, H. Hamer, D. McGarry, Wilson R. L. & T. Froggatt (Eds.), Mental Health: A person centred approach. Melbourne: Cambridge University Press.