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32 cannabis patient care | vol. 3 no. 1 cannapatientcare.com nurse focus people who administer the National Council Licensure Examina- tion (NCLEX [6]). And I sent an email to ask them about what they are doing about including cannabis. Because one of my students last semester told me that the endocannabinoid system was go- ing to be on the NCLEX in 2023," said Casale. Casale emailed them a proposal and is now waiting to hear back. "I am working with a friend of mine who is getting her DNP (Doctorate of Nursing Practice) at Rush University, a re- search university in Chicago, and we are proposing adding the education and integration of cannabis into the nursing curriculum there." Meanwhile, in July 2018, NCSBN published the "National Nursing Guidelines for Medical Marijuana" as a supplement to the Journal of Nursing Regulation (JNR) (7). It is the first com- prehensive compendium of evidence and guidelines of its kind, produced by a committee as a set of guidelines that cre- ate "a strong foundation for safe and knowledgeable nursing care of patients using medical or recreational marijuana." Committee chair Rene Cronquist, RN, JD, director for Prac- tice and Policy, Minnesota Board of Nursing, said that they produced something that they felt was needed and will truly be beneficial, both as guidance to nurses and nursing educa- tion programs. "My hope is that it continues to trigger conver- sation, that it minimizes stigma of individuals using cannabis, and ultimately continues to highlight the need for continuing research," said Cronquist. Early Signs of Progress Casale pointed out that there has been other progress in getting cannabis into medical curriculum. For example, the University of Maryland School of Pharmacy has a master's in medical cannabis science and therapeutics (8). "And I tell stu- dents 'Listen, and hopefully I'm still around, but there is going to be a revolution in health care. We just have to keep pursuing cannabis and get it approved.'" Students themselves can make the change happen. For in- stance, at the University of Vermont Larner College of Medi- cine, student interest drove the university to offer an elective to further integrate medical cannabis into the curriculum due to overwhelming interest. Previous studies have demonstrated a large gap between the public interest, current use of medical cannabis, and medical providers' ability to educate and counsel patients, according to a study published in the medical journal, Com- plementary Therapies in Medicine (9). Most medical cannabis regulations in the US and around the world have been implemented as a result of patient advocacy. A systematic review of healthcare professionals' attitudes and knowledge on medical cannabis recently reported on a lack of self-perceived knowledge on medical cannabis across the fields of medicine, nursing, and pharmacy. It further demonstrated a common desire for additional education and resources to access information about medical cannabis. In general, according to the review (10), while several oth- er studies have shown that healthcare professionals support the use of medical cannabis in clinical practice, for cancer and hospice patients, others have reported on more conserv- ative positions. Such a gap in attitudes and knowledge among healthcare professionals on this topic illustrates the need for a standardized medical cannabis education during training. Only a handful of states have established a requirement for licensed professionals to give medical advice about cannabis. For example, Connecticut requires every dispensary to have a pharmacist on staff. Part of the current gap between public demand and educa- tion provided by healthcare providers is in large part due to a major lack of education at all levels of healthcare, accord- ing to the study. The 2017 National Academies of Sciences, Engineering, and Medicine (NASEM) report concluded that medical cannabis is effective for the management of chronic pain in adults. How- ever, the report added, recommendation of medical cannabis to patients has not been widely adopted by physicians. The report states (10): "In order to create specific educational rec- ommendations for schools, this gap of education and mixed beliefs within healthcare education needs to be bridged." The Situation Today Casale noted that there are all these illegal drugs coming in from various international sources that people take for pain when the opioids they are prescribed either don't work or are not available to them. "People are dying because they don't even know that they just got fentanyl," she said. If patients are in rehab and going to a pain clinic, they get test- ed. "If it comes back positive for cannabis, they all freak out. The doctors then want to take them off everything. I've seen people go cold turkey in the hospital, you know, no pain killers, and they are crying because they are in so much pain," said Casale. She recalled Sulak's recommendation that a health care pro- vider should at least assess a patient on an individual ba- sis and not apply a sort of blanket predetermined criteria that says if this is a psych patient, they don't need any type of pain medicine. "Or at the very least, allow them to be humanely de- toxed," Casale added. To integrate cannabis, a doctor should make an assessment on a patient's situation, reorder their opiates if they think it is appropriate, and then slowly taper them using a combina- tion of opiates with cannabis. "This would be titrating canna- bis up, then opiates down, until they finally get off the opiates all together," she said. "One thing Dr. Sulak says that I never thought about, is how that helps rewire their thought process where they get out of that substance abuse mentality cycle." CONTINUED ON PAGE 35