Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Before we get started, we have some quick housekeeping. We are currently conducting a survey of our listeners to better understand how you listen to ACNL in Action and what topics you're interested in. Filling out the survey not only helps us out, but it will help us to make sure that the show is better for you. To complete the survey, you can find the link in our show notes. And now back to the podcast. Our guest today is Dr. Tanya Scott Kennedy. Dr. Kennedy is the Clinical Services Director for Kaiser Permanente in Oakland and is also an executive board member and treasurer for the American Cannabis Nurses Association, advocating for the integration of cannabis therapeutics into patient care. This is a fascinating frontier in patient care, and we cannot wait to dive in. Thank you so much for joining us, Dr. Kennedy.

Thank you so much for having me. I'm excited to be here today.

Yes, we're so excited to have you and to learn from you. And just to get started, this might be a really basic question, but what exactly is cannabis nursing and how did it emerge as a specialized field?

Well, you know, cannabis nursing is a specialized field of practice that really focuses on the therapeutic use of cannabis and cannabinoid products to manage a variety of health conditions. The actual definition coined by the American Cannabis Nurse Association speaks to the care and the health of care consumers, seeking education and guidance in the therapeutic use of cannabis. So it has emerged as a response to the growing legalization by states over the years and the recognition by clinicians across the country of cannabis as a medicinal plant and substance. So nurses all across the country started really formalizing or seeking out formalized training to understand the pharmacology, the benefits, the risks, and any of the legal aspects around cannabis in an effort to really guide patients who were showing up in clinics, hospitals, skilled nursing facilities, and of course, dispensaries. So the field gained formal recognition with the involvement of organizations like the American Cannabis Nurses Association, which played really a pivotal role in establishing a formal scope and standards of practice that addressed education and certification for this emerging specialty. So in 2018, the National Council for State Boards of Nursing issued its expectations for those practicing nurses, which were basically six clear guidelines. And those guidelines were one, the nurse should have a working knowledge of the current state of legalization as related to medical and recreational cannabis use. The second, the nurse should have a working knowledge of the jurisdictions, medical marijuana program. So if it's legal, what does your jurisdiction say about its medical cannabis program? It also spoke to the nurse having an understanding of the endocannabinoid system, cannabinoid receptors, cannabinoids, and the interactions between them. They wanted nurses to have an understanding of cannabis pharmacology and the research associated with the medical use of cannabis. And really they wanted to make sure that nurses could identify the safety considerations for patients who were who were choosing to use cannabis. And I think lastly, they wanted to make sure that nurses as the most trusted profession in healthcare approach the patient without judgment regarding the patient's choice of treatment and preferences and managing pain or any other type of distressing symptoms. So really those were the guidelines that were set to move this emerging specialty forward and help nursing leaders in the practice environments where we provide care.

Yes, and those guidelines that you shared really speak to what I think a lot of the questions will come from, right, when it comes to cannabis nursing, when it comes to this specialty. And because it's such an emerging specialty for nursing, can you share how you started your journey in cannabis nursing? I know that it may not be a specialty that many others have been part of or have heard of. So really curious to see how you started your journey there.

So I really wish I could give you a very professionally oriented story, but it's not that. Interestingly enough, all my life I've been around cannabis, whether it was relatives who were consumers, friends, relatives of friends. Um, and as a conservatively born Southern Belle, I never questioned it, but nor did I speak about it. Um, I understood it as being not something that I was supposed to touch or do. So fast forward, I came to California in 2016 and I met my now husband and social media influencer cowboy, uh, and happened to drop by his ranch one day when they were having a trimming party. Well, I had never heard of such an event and only recalled these big trash bags in the floor and a room with bud or cannabis hanging from the ceiling. So for me, I just knew any moment the feds were going to drop in through the roof, and that was all it, you know. But he shared with me that in this state of California, medicinal use included individual plants. There were limits on how many that you could have, and that the cowboys were harvesting their personal crops and they were just doing it all together at one time, which made it easier and took less time. And after about two weeks of having to manage my own biases and beliefs associated with cannabis, I realized that I needed to understand more about why this whole community of cowboys were cannabis consumers. I started asking them questions, you know, look, the whys. And I kept asking why until I had an overstanding, not an understanding, but an overstanding of the drivers for consumption. And none of them for that community hinged on recreation. It was primarily pain, stress, anxiety management. I did notice that with age and time being in the space, that a significant factor between recreation and medicinal use really was only associated with age. Um, that many of those individual cowboys, as they had been in the industry and the longer they'd been in the industry, they may have started recreationally, but they actually became what I would call medicinal users over time as they kept getting bronched up, you know, thrown off the bull or off the wall, right? Whatever the case may be. But that's when I really realized that, you know, by them talking openly about it with me, I as a nurse was understanding it at a whole different level. And it became more fundamentally clear to me that a more nurses need to understand this um uh in the space. And uh it and it was just time, especially in a state that legalized it back in 1996, that um we had more conversation about it. So that kind of in a nutshell started started my journey. I I walked in on a butt trimming party.

Yeah, I, you know, I will admit I have never heard of a trimming party myself. And so I really uh learned a lot from your story and for sharing that because I'm sure that you're not the only nurse who's experienced that. I'm sure that others have maybe walked in and they're like, wow, this is different, and I don't really know much about this world. But I really admire how you took it upon yourself to learn more. And and I, you know, you know, kind of challenged the biases that were coming up in this community and in this event. And it was it's very interesting to hear that many of the uses have been the medicinal use for cannabis. And I think there's still so much to unpack there.

Mm-hmm. There is. It was unusual to I found myself saying to myself as I was dealing with the biases, it's unusual for me to be in a state where it's legal, but I don't hear people in my professional space talking about it.

Right, right. Yeah, that's a very good point because it has been legal here for some time, but it's still not a very widespread conversation that's had in our communities and the in our hospitals and our healthcare systems. It still feels very much like a closed door conversation.

Absolutely. So for me, as I moved forward, and my husband as a consumer doesn't consume alcohol, it's not doesn't drink alcohol. Um, I noticed that a lot of the the younger adults don't consume alcohol. They actually are cannabis users. That in and of itself helped me to realize um one day when he went into the emergency room that even during intake, no one asked him about cannabis. He didn't feel comfortable disclosing it. And that didn't make sense to me. And so again, I realized there was a hole there in terms of how we uh actually interview our patients when they come in. It was more lumped inside of substance use under the auspice of abuse, right? As opposed to it's legal here, it's a source and choice for medic self-medication. And let me know more about how you use it and the why.

Right. It's definitely it definitely speaks to how the conversations around cannabis are still very highly stigmatized in our cultures and when it comes to medicine. And I think that creates a lot of barriers that directly impact patients, right? Just like what you just shared, it impacts patients being able to have these crucial conversations with their clinicians, with their providers about very valid treatments that they're using. So um, and very interesting because it is specifically for medical treatment, not, you know, um, at least in that in this case. Um, so so um very interesting. And when it comes to nurses learning and being part of this journey, um, what kinds of special training or competencies would you say are necessary for um a nurse to have this specialty as cannabis nurse and any certifications that that they might um utilize to be in this specialty?

So nurses interested in becoming cannabis nurses can really pursue various types of special training to gain expertise. The level of education really is rapidly shifting to include not only certificate level preparation, but also master's level within a university setting. So, what a nurse really should be focusing on when seeking out a program are those that offer a core curriculum that covers the basics of cannabis pharmacology. It should cover therapeutic applications and definitely include patient care considerations, right, in the program. They should contain classes or or modules that explain the endocannabinoid system, or we call it the ECS, right, for short. Uh, dosing product types, knowledge of what a certificate of analysis is and what a COA should contain, and really delve into the legal aspects and landscape in general at the at the federal, state, and local levels.

Yes, that sounds great. I think that's really important to share because there is a growing interest. Um, in my organization, I actually know of advanced practice nurses who are in this field too. So definitely for registered nurses, for advanced practice nurses, there are options to receive special training or to have these certain competencies to become in this specialty. So really great to hear about. And I'm I'm curious now, just kind of shifting to medical cannabis in general, can you talk a little bit about, you know, this wide variety of medical cannabis that's available? We hear about it all the time. Like there's CBD, there's THC, there's Indica, there's Sativa, Edibles, et cetera, et cetera. It's kind of like this whole new world. Um, so how do patients and providers really make sense of this whole brand new world?

Wow. Yes. Well, you know, navigating the world of medical cannabis can can feel like stepping into a well-stocked apothecary. There's just a vast array of options, and knowing where to begin can really be daunting. So, can you imagine the senior patient that has never thought of cannabis before as a treatment option for pain, but now has a desire to kind of move away from pharmaceuticals to address, say, their arthritis, to a more plant-based option, and then they walk into a dispensary. Now, right? You know, what healthcare professionals or or nurses should have knowledge of is really the basics. So let's start with with with CBD versus THC. I call I call them the dynamic duo. Okay. CBD or cannabidiol is the non-psychoactive cannabis option. So it is the calming one. It's often used as an anti-inflammatory or an anti-anxiety, and for its pain-relieving properties. Cannabis nurses see patients with chronic pain, epilepsy, or anxiety consuming CBD. And because it's it's without the high effect you get right by consuming THC, right? So let's pop over to THC. THC, also known as uh tetrahydrocannabinol, is undoubtedly the more famous of the pair, right? Right. Uh THC. You know, THC is the compound that provides the euphoric or the psychoactive effect or feeling that people most hear um about. It's it is widely used for pain management as well. Uh, but we do see it utilized in uh oncology patient population for nausea, and we see it for appetite stimulation, right? In in a patient population. So then there's this concept of indica versus sativa, right? So these are terms that the industry is moving more and more away from because we now have hybrids, okay? But because most people know indica versus sativa, of all of the chemovars or strains, you know, the word chemo bar has replaced the concept or word of call of strains, but I'll continue to say it for those who may not know it. Um, but for all intents and purposes for today, the cannabis indica is often known for its sedating and relaxing effects, making it really uh the preferred choice for uh patients or consumers at night for treating insomnia and pain. That makes a lot of sense. Uh-huh. It tends to have a higher CBD content related to THC. And um the cannabis sativa chemovars or strains are more associated with a stimulating effect. Um it's cultivated for hemp fiber, seeds, and oils, and and and as well for its psychoactive properties. It generally has a higher, so cannabis sativa generally has a higher THC concentration relative to CBD. But with that said, today you're seeing, again, still far more commercial strains of cannabis that are hybrids created from both cannabis sativa and cannabis indica. And some of them even have cannabis ruteralis, which I didn't mention, but there's a third genus that sits out there. Um, but you see these hybrids because individuals, uh cultivators are trying to produce plants that have specific desired traits, that have specific things like terpenes, flavonoids, and other profiles. They grow a certain way or they have certain effects. So I mean, there's we could go on all day about that. That's that's what I'm saying. You know, the education of it is so incredibly important for digging down into it and helping nurses and nurse leaders understand all of the um entrical aspects that make up just the plant. That's not even how it connects to cannabinoid receptors that are inside of the body. So we've got phytocannabinoids related to the plant, the receptor plants, and then we've got the endocannabinoid system that's inside of our body with the receptors associated with that. So it's just it's just fascinating once you start digging over into it, I tell you, Charlene.

Yeah, it's really interesting because of just the variety of types, just as you mentioned, the direct, the variety of uses, the variety of modalities in which you could consume cannabis. And it's growing every day. I think the technology for understanding um the medicinal properties of cannabis continue to grow exponentially. Um, I feel like it's it's uh evolving over time, just like with our other medical drugs and technologies, which is very interesting because people only know it as just this like indica, sativa, CBD, THC. And that's probably um the majority of what the majority of what people might be aware of. But there's really much more to it. And that makes me think about, you know, this the specialized care plans of each individual, because um, each individual might have a very specific way that they consume it and ratio of of the different products. And I I'm kind of curious about how all these factors come into play when you create all these different specialized plans for cannabis patients. Like, how does how do you just given how um widespread this all is, how do you actually narrow down and choose and create those plans for each individual?

And you know, you know, that's a great question. Um, and it's and it's and it's asked beautifully like a nurse. So So when I go back and I think about you know the concept of a dispensary and a patient walking in and there's no nurse there, right creating that patient's care plan for them in the dispensary. Right, right. There should be a nurse there having that care. That's a great yes. You see where I'm going with that? So yeah. So um, you know, when we think about that care plan, a special, a specialized care plan actually should include all of the disciplines, first of all. So pharmacy has to have a knowledge of cannabis to be able to speak to certain things, right? Nursing has to have their knowledge, the physicians have to have their knowledge, right? Our advanced practice nurses have to have their knowledge as a part of that provider team. Even our even our um speech therapists and physical therapists need to be a part of that. Because when you think about it, if I if I'm if we're creating care plans that are heavy THC, the patient requires PT. Right, right. So a specialized care plan really includes a comprehensive and individualized approach that really tailors the plan to the patient's unique health needs. Um, so we're gonna look at things like a patient's medical history, we're gonna look at chronic conditions, we're gonna look at medication interactions. Many people do not know or understand that if you are on um uh blood thinners, if you will, uh it will impact your bleeding times. Right. So, you know, what kind of uh interactions exist there? So really digging into that medical history, what type of mental health status exists with that patient, really, really concentrating on any uh uh things in the past or current that may be impacting use. Studies um have shown that there is a level of correlation between individuals who have used other substances like opioids and uh getting off of those opioids by using um choosing to use cannabis as a result. So, you know, but really digging in there and finding out what that what that looks like. Because if you've got, say, an orthopatient who comes in for surgery and they were previously using opioids, what are you gonna give them for pain? Right. More opioids? And from what I understand, that's a pretty painful operation when we start talking about orthopedics, right? So again, you know, we're gonna look at patients' medical history, we're gonna look at a cannabinoid profile, THC to T to CBD ratios. We're gonna determine the balance and what what balance is is the right balance, um, because that balance is central to a patient's care plan. CBD can counteract some of the the effects of THC and provide therapeutic benefit without the high, right? So we're gonna we're gonna talk about the minor cannabinoids like CBN and CBG and terpenes, those, you know, the terpenes I love because they're those aromatic compounds that um that can have therapeutic effects. They also play a role in um uh these minor cannabinoids play a role in tailoring the treatment to the patient's specific symptoms. Um, we're gonna ask inside of a care plan what are the patient's goals and preferences? So how are we aligning with the patient's um symptoms? Whether it's pain that we're trying to provide relief for, are we reducing seizures? Is that the goal? Is there are we dealing with sleep uh uh improvement or are we reducing anxiety? We're gonna talk about quality of life and enhancing daily function if that's an issue. And we're gonna actually talk about personal preferences, ease of use. So uh I had this conversation not too long ago with a um uh with a family member who has been a consumer for many years, and as that individual is aging, they don't want to um uh their route of administration inhalation no longer is key for them. Now it's a big deal if you can smell it.

Right.

I remember when they were younger and it didn't matter at all to them.

Right.

But now, as they've gotten older, you know, for them, their personal preference, social considerations associated, you know, those types of things. Now their route of administration, their their their ask is different. So, but you are gonna talk about you know the route of administration, you're gonna talk about inhalation, smoking versus vaping, you're gonna talk about oral edibles, you're gonna talk about um um how long um how long something lasts versus not lasts, right? Topical applications, you're gonna look at all of those routes to see what is going to be best, right? For this patient. You're not gonna, no one would ever create a care plan for a COPD patient and say, here, smoke this. Right. Yeah, that's where the nurse comes in, right? And the provider team with saying, you know what? Let's look at something a little different for you based on your diagnosis and based on what's happening with you. We need to address this care plan a little differently. So we're gonna look at dosing, we're gonna look at um all those considerations, start low, go slow. That's always the key.

Yeah, start low, go slow. And it really sounds like a holistic approach overall, just like many other medications and many other treatments that we um share with patients. It's it's looking at the individual as a whole. It's look, it's meeting them where they're at, seeing what they could tolerate, seeing what their preferences are, while finding the most effective treatment. Um and uh endless options, it sounds like, um, for for this. And and that's part of the beauty of of this world is just knowing that there are a lot of options. There's still so much to unpack, but then you could still individualize down to the individual.

Exactly. Exactly. And that's how we that's how we are supposed to be caring for our patients, right?

Absolutely. And, you know, I want to to speak a little bit about kind of more of the legal side of cannabis, because you know, currently, as we're recording today, cannabis is classified as a Schedule I substance at the federal level and is only legal for medical use in 38 states. Um, but what challenges do you, you know, face when it's when it comes to navigating state and federal regulations? You know, what what's the likelihood that the medical use for cannabis can be expanded to all 50 states?

Well, you know, I think the likelihood of it is extremely strong. Um the uh federal government uh just uh closed its um um just closed the time associated with public comment associated with moving cannabis from schedule one potentially to schedule three, and giving the opportunity for uh uh commenting on what that may look like, feel like, and is it a positive thing? And so many, many, many individuals uh commented, and from what I am understanding, probably oh greatly over 70% of those comments, it seemed, were positive associated with the rescheduling. Now, I think for many individuals in this space, the scheduling is what is the ideal. But at least if rescheduling can occur, it does allow for greater levels of opportunity for research with human subject uh inside of this country and being able to understand it, uh, the cannabis plant at a much more fundamental level and its impact on patient care. And so for us, you know, the nursing voice is it can be very loud, it can be very clear. And when you have such a significant um uh challenge between federal and state law, so the state law says, hey, go for it, you know, have a not take this opportunity to, as an individual living in this state, to explore this as an option for your personalized care. And you have those in the state who are licensed by the state, right, to provide that care and advise on that care, but then you have a whole federal government that says, uh, nope, it's there is no medicinal uh uh piece to this, and therefore it's scheduled one. And we're saying, as the trusted individuals within the profession, there is a medicinal quality to it. So we need the federal government to recognize and understand that it's the clinicians now who are standing up and saying, yes, there is a medicinal piece to this. We knew there was a medicinal piece to it before it was created as a Schedule One. But now, fast forward, we are seeing a lot of anecdotal evidence. We have consumers all over the country in 38 states. I think at this point, we probably would have had something to do, right, that would have kept all 38 of these states from moving forward, right? So overwhelmingly, I think the anecdotal evidence is there. At least scheduled rescheduling will give us the opportunity to really talk about it more freely, more openly, without bias.

Right. And that's such a great point that you made about the medical community and using our voice to really advocate for, you know, um use of cannabis as a medicinal property, as a medicinal drug treatment. And that's really how we could help to influence um the expansion of this in um all 50 states. Yeah. And I feel that we could talk about this for so much longer, um, but we do have to wrap up our conversation for today. But I do want to leave the last word to you and just see if there's any final comments or any final um words that you'd like to share with our audience or nurses who are listening to this and anything that they should know about um this topic in particular.

Absolutely. You know, um I think that it is time for nursing leaders, nursing executives to create space for this conversation. It's time for nursing leaders to really mobilize together and create the psychological safety that's required for nurses at the bedside who are the experts at taking care of our patients, creating psychological space for them to start talking about it, for them to start talking about it with their patients comfortably, but even more importantly, for us to create cultures and environments inside of the organizations that we are responsible for creating safety in and quality, creating a space for the patients to come through our doors, whether it's through the emergency room, whether it's through the operating room, whatever it is, our clinics and their patients, their family members, and everyone else involved in that care team, comfortably have a conversation about the patient's choices for self-medication and not leave the family and the patient feeling as though they're criminals. And so if I could shift anything, it would be to begin those conversations because let's just say rescheduling does happen. Not what? Do your policies match? Do your policies allow for? So are we truly ready? Well, to get ready for rescheduling, we should at least start having these conversations.

Yes, absolutely. So much of our progress starts with conversations, and this is a very important one to have in so many of our different systems, you know, clinics, hospitals, um, leadership conversations, and across some and across frontline staff as well. So um thank you so much, Dr. Kennedy, for your expertise. And we definitely need to have you back for part two so we could talk a lot more about um some more of the regulatory, legislative types of uh, you know, types of topics for for cannabis um nursing. But thank you so much for being part of our podcast today.

Thank you so much for having me. I do appreciate you.

And our guest today was Dr. Tanya Scott Kennedy, Clinical Services Director for Kaiser Permanente in Oakland and treasurer for the American Cannabis Nurses Association. We would love to hear your feedback. Email us at socialmedia atacnl.org and connect with us on LinkedIn and Facebook at ACNLNurse. And as always, if you like the show, please remember to rate, review, and share. ACNL in Action is presented by the Association of California Nurse Leaders with new episodes on the first Friday of every month. To learn more about the show or ACNL in general, visit us at acnl.org. Thank you for listening.