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Nurse Linda Casale discusses her mission to get cannabis on the list of treatments to help treat chronic pain.
One nurse sees that better patient care is possible, as she works to get cannabis on the list of treatments to help.
Sometimes, when working in healthcare, an attentive nurse can see things that just aren’t right.
Treatments don’t work, yet doctors persist in repeating them. Pharmaceuticals, especially opioids, are prescribed that do more damage over time than the condition for which they were prescribed.
Changing procedures for the better, changing treatments to better align with what the patient needs, or changing pharmaceuticals that do good things for the patient, don’t happen fast—if at all.
But other times, when a nurse sees things that should be changed, and has the motivation to do it based on what she sees, things can and do change for the patient. After all, that is what healthcare is designed to do—achieve the best outcome for the patient.
Linda Casale, MSN, RN, PMHN-BC, the CEO, president, and founder of Whole Health Action Management (WHAM) veterans program, providing whole health education and cannabis consulting, is one of those perceptive nurses who knew she could find better ways to assist her patients (1). She worked on the mental health unit at her local Veterans Administration (VA) for more than 25 years where she witnessed treatment she thought was “inhumane.”
“A lot of times the veterans were admitted for pancreatitis, gastritis, or something else. These are very painful conditions, and they are taking painkillers,” she said. “When they get medically stable, they transfer down to psych to finish their detox.”
She remembers when she had a patient transfer, and she called the doctor to get some pain meds for him. “The doctor called back and said, ‘Why wasn’t his Percocet just continued when he was transferred since it was an active order?’ And I said I don’t know,” Casale said.
“The doctor ordered the Percocet (2), but one of the ward clerks clued me in and shared that, built into the VA system was the rule that if anyone is transferred to psych from an inpatient medical unit, all their narcotics are discontinued automatically, even if it’s an active order,” Casale said. “They would just discontinue a patient’s pain medications if they transferred to psych from an inpatient unit. There is no taper. They just cut them off. Nobody will give them anything.”
She recalled her conversation with a psychiatrist at the VA who had transferred from Puerto Rico where he was in private practice for years. He was a veteran. “He told me he had fallen from a helicopter in Afghanistan, and that he had healed himself in Walter Reed for six months.” But he works in integrative medicine, she explained, so he believes in cannabis very much, and was going to start his own practice.
“We knew that patients were taking cannabis for their pain. But you can’t say anything or even recommended it or anything, because of its status as a Schedule I drug,” she said. “I just get so frustrated with it all. And doctors, unless they’re really integrative types or a have a holistic mentality, know nothing about cannabis because it’s not taught in med school.”
Casale began her own exploration of integrative medicine using cannabis, looking for answers and trying to find a pathway to better healthcare for her patients.
According to the National Center for Complementary and Integrative Health (NCCIH) (3), the use of integrative approaches has grown within care settings across the US. Researchers are currently exploring the potential benefits of integrative health in a variety of situations, including chronic pain management for military personnel and veterans (as in the case of Casale), relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors.
Chronic pain is a common problem among active-duty military personnel and veterans. NCCIH, the US Department of Veterans Affairs, and other agencies are sponsoring research to see whether integrative approaches can help. For example, an NCCIH-funded study is developing an innovative, collaborative treatment model involving chiropractors, primary care providers, and mental health providers for veterans with spine pain and related mental health conditions.
Integrative health care may include chiropractic therapy, yoga, meditation, and more. Integrative providers could include medical doctors, Doctors of Osteopathy (DO), Physician Assistants (PA), or Nurse Practitioners (NP). Some are board-certified in integrative medicine, meaning they passed rigorous exams. Others are licensed therapists.
Integrative health brings conventional and complementary approaches together in a coordinated way. That approach emphasizes multimodal interventions, which are two or more interventions such as conventional medicine, lifestyle changes, physical rehabilitation, psychotherapy, and complementary health approaches in various combinations, with an emphasis on treating the whole person rather than, for example, one organ system.
Casale discovered that that’s the key for an integrative approach using cannabis—it’s all about trying to find whole person health. Whole person health refers to helping individuals improve and restore their health in multiple interconnected domains—biological, behavioral, social, and environmental—rather than just treating disease.
Research continues on whole person health, including expanding the understanding of the connections between these various aspects of health, and connections between organs and body systems (such as the endocannabinoid system).
One current NCCIH-funded study is testing the effects of adding mindfulness meditation, self-hypnosis, or other complementary approaches to pain management programs for veterans. The goal is to help patients feel and function better and reduce their need for pain medicines that can have serious side effects.
In 2015, Casale completed her Diploma in Nursing Education from the University of Dundee and in 2018 she obtained her Master Science in Nursing Administration at Capella University, based in Minneapolis, Minnesota. Her husband, Stoly, a veteran, had gone through all the alternative interventions at the VA, such as epidurals and chiropractor adjustments. “They told him the only thing left is back surgery,” she said. “He didn’t want back surgery.”
Casale had been hearing about how some of the vets she was working with had used cannabis. “They kept coming in and saying that cannabis is really helping them, especially with anxiety, PTSD, and their pain symptoms. So, I thought, when I graduate, I’m going to find out about this cannabis stuff because I know it really works,” she said. “And I’ve just been diving into it.”
She has taken three certification courses: two were self-instructed and the other was a 6-month course at the Pacific College of Health and Science based in Chicago, on a comprehensive program of medical cannabis and she is learning more about it all the time. “It’s one of those things where the more you know, the more you know you don’t know.”
Casale has also been taking classes with Dr. Dustin Sulak at healer.com (4), who has a whole section on cannabis and opiate withdrawal. Dr. Sulak is an integrative medicine physician based in Maine, whose practice balances the principles of osteopathy, mind-body medicine, and medical cannabis. Regarded as an expert on medical cannabis nationally, Dr. Sulak educates medical providers and patients on its clinical use, while continuing to explore the therapeutic potential of this emerging medicine.
Casale’s given four presentations at Pacific College of Health and Science and is also an adjunct professor at Palm Beach Atlantic University School of Nursing, helping to mentor students during their psychiatric mental health nursing rotation in the clinical environment.
She does the clinical for nursing students psych rotation with psychiatric mental health faculty, while the department chairperson does the didactics (lectures and theory) (5). “The department chairperson told me that during her didactics on substance abuse, I could come in and talk about the opioid epidemic and cannabis,” Casale said. “So, I gave a whole presentation to students there. And the next day as I was doing clinical work, I was told that people paid more attention to my presentation than they had to anything all semester. I was glad to hear that. But I thought to myself: ‘I don’t think it was for me or my presentation. I think it was about the content.’ These students are just hungry to learn about it. And there’s no curriculum or even mention of cannabis in any nursing schools.”
That gave Casale an idea: Let’s get the discussion about cannabis going as soon as possible in teaching new nurses. “I called the NCSBN (the National Council of State Boards of Nursing), the people who administer the National Council Licensure Examination (NCLEX ). 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 going 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 research university in Chicago, and we are proposing adding the education and integration of cannabis into the nursing
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 comprehensive compendium of evidence and guidelines of its kind, produced by a committee as a set of guidelines that create “a strong foundation for safe and knowledgeable nursing care of patients using medical or recreational marijuana.”
Committee chair Rene Cronquist, RN, JD, director for Practice 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 education programs. “My hope is that it continues to trigger conversation, that it minimizes stigma of individuals using cannabis, and ultimately continues to highlight the need for continuing research,” said Cronquist.
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 students ‘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 instance, at the University of Vermont Larner College of Medicine, 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, Complementary 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 other 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 conservative 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 education provided by healthcare providers is in large part due to a major lack of education at all levels of healthcare, according 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. However, 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 recommendations for schools, this gap of education and mixed beliefs within healthcare education needs to be bridged.”
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 tested. “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 provider should at least assess a patient on an individual basis 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 detoxed,” 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 combination of opiates with cannabis. “This would be titrating cannabis 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.”
Casale’s work with veterans and other health care providers continues, as she probes why nursing schools and medical schools still resist any training about cannabis.
Her personal journey, her discoveries along the way about how cannabis works for pain, are all part of what drives her. “I have been to Washington, D.C. to promote cannabis for veterans… but it’s just a tedious, involved process that you just can’t give up on,” she said. “I think we’re heading around the corner because it’s becoming more accepted. People are using it and getting results that they couldn’t get any other way.”
She wants cannabis out of Schedule I through legislation. “I think that will definitely free up the environment and allow researchers to do more research and get funding to find out cannabis’ full potential,” Casale said. “Secondly, it would allow us to see cannabis integrated into nursing and medical curriculums, including studies of the endocannabinoid system, and give health care professionals training about more of a holistic integrative approach to pain management.”
Casale wants other nurses and health care professionals to know that there’s been more research on cannabis than anything else. “The government has a patent on cannabis. We all have just been lied to for the last 40 years. It’s all political and business. That’s just the bottom line.
“Part of the propaganda was calling it marijuana and not cannabis, and that people just wanted to smoke and get high all day. But it’s like any other medication that needs to be respected and monitored,” she said.
“Like I said to nursing students, cannabis is going to revolutionize health care, and they want to learn about it,” said Casale. “And hopefully next fall, the Dean of Nursing will be incorporating s session on cannabis and nursing, and the endocannabinoid system, as a part of a viable alternative and complementary to health.”
David Hodes has written for many cannabis publications, and organized or moderated sessions at national and international cannabis trade shows. He was voted the 2018 Journalist of the Year by Americans for Safe Access, the world’s largest medical cannabis advocacy organization.