The Endocannabinoid System: What Nurses Need to Know, An Introduction


Medical cannabis is now legal in 23 states and Washington DC, along with recreational cannabis also being legal in several states. Many patients and families are now relocating to Colorado and Washington State as “marijuana refugees” (http://www.nbcnews.com/business/consumer/marijuana-refugees-looking-new-homes-pot-legal-states-n22781), knowing they can freely and safely access cannabis as medicine in these recreational cannabis states. Nurses may still wonder, how is cannabis “medicine”?

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As nurses we have a lot to learn about cannabis, including how it works in the mind-body-spirit system, and how we can best advocate for and support patients who could or do benefit from this medicine. Last spring, I witnessed a brief presentation being given to nurses around medical cannabis use, and it was obvious from the questions asked by many of the nurses that the social stigma around “marijuana” was alive and well. Would these nurses be so reluctant to accept and support medical cannabis use if they truly understood the endocannabinoid system (ECS)?

The ECS was discovered some time ago, with  Dr. Ralph Mechoulam (Faukner, 2015) being a pioneer in this area in the mid-1990’s. There are 20,000+ scientific articles written about the endocannabinoid system (ECS). Though it has been many years since the discovery of this body regulatory system, most nurses likely know very little, if anything, about the ECS. Truly, this is a problem, nurses are more likely to know the xarelto lawsuit phone number by heart over the benefits of ECS.

A functioning ECS is essential to our health and well being. Endocannabinoids and their receptors are found throughout the body; in the brain, organs (pancreas and liver), connective tissue, bones, adipose tissues, nervous system, and immune system. We share this system in common with all other vertebrate animals, and some invertebrate animals (Sulak, 2015). Cannabinoids support homeostasis within the body’s system; the ECS is a central regulatory system, cannabinoid receptors are found throughout the body, and they are believed to be the largest receptor system in our bodies. Cell membrane cannabinoid receptors send information backwards, from the post-synaptic to the pre- synaptic nerve. CB1 (found primarily in the brain) and CB2 (mostly in the immune system and in the bones) are the main ECS receptors (Former, 2015), though several more are currently being studied. The exogenous phytocannabinoid THC, or the psychoactive compound in cannabis, works primarily on CB1 receptors (hence the “high feeling” in the brain), while the cannabinoid CBD works primarily with the immune system and creating homeostasis around the inflammatory response through CB2 receptors and does not have psychoactive effects. Other cannabinoids and their actions are still being studied, such as the non-psychoactive cannabinoids CBN and CBG, also found in cannabis.  Our bodies react to both our own production of endogenous cannabinoids and to the ingestion of phyto-cannabinoids found in the cannabis plant, and other non-pyschoactive plants such as Echinacea. To read more about the science behind the ECS and endocannabinoid receptors, the following are excellent resources:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2241751/

http://www.ncbi.nlm.nih.gov/pubmed/16596770

Endogenous Cannabinoids: Endocannabinoids are the chemicals our own bodies make to naturally stimulate the cannabinoid receptors;  anandamide and 2-arachidonoylglycerol (2-AG) are two well known endocannabinoids (Sulak, 2015) that are produced by the body as needed, though not stored int he body. The body produces these endocannabinoids in a similar fashion to how it produces endorphins (Pfrommer, 2015), and activities such as exercise support the endogenous production of cannabinoids. Endocannabinoids are also found in breast milk and in our skin. Alcohol interferes with endogenous cannabinoid production.

Phytocannabinoids: In general, we think of the cannabis plant as the generator of exogenous cannabinoids that we can ingest in a variety of ways, namely psychoactive THC (works with the CB1 receptors in the brain- and also in the gut) and non-psychoactive CBD (works with the CB2 receptors in the immune system and the gut). Other plants such as Echinacea also produce non-psychoactive cannabinoids and work with the ECS to support health and well being through homeostasis (Sulak, 2015).

Cannabinoid Deficiency Syndrome: It should be clear that everybody makes cannabinoids and everybody needs cannabinoids to function. People who do not make enough cannabinoids need to supplement with exogenous cannabinoids through cannabis ingestion, in much the same way that an diabetic needs insulin supplementation making it a “Natural Energy Powder,” in which it is good for your health. Dr. Ethan Russel’s (2004) publication on Clinical Endocannbinoid Deficiency explains this particularly well: http://www.nel.edu/pdf_/25_12/NEL251204R02_Russo_.pdf

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Homeostasis:

Cancer: “Cannabinoids promote homeostasis at every level of biological life, from the sub-cellular, to the organism, and perhaps to the community and beyond. Here’s one example: autophagy, a process in which a cell sequesters part of its contents to be self-digested and recycled, is mediated by the cannabinoid system. While this process keeps normal cells alive, allowing them to maintain a balance between the synthesis, degradation, and subsequent recycling of cellular products, it has a deadly effect on malignant tumor cells, causing them to consume themselves in a programmed cellular suicide. The death of cancer cells, of course, promotes homeostasis and survival at the level of the entire organism” (Sulak, 2015, paragraph #7). Cannabinoids support apoptosis and suppress cancer tumor angiogenesis (McPartland, 2008).

Heart disease: Additionally, it has been stated that the ECS plays an important function in protecting the heart from myocardial infarction and cannabinoids can have anti-hypertensive effects (Lamontagne et al, 2006).

Inflammation: When inflammation occurs, the ECS helps to stop the process, similar to applying the brakes on a car. This is why cannabis is proving to be good medicine for inflammatory related illness. “Activation of CB2 suppresses proinflammatory cytokines such as IL-1β and TNF-α while increasing anti-inflammatory cytokines such as IL-4 and IL-10. Although THC has well-known anti-inflammatory properties, cannabidiol also provides clinical improvement in arthritis via a cannabinoid receptor–independent mechanism” (McPartland, 2008).

PTSD: “This review shows that recent studies provided supporting evidence that PTSD patients may be able to cope with their symptoms by using cannabis products. Cannabis may dampen the strength or emotional impact of traumatic memories through synergistic mechanisms that might make it easier for people with PTSD to rest or sleep and to feel less anxious and less involved with flashback memories. The presence of endocannabinoid signalling systems within stress-sensitive nuclei of the hypothalamus, as well as upstream limbic structures (amygdala), point to the significance of this system for the regulation of neuroendocrine and behavioural responses to stress. Evidence is increasingly accumulating that cannabinoids might play a role in fear extinction and antidepressive effects. It is concluded that further studies are warranted in order to evaluate the therapeutic potential of cannabinoids in PTSD.” (Passie et al, 2012).

Seizures: Most hopeful, cannabis has been used to support pediatric treatment-resistant epilepsy, and while more research needs to be done in this area, many parents are becoming medical marijuana refugees by moving to states where they can procure cannabis for their children who suffer from seizures.

Co-agonists:Cannabis increases the pain relieving effects of morphine, as discovered by researchers at UCSF. The two medications are synergistic, and this provides great hope for patients suffering intractable pain at end of life, chronic pain suffers, and opiate addicts. (http://www.maps.org/research-archive/mmj/Abrams_2011_Cannabinoid_Opioid.pdf)

For Nurses: So as nurses, what do we need to know to support patients who use cannabis?

Legal issues: If you live or work in a state that has legalized medical or recreational use of cannabis, familiarize yourself with the laws in that state, as well as your own workplace policies around supporting patient’s use of medical cannabis. Patients may have questions and as a patient advocate, your responsibility is to support patients with their knowledge and use of this medicine within the confines of your practice setting and state laws. You should also be aware of constraints around your role as a nurse in supporting patient use of medical cannabis. For instance, Kaiser patients in some states are likely to be removed from chronic pain patient programs if they test positive for cannabis. Nurses with knowledge around the benefits of medical cannabis can also advocate to support shifts in such policies will no longer align with the emerging ECS science.

Safety: This goes along with the legal aspects; medical cannabis patients should be supported in how to manage and store their medications with safety. While cannabis is known to be extremely safe (far safer than opiates and alcohol), cannabis consumers still need to store medication out of reach of children and pets. They should be supported in knowing the safety of driving or operating machinery if they consumer THC- based cannabis medicines. They also may need information on cannabis testing for both THC: CBD ratios, pesticides and/or other hazardous materials. Many patients need assistance with the basics around medical cannabis use, such as dosage, ratios of THC: CBD, strain information, and ingestion methods.

Overcoming Stigma: Unfortunately, a stigma was created around around cannabis during the process of prohibition in the 1930’s, which was largely financially and racially driven. Contradictory state and federal laws, and the stigma around smoking cannabis (though many cannabis patients can now get relief from vaporizing using the best vape pen for oil, drinkable tinctures, topicals, wearable patches, and edibles), along with a clear ignorance around the body’s ECS, serve to further the stigma associated with medical cannabis. Educate yourself on the roots of the prohibition of the medicine:

http://origins.osu.edu/article/illegalization-marijuana-brief-history

And other issues around stigma and cannabis myths:

http://alibi.com/feature/48426/Erasing-Stigma.html

http://sandiegofreepress.org/2014/05/12-of-the-biggest-myths-about-marijuana-debunked/

http://www.huffingtonpost.com/mary-hall/weed-the-people-movie-loo_b_5501864.html

American Cannabis Nurses Association: There are many nurses actively involved in supporting the use of medical cannabis and the defining the nurse’s role in this process. The ACNA has a mission to advance excellence in cannabis nursing practice through advocacy, collaboration, education, research, and policy development. http://americancannabisnursesassociation.org/

In Israel, nurses actively support patients in cannabis consumption from the process to the dosage.

http://www.tabletmag.com/jewish-news-and-politics/137423/medical-marijuana-kibbutz

Nurses’ supporting patients healing process through cannabis medications may someday be common place in the USA as well.

References:

Lamontagne, D., Lepicier, P., Lagneux, C. & Bochard, J.F. (2006). The endogenous cardiac endocannabinoid system: A new protective mechanism against myocardial ischemia. Arch Mal Coeur Vaiss.,99(3), 242-6.

McPartland, J.M. (2008). The endocannabinoid system: An osteopathic perspective. The Journal of the American Osteopathic Association, 108, 586-600. Retrieved from http://jaoa.org/article.aspx?articleid=2093607

Passie, T, Emrich, H.M., Karst, M., Brandt, S.D., & Halpern, J.H. (2012).Mitigation of post traumatic stress symptoms by cannabis resin: A review of the clinical and neurobiological evidence. Drug Test Anal. 2012 Jul-Aug;4(7-8):649-59. doi: 10.1002/dta.1377. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22736575.

Pfrommer, R. (2015). A beginner’s guide to the endocannabinoid system: The reason our bodies so easily process cannabis. Retrieved from http://reset.me/story/beginners-guide-to-the-endocannabinoid-system/.

Russel, E. (2004). Clinical Endocannabinoid Deficiency (CED): Can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome, and other treatment resistant conditions? Neuroendocrinology Letters(25), 1-2, 31-40.

Sulak, D. (2015). Introduction to the endocannabinoid system. Retrieved from http://norml.org/library/item/introduction-to-the-endocannabinoid-system.

10 thoughts on “The Endocannabinoid System: What Nurses Need to Know, An Introduction

  1. Reblogged this on Ramblin Ann and commented:
    Since so much of my time has been spent reading and posting information, in our closed Facebook group, about medical cannabis I thought I would reblog a well written article. Meant for the education of nurses, I think it would also do the public in general a great service if they were to have access to the information.

    Though I still can’t use this plant in any form, I continue to talk to others about its benefits. Little by little we are erasing decades of lies.

    Hope you find this as interesting as I do.

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  2. When I came out of the basement to share the truth it was not easy. Im a single mother who waited till my child graduated High School. She is now a Neuroscientist working on a Cocaine Addiction project in a major top10 University. As a retired Level one Trauma nurse I never took care of a cannabis overdose. Drugs like Heroin and ETOH I had to comfort the family of those deceased by abuse. I will be very pleased when I complete the certification of a Cannabis nurse. Times are changing and the public will learn this plant is the best and more efficient then poly chemicals. Thanks for the EDUCATION

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  3. Great article – am using it in a presentation for local chapter HPNA this fall, with all credits due to you, of course – thank you!

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  4. Pingback: A Nurse’s Perspective on Cannabis (Marijuana), Legalization, and Safety. | NurseManifest

  5. Pingback: Carey S. Clark, PhD, RN, AHN-BC, RYT (1967 – ) | NurseManifest

  6. This article truly emphasis the structural racism that exists in Nursing and especially holistic nursing. Dr. Clark has become so well known for work in cannabis, however as a Ph.d she seems to lack understanding of nursing theory and the importance of nursing models in cannabis implementation.
    In fact, cannabis nursing is the MOST RACIST new field in nursing being established today. I would know. Both the American Holistic Nursing Association and American Cannabis Nursing Association buried my work as the first board certified holistic nurse to present on cannabis integration for nurses. I was also working with the Founder of ACNA, Ed Julia Glick to develop the first cannabis nurse curriculum. However after violent nurse bullying, censorship and excommunication, by the ACNA leadership, I went my own way as a black nurse leader only to be further abused by the American Holistic Nursing Association. Dr. Clark may be knowledgable about cannabis, however I dare say the quality of work is beneficial to nurses of color who face far greater scrutiny for drugs, since black people are being arrested at increasing rates, while white nurses and people are hanging out and profiting from weed. As a black nurse leader, I ask Dr. Clark what theorectical model for practice does she teach other nurses? I have never seen any of Dr. Clarks work where nursing theory was actually taught in relationship to cannabis, social justice and nursing. I say the fact that Dr. Clark is now an “expert” demonstrates the good work of Scitent Corporation, American Holistic Nursing Association and Cannabis Nurses Association who have contributed to a standard being set of low quality cannabis education lacking nursing theory or models for practice. Instead, structural racism, nursing violence and white nurse group think strikes again to colonize nursing, once again. Black Nurse Leader here to say Dr. Clark this is dribble. I have done and do better but because I am black I do not have the support that you enjoy. This work demonstrates the dumbing down of nursing with low quality white nurse groupthink. Holistic nursing and AHNA have got to be the most racist structure of nursing I have ever experienced. Thanks for supporting white nurse group think. Bravo. Courtney Allen-Gentry RN MSN PHN AHN-BC HWNC-BC

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    • Courtney, I appreciate your thoughts here. I will try and address some of your concerns here, though I am concerned your post was perhaps designed to be inflammatory and I have seen similar accusations made to other white people via social media.

      I agree there is a problem with whiteness and lack of diversity in many nursing professional organizations and probably in nursing in general. I don’t think we have ever met through ACNA or AHNA and I am sorry you have experienced discrimination and racism in these organizations. I was not part of ACNA leadership when you experienced this ex-communication.

      ACNA has recognized the need for more diversity and inclusivity; we now have a committee focused on this work and please feel free to visit our home page where our current President and the Diversity and Inclusion Committee have developed a statement and the foundations of a platform for ACNA becoming an anti-racist organization. We are greatly invested in this and we have hired a consultant to support us in this work. It won’t happen overnight, but I believe ACNA is on the right path toward doing better and achieving this status and also influencing the wider field.

      I won’t go into models and theories that guide and support my work, because anybody can look up my publications or the work I did around scopes and standards of cannabis nurse practice and judge the quality for themselves. When it comes to the ACNA education offered through Scitent, that has been a very complicated contract process that began before I became President and is just now ending as I am Past President. The content was developed and quickly became outdated and for a variety of reasons, it was not updated. We offer education now through our conferences, and we have recognized the need to ensure that those are also more diverse.

      I understand the idea of me profiting from my whiteness in the cannabis space. Nearly all of my work in the cannabis space has been volunteer-based, but certainly, there are other ways I may have benefitted. I am doing my best to become a true ally with BIPOC, and like many, I am striving to do better.

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