Evaluating the Evidence: Cannabis and Psychosis, Part II


As promised, I am back with more of the analysis. Before I jump into the findings, I do want to let you know I have been ruminating a bit about the issue of cannabis testing. 

To attempt to state my thoughts succinctly here, until we start testing the cannabis that patients in these types of studies are using, we won’t be doing good science. Granted, we know that THC is responsible for many of the side and and adverse effects of cannabis, but to state that the issue with the cannabis is that it has become so high in THC% is far too reductionistic. There is no specific proof that this one cannabinoid alone is the issue when it comes to the relationship between cannabis and new onset of psychosis. The researchers did state that they opted not to test patients’ cannabis because it provides only a snapshot of a moment of cannabis use in the person’s history.

However, relying on reports of what cannabis is available in the area, because it still in my mind, when I think of the wide variety of cannabis strains available, leaves too much of a gap in getting a handle on what patients are actually consuming. Cannabis is a complex plant with over 500 chemicals, but a few simple tests could provide a wealth of information when it comes to determining if high potency THC cannabis truly does play a role in onset of psychosis, or if something else is going on here.

If a similar study were run again, I would suggest testing the actual cannabis that these psychosis patients had used. Those tests should minimally include the cannabinoid and terpene profiles, in addition to testing for heavy metals and pesticides. While this would have some associated costs, it may at least let the researchers know if the profile of the last cannabis used, which could be very enlightening.

Another consideration with testing cannabis: there is a long history of concern when it comes to the role of heavy metal ingestion and the onset of psychiatric symptoms (Attademo , Bernardini , Garinella , & Compton 2017; .Orisakwe, 2014 ). Cannabis plants can easily become contaminated with heavy metals when grown in soils containing heavy metals. Pesticides can also contaminate cannabis, and the consideration of pesticides as both endocrine disruptors and a possible contributing factor to schizophrenia/.psychosis has also been researched over the years (Maqbool F1, Mostafalou S2, Bahadar H3, Abdollahi M4,, , 2016). What if what we really need to regulate or worry about is not the cannabis plant and THC potency so much as what contaminants are in the plant? In my thought process, this really becomes an ethical question of what we are researching, and what might actually bring harm to patients and vulnerable populations. One of the issues around the end of cannabis prohibition and the beginning of regulation of cannabis should be that people have access to a an herbal medicine that is tested and safe, so people know what they are consuming. Beneficence and autonomy come to mind.

This would encourage cleaner product to be produced and help support people with their own healing quests and/or help them to be a more informed consumer. While I don’t particularly care to draw analogies to alcohol (which comes with its own costly public health concerns namely that alcohol is potentially deadly and cannabis is not), imagine buying alcohol without knowing how strong it is, what is really in it, and so forth. Remember the days of prohibition of alcohol and all of the issues with people making “moonshine”?

And now I will continue to look at the findings. 

Participants: Theres seems to be a good split between male/female, with the median age of 36 for control and 31 for case. The median age coupled with the wide range of ages (18-64) included in the study was just a bit concerning, because we know that first time psychosis tends to happen in the early-mid 20’s. The vast majority of all participants were white with at least some college or vocational training and full time employment. It was also clear between case and control, there was much more use of cigarettes, cannabis, and other “drugs” (stimulants, hallucinogens, ketamine, etc) by the case group. Alcohol was not included the summary data table, but in the body of text it states there no difference in alcohol consumption amongst the case vs control groups. And this points to another issue, that it’s really hard to control these types of studies, because most people who are using “drugs” tend to use many different types of substances and it is hard to determine which is having the impact, particularly as we know their can be short term and long term implications. I began to question the issue of poly substance abuse perhaps being a greater issue here then just looking at the % of THC in cannabis, and that lead me to this research….

The International Early Psychosis Association published research by Neilsen et al (2016) that found that alcohol, cannabis, and other drugs increase risk for developing schizophrenia later in life. This was a large retrospective study with the Danish population. The full paper can be accessed here: https://pdfs.semanticscholar.org/1d58/2eaad2f2f9b61f5952f2ecf696bb81a55c7e.pdf Actually, as I ruminate and dig deeper into the Neilsen et al study, I discover it’s having the diagnosis of substance abuse that is correlated with the risk for being diagnosed with schizophrenia 6 fold.  Indeed both cannabis and alcohol greatly increased the risk for diagnosis, but Neilsen et al are careful to state that they cannot say alcohol and substance abuse caused the schizophrenia.

Let’s keep in mind with the study being analyzed DiForti et al (hopefully you aren’t getting lost as I move between the primary study and supporting studies I have included!) also found in their population that most people who have a substance abuse disorder do not use one substance alone. In fact the case participants in most of the drug categories used nearly twice as much as the control groups. So is poly substance abuse a factor here? 

And that brings me to my next thought: Self-medicating. I don’t see this addressed at all in this article, but were the participants asked about why they used cannabis? Seeing as most people with  psychosis have at least 1 year of symptoms prior to being diagnosed with the new onset psychosis, during that time they may be self-medicating or abusing many different substances. My mind starts to question: What if cannabis is actually helping them manage their symptoms, and they would actually would be worse off without it?

And then I come along this little article, that although it’s not in a peer reviewed journal, it clearly explains a possible link between THC, reduction in glutamate, lowered NMDA, weakened CB1 receptors, dopamine receptor D2 being elevated….all this comes together to create hypersensitivity in the limbic system, which may create an environment where schizophrenia could occur.  I didn’t see any of this info in the article be analyzed, f I missed it, somebody let me know! There is conflicting research on whether CBD might help with schizophrenia as it changes/modulates CB1 receptors, but we can ‘t forget that CBD % is an important consideration when looking at cannabis plant profiles. https://www.leafly.com/news/health/link-between-cannabis-and-schizophrenia

The leafy article also linked me out to another article looking at causation between cannabis use and psychosis. The authors Louise Arseneault (a1), Mary Cannon (a2), John Witton (a3) and Robin M. Murray

in their meta analysis of five other research articles found that while youthful cannabis use may create a two fold  a risk factor for psychosis, and may be responsible for up to 8% of the worlds schizophrenia diagnoses, it also is just one part of a “complex constellation of factors”, and of course vulnerable youth should avoid use of cannabis. 

What if people with mental health issues find some relief, for some period of time, from cannabis, that they don’t find from other medications or activities? Why are there so few qualitative studies around cannabis use and self-medication? And why do we have such a stigma associated with self-medication, in much the same we have a stigma around being diagnosed with a mental health issue? The questions go on and on in my mind. 

Overall Findings: Okay, let’s get down to the meat of the findings here. The statistical analysis seem logical and well run (I am not a statistician, in fact I found a statistician to work with as I am doing my own quantitive study on an unrelated topic at this time.).  

Simply stated, the findings correlate starting use of cannabis before age 15, using high potency cannabis (>10% THC), and  daily use as seeming to have the greatest correlation to psychosis (keep in mind causation is not proven here, and almost all of the case participants had also indulged in other substance use at much higher rates than the control group, the issue of possible contamination of ingested cannabis, the lack of knowledge around the full cannabinoid and terpene profile of the cannabis used, and so on). 

Conclusions: For me personally, this study did little to change my mind about cannabis and its safety profile, nor change my overall thoughts on safe use of cannabis, including the idea that cannabis should likely not be used recreationally by young people in their teens and early 20’s.

For most people using cannabis medicinally,  a high potency THC cannabis is likely not needed, but having safe tested cannabis helps people to make informed decisions about the quality of cannabis they are ingesting and the amount of THC they are consuming. High potency THC cannabis or escalating doses of THC may indeed be risky for some people, most likely young people, those with a predisposition to addiction or history of familial psychosis episodes, those with childhood trauma, those with familial history of substance abuse, and those who currently are poly- substance users. 

  • Avoid using cannabis (and really all “drugs” and alcohol) until one is in the mid-20’s and the brain is well developed. This does not account for the idea that teens will use substances, so I would say avoid poly-substance use, and cannabis is still generally safer than alcohol (psychosis risks aside). Alcohol is far more readily available for teens to access, also it too is a significant risk factor for psychosis (and of course immediate death if one becomes extremely intoxicated….you can’t die from cannabis ingestion).
  • Use tested cannabis that is free from heavy metals, pesticides, fungus, and mold.
  • Know the potency of the cannabis medicine you are using. Avoid long term use of “high potency THC cannabis”, or better yet know your THC consumption in mg and limit it to 15 mg max/ day (divided into TID doses), balanced with CBD (up to 20 mg/ day) and terpenes from whole plant medicine (MacCallum & Russo, 2018). 
  • Take regular cannabis breaks (for the recreational user,  avoid daily use and avoid regular use of high potency THC strains; for the medicinal user, consider working with your healthcare provider to determine what a break schedule might look for you, and use lower THC strains if they are still effective at managing symptoms). The website www.healer.com has great info about dosing. 
  • Medicinal users of cannabis: start low, go slow with the THC dosing. One does not need to be “high” in order to feel relief of symptoms, and with cannabis being a biphasic medication, sometimes less is more. For specific dosing guidance, see MacCallum & Russo (2018). 
  • For researchers: as prohibition ends and we move toward an era of regulation, let’s find ways to create the best body of evidence available when it comes to the benefits and risks associated with this herbal medication. Let’s base our public policy and educational efforts in sound science. Let’s not jump from correlation to causation, which means we will have to approach the study of this plant with a complexity lens. 

 

References:

 Arseneault, L.  (a1), Cannon, M.,  (a2), Witton, J.  (a3) & Murray, R.M. (a4 .

(2004). Causal association between cannabis and psychosis: Examination of the evidence. The British Journal of Psychiatry, 184(2), 110-117. https://doi.org/10.1192/bjp.184.2.110

Attademo L1, Bernardini F2, Garinella R3, & Compton MT4.(2017). Environmental pollution and risk of psychotic disorders. Schizophrenia Research, 18, 55-59.

MacCallum, C.A.. & Russo, E.B. (2018). Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 49 , 12–19.

(Maqbool F1, Mostafalou S2, Bahadar H3, Abdollahi M4,, ,(2016). Review of endocrine disorders associated with environmental toxicants and possible involved mechanisms. Life Sciences, 145, 265-273. 

Nielsen, S.M., Toftdahl, N.G., Nordentoft, M., & Hjorthoj, C. (2016). Association between alcohol, cannabis, and other illicit substance abuse and the risk of developing schizophrenia: A nationwide population based register study. Retrieved from https://pdfs.semanticscholar.org/1d58/2eaad2f2f9b61f5952f2ecf696bb81a55c7e.pdf

Orisakwe O. E. (2014). The role of lead and cadmium in psychiatry. North American journal of medical sciences, 6(8), 370-6.

Evaluating the Evidence: Cannabis and Psychosis, Part I


Over the last few days on facebook and across social media platforms, there has been the evocation of fear based in the findings from a new study around the evidence that high potency cannabis used daily may cause increase the risk for psychosis. While alarming at first glance, as someone who understands the endocannabinoid system and the benefits of cannabis, and as an advocate for patients’s rights to access this herbal medicine, I feel obligated to take a closer look at the evidence as presented in The Lancet. So feel free to join me on this journey of evaluating the evidence (or perhaps for those of you with advanced research analysis skills, take a look at the article yourself and see, regardless of your stance on cannabis, what the researchers did well and where they might be flawed). As President of the American Cannabis Nurses Association, my bias toward being pro-cannabis is clear, but I am also pro-patient and pro-safe use of cannabis, so I will do my best to provide an honest analysis. My approach here is the same that I would use in my work with my RN-BSN students, going through each area of the research, and using an approach to express my concerns that all levels of educated healthcare professionals can understand. 

The full text article can be found here: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30048-3/fulltext

(Be sure to download the appendix as well, if you are following along!). 

My thoughts are in blue font.  

Title: The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): A multi center case-control study. (long title, but fairly clearly depicts what the study is about). The article is open access, which I like. 

Journal: Lancet Psychiatry (reputable!)

Authors:Lots of good credentials here; a mix of MDs and PhDs. There are over 30 authors, which I find interesting. Sometimes this is a good thing, sometimes it doesn’t mean much. In the field of nursing, 30 authors would be quite large; in the world of physics hundreds to even thousands of authors can get credit…but are they really authors? Here is a link that looks at this issue (if you care or if your dare!), but this seems reasonable in this case: https://physicstoday.scitation.org/doi/10.1063/PT.3.1499

Funding: This was funded by the Medical Research Council, the European Community’s Seventh Framework Grant, Sao Paulo Research Foundation, the National Institute for Health Research Biomedical Research Center, Maudsley NHS Foundation Trust (South London and University College London), Kings College London, and Wellcome Trust.

At least five of the authors report funding from pharmaceutical companies, though stating that they were funded for other studies, not this study. Check out the full list at the end of the article. Getting funded is part of people’s jobs within research. Its just one of those little tidbits, to keep in mind, that certain loyalties and biases may be playing a part in the research here. “Big pharma” can be viewed as having vested interests in people using cannabinoids (which they may eventually be producing medicines for us all to use someday) or people sticking with their traditional allopathic medicines (I won’t get into the poly pharmacy issue and all of those implications) or even creating pharmaceuticals that help people managing psychosis. 

Problem: In the beginning of the article, the authors state that with legalization movements, we may have “an increase in cannabis use and associated harm, even if the later only affects a minority of patients” (p. 1) and they go on to state that several studies “support a causal link between cannabis use and psychotic disorder”(p.1). Ideally I would have time to thoroughly analyze each of the 5 cited studies in the first paragraph, but seeing as nobody is paying me to do this work, I instead decided I would check out at least one of the articles cited. I went to the fifth article cited because of the researchers’ claim  that the research may “support a causal link” (which was very concerning to me, because I keep running around saying “correlation is not causation…!” and people don’t seem to get that). 

And it turns out that key word “support” is very important: when I reviewed the cited  study by Gage, Hickman, and Zammit (2016) entitled “Association Between Cannabis and Psychosis: Epidemiological Evidence”, their conclusions lead me to believe that they did not determine causation. Gage at al basically looked at the evidence from longitudinal studies, and in their findings, they distinctly refrain from making a “causal” statement: “Overall, evidence from epidemiological studies provides strong enough evidence to warrant a public health message that cannabis use can increase the risk of psychotic disorders. However, further studies are required to determine the magnitude of this effect, to determine the effect of different strains of cannabis on risk, and to identify high-risk groups particularly susceptible to the effects of cannabis on psychosis”. When people read articles like this one we are analyzing here, it’s just too easy to assume that somehow causation has already been proved, when it clearly has not. 

The authors in the introduction go on to state that there is a rising incidence of schizophrenia in the world. “Differences in the distribution of risk factors for psychosis, such as cannabis use, among the populations studied might contribute to these variations” (p. 1). Hmm, well,  this might be related to cannabis use, but when I checked out the articles cited, they had more to do with income, urbanicity, migrant status, age, race/ ethnicity, and whether or not the person owned their home. I think we just have to be careful as readers and consumers of evidence to pay very close attention to the subtle nuances. What the researchers are saying is that they think cannabis should be examined in light if rising schizophrenia diagnoses (though some of the literature I read as part of this process stated that schizophrenia is not rising, rather its falling as we do a better job of differentiating and diagnosing). More on this later…

In a  pink box on page 2, the authors summarize some of the previous work done in this area I found their review of the literature (I think that is part of the purpose of this box?), a bit compelling, though they only found 3 articles that matched their criteria for psychotic disorders in combination with specific terms like “high potency cannabis””skunk-super skunk” or “high THC cannabis”. Two of the articles were their own work, and the third article was much older, going back to 1965-1999 London where increasing rates of schizophrenia “might be related” to cannabis use in the previous year.

 I couldn’t find the authors of this rise in schizophrenia article cited on the reference list, so I asked Dr Google for some help. I did eventually find the article and review the abstract…it then lead me to wonder about the idea of increasing diagnosis of schizophrenia during this time period, which then lead me to stumble upon a major issue with the criteria for schizophrenia, how it was historically diagnosed, and the argument that there may be some big issues around valid DSM criteria for the various types of schizophrenia  (rabbit hole alert, check it out, check it out…https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5103459/). Though I worked in psychiatric nursing a few eons ago, I am clearly not up-to-date on all of the controversies that the DSM seems to spark. 

As near as I can tell, “psychotic disorders” are pretty much undifferentiated, and this is why the authors used this term vs chasing a more definitive diagnosis like perhaps bipolar or schizophrenia, which may be more difficult to make and of course may take time to differentiate. According to the NIH/NIMH, “psychosis” describes conditions where the person has a mind condition, and they have lost contact with reality: it can be a sign of a mental illness or physical illness, it can be caused by medications/ alcohol/drug abuse, 3% of the population experiences it, and symptoms include hallucinations, delusions, paranoia, and disordered thoughts/speech. Studies show that is common for people to have symptoms for more than a year prior to diagnosis.

 https://www.nimh.nih.gov/health/publications/raise-fact-sheet-first-episode-psychosis/index.shtml

This is extremely important to note because the researchers here looked at cases of first-psychosis, but there appears to be no follow-up regarding if these were “temporary” diagnoses, or if they persons were eventually diagnosed with schizophrenia or bipolar. They did use ICD-10 criteria to define the population eligible for the study : https://www.icd10data.com/ICD10CM/Codes/F01-F99/F20-F29/F20- but it remains vague to me as far as differentiating this population and they simply lumped all psychotic disorders together. 

It is known that adverse effects of cannabis can be things like hallucinations and paranoia, so I started to worry a bit and wonder if these folks were high at the time of intake into the ER, and if they were experiencing adverse effects vs a mental health diagnoses. Thankfully,  I do see some distinction of this in the article: if the symptoms were from acute intoxication, the person was not included in the study. Phew! I can assume they knew how to differentiate this.  

Participants: Participants were people age 18-64, they were diagnosed using the ICD-10 criteria for psychosis (which envelops a lot, check out link above). Control groups were apparently randomly selected from the same area using postal address, age, race, gender, ethnicity,  and lack of psychotic symptoms as the control criteria. The researches had participants in the 17 areas of England, France, the Netherlands, Italy,  Spain, and Brazil. The researchers were striving to assess 1000 first time psychosis and 1000 controls. I did not see in the study that cannabis use was ever confirmed by a urinalysis or blood test. This seems obvious to me, but since they are looking a year back, maybe it’s not needed? I really would have liked to have known their current status of testing positive for cannabis. 

The n for each group was good: control = 1237, cases= 901

Methods:

The researchers asked the participants about 6 measures of cannabis use: lifetime use (whether or not they ever used cannabis), current use, age at first use, lifetime frequency (pattern or most consistent use), money spent weekly (or during most consistent use period), The researchers then used data from the European Monitoring Centre for Drugs and Drug Addiction 2016 report to determine cannabis potency by THC.  (download it, you’ll like it, it’s fascinating: http://www.emcdda.europa.eu/publications/edr/trends-developments/2016_en) , however,  I actually ended up finding the data elsewhere on the website, where they have info about potency. The data available now is from 2018, I am assuming the researchers used 2016 data http://www.emcdda.europa.eu/data/stats2018/ppp_en

Okay, wait, what, don’t tell me…they didn’t ask the patients what specific strain they were using, nor actually test the cannabis strains the patients used, they conjectured from the data? I think I would have felt more comfortable if they would have collected some kind of data from patients beyond frequency of use that demonstrated that they were actually, truly consuming high potency cannabis. Additionally,  I had to dig around the website to find the potency, and the data is not well labelled. 

Also, another discovery in the EMCDDA report (figure 2.1) tends to show a downtrend in cannabis use in Europe, particularly in the 3 countries that previously were high prevalence countries such as Germany, Spain, and the UK. So while cannabis may be getting stronger, it’s use sure has dropped off greatly since the year 2000 in these 3 countries (which perhaps goes against the researchers thoughts that cannabis use is on the rise and posing a greater risk for psychosis).

 EMCDDA (2016). 

image.png

 

Back to the Methods. I am directed to the appendix to further investigate how they determined “high potency”. I am feeling frustrated, because there is no appendix on the pdf I downloaded, and luckily I did find it on the main page. The appendix has lots of great further details and I am left to wonder why the editors had them put this crucial data in the appendix. 

Based on the data, low potency cannabis was <10% THC and high potency cannabis was >10% THC. Participants were asked to report the type of cannabis used, in their own language, and potency was estimated based on the data from EMCDDA. The participants seemed to give what I can only categorize as broad terms for the cannabis they were using, including UK home-grown skunk/sensimilla UK Super Skunk, Italian home-grown skunk/sensimilla , Italian Super Skunk, the Dutch Nederwiet, Nederhasj and geimporteerde hasj, the Spanish and French Hashish (from Morocco), Spanish home-grown sensimilla, French home-grown skunk/sensimilla/super-skunk,  and Brazilian skunk. (To clarify, in the UK “skunk” is a term used for all high THC % cannabis plants, but I could not find a clear definition for “skunk” in terms of strains or exactly what the cut off is for a plant to be called skunk). https://www.independent.co.uk/news/uk/home-news/uk-cannabis-market-skunk-drug-strength-weed-spice-street-sales-dealers-a8231426.html

This process of asking data based questions of patients experiencing first time psychosis brings up red flags for me: firstly, asking patients who are in first time psychosis what “type” of cannabis the participants were using seems highly unreliable to me. The problems with patients and participants self-reporting data are well known, and yet this whole study is about self report, I get it…we may not have better ways to collect the data (yet), but it remains an issue for me. They did also have some other questions around intoxicants, which is good, but I will get back to that with results. 

Secondly, the actual cannabis was never tested for true potency (back to the idea of the researchers claiming these patients used high potency cannabis, but the only evidence of them doing so was that they may have consumed cannabis in a geographical area where high potency cannabis is available), nor was there any indication that the patients were tested for THC (granted they could have tested negative and last use could have been some months before the episode). 

 

What about the actual findings????

Hang on for Part II of the analysis!  The findings and conclusion analysis coming up in Part II! 

 

References:

European Monitoring Centre for Drugs and Drug Addiction. (2016). European Drug Report 2016: Trends and Development. Retrieved from http://www.emcdda.europa.eu/publications/edr/trends-developments/2016_en

 

Forti, M.D., Quattrone, D., Freeman, T.P., Tripoli, G., Gayer-Anderson, C., Quigley, H….et al. (2019). The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. The Lancet, Psychiatry. Open Access. DOI:https://doi.org/10.1016/S2215-0366(19)30048-3

Drug Wars, Drug Addiction, and Social Justice Issues


I have been reading Johann Hari’s Chasing the scream: The first and last days of the war on drugs. 

418d-BLWW6L._SX248_BO1,204,203,200_.jpg

This book provides a very detailed account of how we came to be an anti-drug \ and pro-prohibition nation that lead the way toward making criminals out of people who struggle with use of substances and millionaires out of people/ cartels who sell drugs on the black market to drink ayahuasca in the Andes. I have found the book in some aspects hard to read because the political manipulation of our global population and the injustices that have arisen from this global movement. I get angry about what has happened as I read and I have to step away for awhile.

Some key points from this text for nurses to consider:

  • The dominant medical establishment (in particularly the AMA) was initially very against “drug” prohibition, but key vocal players were forced into silence by the government.
  • Overall, 90% of people use substances we call “illicit drugs” without having addiction issues, yet we continue to think that people need to be cautious with drug use. For instance, many (not all) soldiers used heroin in Vietnam to get through the hellish experiences, yet many (not all) had no issues with heroin addiction when they returned stateside.
  • There is a clear connection between lack of social support, childhood abuse, and adverse childhood experiences (ACEs: see the CDc website for more info on this) with addiction. We need to be compassionate toward those who are suffering, because these childhood experiences literally changed how their brains function, making them very vulnerable toward addiction. Adverse childhood events impact young people across the socio-economic spectrum, and many people who came from “good families” have also experienced a lot of childhood trauma.
  • When it comes to death and illness, our two leading “drug use issues” are likely nicotine and alcohol, both legal, and both toxic and deadly. Yet, we simply put warning labels on these drugs and let folks self-determine their fate. Why are these drugs okay, but others are not? Because they are socially acceptable? Because they are “cheap”?

When we think of the opiate crisis, one of the biggest issues of course is people not having safe and affordable access to opiate medications: when people are cut off from safe supplies (ie, their pain prescriptions which the medical establishment has endorsed and prescribed, with potentially some of the cost covered by their medical insurance ), they may turn toward heroin and other “street” opiate medications. These drugs are expensive, sometimes hard to find, and in many ways they force or perhaps support people to live a life of crime in order to maintain their habits, if people have gone that far they must get help. And people overdose because they have no idea what is in the products they are obtaining.

Maybe, we have created an addiction monster in our society.

However, Portugal has found a way out of the addiction monster’s clutches. In 2001, with a growing heroin addiction problem, Portugal decriminalized all drugs and began to consider addiction to be a public and personal health issue. Drug addiction was viewed for what it is:  a chronic, debilitating illness. People caught with a 10 day supply of any drug are referred to a sociologist who helps to determine their treatment options. And what Portugal has realized is that not only is this a more humane approach, it is also far less expensive to provide adequate medical care and treatment to addicts versus incarcerating them. Portugal has experienced a 75% drop in addicted persons from the 1990’s, and their addiction rates are 5 times lower than the rest of the EU. Meanwhile, drug related HIV infections have dropped by 95%, and the stigma around addiction has lessened dramatically.

http://www.npr.org/sections/parallels/2017/04/18/524380027/in-portugal-drug-use-is-treated-as-a-medical-issue-not-a-crime

As nurses, we are concerned about social justice issues and public health issues. I would posit that nurses and politically active nursing organizations should be taking action around the opiate crisis in several ways:

  • Calling for safe injection sites and distribution of clean needles (or needle exchange centers) and free condoms.
  • Looking at prevention and early identification of at risk persons (both ending early childhood trauma through supporting parents at risk for enacting trauma and assessing for early childhood trauma both across the lifespan and across all populations to determine risks for addiction).
  • Supporting harm reduction techniques.
  • Supporting a view of addiction as a public health issue, and a chronic disease issue.
  • Considering a call toward decriminalization of drugs and ending incarceration for addicts (the Portugal Model).
  • Acting compassionately toward all addicts (even the “drug seeking” ones).
  • For emergencies, call medicaltransport.co.

If you are interested in this topic, I do recommend reading Chasing the scream. This text provides great historical insight into how we came to where we are at with the global  “war on drugs” and the escalating issue of for-profit prisons.

We have become the nation with the greatest number of incarcerated individuals (not %, but sheer number!): though we only have 5% of the world’s population, we incarcerate 25% of the world’s total prison population (this link looks at the complexity of these numbers and supports the idea of the truth that in the land of the free, we incarcerate a much higher percentage of people due to lack of alternative ways to provide help https://www.washingtonpost.com/news/fact-checker/wp/2015/07/07/yes-u-s-locks-people-up-at-a-higher-rate-than-any-other-country/?utm_term=.1ca70c3620af).

Columbia University’s CASA group has released multiple reports that link drug addiction issues to crime, incarceration, and repeat offenses. Sadly, while 65% of our prison population qualify for addiction treatment, only 11% actually receive treatment. Meanwhile, the majority of violent crimes are committed by those suffering from addiction. https://www.centeronaddiction.org/newsroom/press-releases/2010-behind-bars-II

Poverty, race, and income inequality also play a role in both addiction and incarceration, and as nurses, we are ethically obligated to advocate for change in healthcare and system wide policies that impact vulnerable populations. Raising awareness is a first step, but perhaps nursing organizations need to also start taking stances and lobbying for more humane treatment of those who struggle with addiction.

 

 

The Ethics of Nurses Being “Political”


A few weeks ago (I know, don’t tell me it feels like months!), when the 45’s “Muslim Ban” was in full swing, Pamela Cipriano, the current President of the American Nurses Association, issued a statement that reads as follows:

“Nursing is committed to both the welfare of the sick, injured, and vulnerable in society and to social justice. The ANA Code of Ethics for Nurses with Interpretive Statements establishes the ethical standard for the profession in its fervent call for all nurses and nursing organizations to advocate for the protection of human rights and social justice.Therefore, ANA opposes any action that erodes the human rights of people, and strives to protect and preserve the rights of vulnerable groups such as the poor, homeless, elderly, mentally ill, prisoners, refugees, women, children, and socially stigmatized groups.This underlying principle must be considered in light of the current Administration’s efforts to halt refugee admissions for 120 days and block citizens of seven Muslim-majority countries from entering the United States for 90 days.Any actions taken that are intended to increase the safety of our country must be clearly defined and not jeopardize human rights nor unfairly target religious groups.” (http://nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2017-NR/ANAPresidentResponds-ImmigrationEO.html).

Social Media Reaction 

I happened to read this on facebook, so of course I was very excited to see a nursing leader take a public stand. As I moved onto the comments section, I was concerned by what I saw, as it seems about 50% of the nurses commenting were concerned about the political nature of Dr. Cipriano’s statement, and comments were made that nurses should not be making political statements, that ANA should not be taking political stances, and that there is no room for politics in nursing.

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We still have a lot of work to do in educating nurses, both in the academic and professional settings. We need to ensure that nurses understand their ethical obligation to act as advocates for populations; and that this obligation extends beyond the bedside and workplace setting and out into the wider arena of politics.

Ethics and Political Action, Advocacy, and Activism

The Code of Ethics for Nurses With Interpretive Statements (American Nurses Association, 2015: http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html) guides us in our nursing practice. In particular, nurses should be aware of the implications around the following provisions (emphasis added with italics):

  • Provision 7: The nurse in all roles and settings advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
  • Provision 8: The nurse collaborates with other health professional and the public to protect human rights, promote health diplomacy, and reduce health disparities.
  • Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

All nurses can access this document for free online at the above link, and I would recommend particular attention be paid to provision 9.3 (integrating social justice, p. 53) and 9.4 (social justice in nursing and health policy, pg. 53-54).

I particular like how the ANA code provides a context for nurses to realize that our work does not stop at the bedside; we care for and advocate for those who do not have a strong voice, those who need support in attaining the best pathways toward good health and healing, and we care for and advocate for populations and the planet.

In this sense, when we made aware of political issues like the possible repeal of the Affordable Care Act, it becomes clear that we are ethically obligated to take action to ensure that vulnerable populations do not lose access to their healthcare, and that we be part of the conversation as new processes and policies emerge via federal and/or state mandates regarding healthcare insurance. This area may seem obvious, but we are also ethically obligated to take action when we see the health of specific populations and the health of the planet at risk. Image result for picture nurse political

One example of this might be the “extreme vetting process”, which is targeting refugees from specific war torn areas such as Syria. The atrocity of human destruction in Syria and the need for refugee re-settlement is one that nurses should be concerned about; the damage that is done to human life and the degradation of the environment and the planet in Syria is a global concern, and a nursing concern. Nurses should therefore be fulfilling our ethical obligation by questioning the new extreme vetting process and supporting a call to assist Syrian refugees. A war torn vulnerable human population requires social justice action.

I am sure there will be more examples that require nurses to fulfill our ethical obligations in the forthcoming days and weeks as we look at this administration’s stances around the environment, healthcare, and even education (yes, our children are a vulnerable population away, one that needs a strong voice in support of the best educational practices).

So what can we as individual nurses do? 

Make an action plan around a singular or perhaps a few areas of political concern. Keep in mind, your actions do not need to be huge or time consuming; calling, emailing, or writing your representative on a regular basis can take just a few minutes of your time, and it can be of great impact. Don’t forget to mention you are a nurse, and always strive to share personal stories around your topic of choice. Align yourself with other like-minded nurses, and take steps to balance your work-family-advocacy-self-care efforts. Rejuvenate yourself, and find communities that you align with.

The reason why we became nurses may vary to some degree, but most of us felt a calling toward healing, toward caring, toward supporting people and populations in maximizing their health. And the world needs nurses right now to fulfill their ethical obligations in the political arena. Image result for picture nurse political

 

The Call for Community, Art, and Artists in the Resistance Movement


This week, members of the Nurse Manifest Team gathered together by the warmth of our computer screens for engaging video conference. We took the time to welcome some new members and talk about the future of the movement. I have to say for me, being with like minded #NurseResisters was so energizing (even though I have been suffering through a bout of the flu this week!) and also very comforting.

It’s important for #NurseResisters to remember we are not alone and to gather those around us during these challenging times: when change seems to be happening at a rapid pace, when social media pages are filled with what resisters might find to be concerning or bad governmental news, when there are 10 things you would like to take action on, but you can’t be on the phone all day….it can become easy to become discouraged, overwhelmed, or burned out. This is where truly being with a like minded community can lift your spirits and buoy your endurance.

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And endurance is what we will need. I know right now it sometimes feel like a sprint…get out there and get things done now, get to this march, make your signs, write your emails and postcards, get on the phone….because the administration has been creating changes at a rapid pace, the media and social media have been bumping up our energy, and we feel drawn to create change now.

The thing is, this is not a sprint and it’s not a solo race…it’s more like a team based marathon or ultra-marathon, and it is going to take teams of like minded community members to both participate in and complete the race.

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Individual Sprint

Versus

Team Marathon

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We need to carry lights, march together through the dark night with our nightingale lamps, and strive toward unity. There is no clear finish line, and no medals for winners, second, and third place. There is a beautiful planet and population of people that need caring for and this endurance test is in part about not giving up that vision of a caring, compassionate, kind, peaceful, unified, and spirit filled world.

I suggest other #NurseResisters start gathering with your communities in real life or as we did last week, in real time via video or phone conferencing. Set aside thoughtful, meaningful time to be together, to discuss future actions, and also to just support one another, to laugh together, to share your stories. Communities can rejuvenate and recharge us, and they are a must for folks who plan to run the long race.

I also did want to share that part of our discussion last week focused on the use of humor, satire, parody, art, and music to support and gather people together. Saturday Night live is becoming a great example of the power of humor, parody, and satire to help us lighten our load, to help us rejuvenate, to connect us across time and space.

 

 

While there are many older political songs we can use (Carol King just re-released One Small Voice with free download!: https://soundcloud.com/user-844282824/one-small-voice), it remains imperative that we also create new art and new music that reflects our current siutation here, now in 2017. Until then, let’s be strong together:

“One small voice speaking out in honesty
Silenced, but not for long
One small voice speaking with the values
we were taught as children
Tell the truth
You can change the world
But you’d better be strong”

(Carole King/ copyright Rockingdale Records).