Nurses’ Concerns with COVID19 Update: March 22, 2020


I know for many people at this point a day might feel like a decade. We are worried and stressed. I myself have some concerning symptoms (headache, fatigue, weakness, sore throat, nasal congestion; no fever), but I will ride it out at home for now as we all know it could be a cold, the flu, or even adenovirus.

Cloth Facemasks, Update from the CDC: “In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.” https://www.cdc.gov/…/hcp/ppe-strategy/face-masks.html

In other words, the CDC is recognizing that an adequate barrier is still needed. I have heard from nurses that face shields are also in low supply; they are being shared, cleaned, and reused. I would assume this may be a safe practice for some face shields, and not for others.

From the nurses: One of my nurse colleague friends stated the hardest part of working in an ER is the changing circumstances; she told me that the recommendations for how they can safely care for patients literally shifts every 12 hours. In order to keep herself and her colleagues safe, she was able to purchase PPE, spending her own money, and they were allowed to bring it into the facility.

Some facilities are not allowing nurses and other providers to bring in their own PPE.

Some nurses on social media platforms state that they are buying, and some facilities are investigating the use of, what one might call industrial-grade respirators that have filters, which can be changed. Nurses have posted pictures of themselves in these types of respirators on social media pages. I have no data on whether these we will work and if this is the right move to make to be protected. I don’t know if a face shield works with them.

 

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Lastly, nurses on social media platforms are concerned that they are being told that they cannot wear PPE unless absolutely called for, and hospitals are establishing those guidelines of when PPE is appropriate. They are being told that it’s an optics issue and that the administrators are concerned if everybody is wearing PPE in a setting like the ER, it gives patients and families the wrong image. And in this time of PPE shortage, there is the need to conserve PPE. This means that many nurses feel like they are taking unknown risks every time they work. Many have stated that they generally don’t feel safe, and they have anxiety about being in these settings.

I reached out to my federal representatives and received canned responses. I do suggest everybody do the same and consider manning the phone on Monday and calling their elected congressional representatives and senators to express concerns and ask for clarity around how the federal government plans to address the lack of PPE.

Ask them how the Defense Production Act is being used to ensure that those on the frontlines are being protected: it’s enacted, but it needs to be implemented. According to CNN, there is little evidence that it is being used to actively enhance the production of PPE and medical equipment like ventilators.

https://www.cnn.com/2020/03/20/politics/defense-production-act-trump/

Ask them for a clear plan for your state in procuring PPE.

 

 

Nurses’ Concerns with COVID19 Update: March 21, 2020


This will be a quick update to implore nurses to not use cloth masks and not call for the creation of more cloth masks. The evidence shows that they are ineffective, do not create a barrier for transmission, and may in some ways increase transmission.

We all learned in nursing school that once the mask becomes damp it’s not effective. Cloth masks will become damp within minutes and we have no evidence around if adding in a filter or other materials sandwiched between layers of cloth will help. Add to this that one then has a wet, potentially contaminated cloth mask that should likely be disposed of, but at the very least needs laundering, and it becomes clear that cloth masks are not the answer. They may indeed be harmful.

In my humble opinion: The CDC stating that bandanas, scarfs and cloth masks could be helpful when they are actually potentially harmful is reprehensible.

Please review the BMJ Open article entitled:

A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.

https://bmjopen.bmj.com/content/5/4/e006577?fbclid=IwAR2bng1KIAtVW3PjBns3usq_3tOmQG2wvYxWiSxJXdITf4uqvIuB-tMcHy4

While the ANA has called out the CDC on their call for non-evidence based protocols and statements and addressed the white house, nurses are going to have to act locally.

At the very least please contact your representatives and demand access to proper PPE, increases in manufacturing, the federal government taking more responsibility for ensuring our safety.

How can we organize ourselves around advocating for proper PPE?

 

Nurses’ Concerns with COVID19: March 20, 2020


Like many of you reading this, I have a range of emotions and feelings as the pandemic of COVID19 grows in the USA: anxiety, fear, and anger. Today (and for the last several days), I am angry about the lack of Personal Protective Equipment (PPE) available for nurses who are being called to care for those who are most ill and the most contagious. The following is my attempt to express my personal concerns and align them with nursing’s guiding ethical principles.

There may be flaws in my thinking and I am open to respectful dialog about these issues. I understand that emotions are running high and that we may not agree, but we can and should have civil discussions and dialogs.

Lack of Personal Protective Equipment. On February 7, 2020, the World Health Organization warned of a shortage of Personal Protective Equipment in China and beyond. As that was 6 weeks ago, there has been time to ramp up the production of PPE. Meanwhile, state’s governors from Maine to Wisconsin to Florida and Washingon are asking to access the federal stockpiles for access to PPE:

https://www.penbaypilot.com/article/governor-mills-urges-federal-government-vice-president-release-personal-protection-eq/131972

https://www.nbc15.com/cw/content/news/Evers-asks-federal-govt-for-much-needed-supplies-from–568975621.html

https://www.propublica.org/article/heres-why-florida-got-all-the-emergency-medical-supplies-it-requested-while-other-states-did-not

https://www.doh.wa.gov/Newsroom/Articles/ID/1117/Addressing-shortages-of-Personal-Protective-Equipment-PPE

Nurses Quitting: A few days ago, one of my Facebook friends quit her job because she was no longer being provided the proper PPE, She was not directly caring for COVID19 patients, but she needs proper PPE to keep herself and her patients safe during the provision of care,  and her quitting her job got me thinking, considering ethical issues, advocacy, the role of the nurse, and so on.  I respect her decision, and I hope this post makes it clear that during these frightening and murky times, the decisions we make as nurses are going to be hard ones.

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I want to say, from an ethical perspective, it is perfectly acceptable for nurses to quit their jobs and/or refuse to work without proper PPE. Refer to my previous post of the ANA calling for the CDC to provide evidence when they make guidelines, and consider the recent use of bandanas and reuse of face masks protocol from the CDC: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html. This flies in the face of everything we know about the transmission of viruses.

Ethical Principles: The overarching ethical principles at play here that help to guide nurses’ decision making are beneficence (doing the good thing, moral obligation to do the right thing, what is best for the patient) and nonmaleficence (do no harm to patients). When we work without proper PPE, there is a very real risk that not only might we harm ourselves, we potentially spread pathogens to patients. When we don’t have proper PPE, our stress, fear, and anxiety can be magnified and potentially may harm patients.

Additionally, The code of ethics for nurses (https://www.nursingworld.org/coe-view-only) requires a lot of us.  To begin with, we must be deeply familiar with The code and how it guides our decision-making processes. The following are some excerpts from The code that guide our decision making at this time:

The code: 3.5 Protection of Patient Health and Safety by Acting on Questionable Practice 

This concept is all about the reporting of inappropriate and questionable practices. We may become stymied when even our boards of nurses are aware of dangerous and non-evidence-based practices, but they may see no way around them. We can report the issues, but when the governing bodies we report to are not holding up our own ethical standards, the field is put at greater risk for collapse (from infection spreading and/ or providers quitting).

Even as standards are relaxed, entities such as the Oregon Board of Nursing should be taking more responsible action and not placing nurses and patients at risk. The following is a statement by the Oregon Board of Nursing that states that nurses cannot refuse assignments because of sub-par PPE that does not align with CDC or WHO regulations. In other words, in this case, the BON is either not considering the greater harm for both patients and nurses by not recognizing the greater ethical concerns and personal risks nurses are being asked to take, or they simply see no other solutions. The paragraphs about the social contract and evidence-based approaches contradict the highlighted area regarding changes in PPE approaches and the right to refuse assignments.

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Regardless of what our boards of nursing state, Provision 4 makes it clear that we are ultimately responsible for our own practice:  “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions, and takes action consistent with the obligation to promote health and to provide optimal care”. Specifically, Provision 4.1 states that “Nurses bear primary responsibility for the nursing care that their patients and clients receive” and “Nurses must always comply with and adhere to state nurse practice acts, regulations, standards of care, and ANA’s Code…”. This does lead to interesting paradoxical issues with the Oregon Board of Nursing, as one could view this as a regulation, but it contradicts further statements in The code, including:

Provision 4.3: “Nurses are always accountable for their judgment, decisions, and actions: however in some circumstances, responsibility may be borne by both the nurse and the institution. Nurses accept or reject specific role demands and assignments based on their education, knowledge, competence, and experience, as well as their assessment of the level of risk for patient safety. Nurses in administration, education, policy, and research also have obligations to the recipients of nursing care” and “Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review”.

Most importantly, The code calls for us to take good care of ourselves so that we can take care of others. We see this shown in Provision 5, particularly:

Provision 5.2 Promotion of Personal Health, Safety, and Well-Being

“…nurses have a duty to take the same care for their own health and safety. Nurses should model the same health maintenance and health promotion that they teach and research, obtain health care when needed, and avoid taking unnecessary risks to health or safety in the course of their professional and personal activities.” The sticking point here is arguing whether or not the risks of not wearing proper PPE, which include risks of death for oneself or other patients who have not yet been exposed, is necessary or not. From my perspective, I can see where working without proper PPE could be too large of a risk to oneself and the communities served.

And I get concerned when nurses seem to think it’s only about them be willing to take on the personal risk for themselves, forgetting about how they may also become the vector.

One last ethical issue, we have to do our own self-care during these challenging times. As nurses, we are required to take care of ourselves. Provision 5.2 continues: “Fatigue and compassion fatigue affect a nurse’s professional performance and personal life. To mitigate these effects, nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs…it is the responsibility of nurses leaders to foster this balance within organizations”

Now onto a round-up of current COVID19 issues for nurses as I am seeing on social media:

Masks: Some nurses are being told to store their 1 daily mask in a paper bag and remove/ doff between patients, and replace/don the old mask for new patients. Of course, the bag and the mask would all be potentially contaminated; the bag actually creates a source of contamination and risks for greater transmission. I also heard rumors on social media of nurses being told to share masks, and I am hoping this is simply just false information, as I couldn’t verify that claim. I did hear that eye shields were being shared. I have confirmed that nurses who are normally required to wear masks because they have not been vaccinated for the flu are now being told to not wear masks because there is a shortage of masks. I have also confirmed that having a doctor’s note regarding why one must wear a mask (verification that they are immunocompromised) may work in some settings to either ensure masks are available to the person or excuse them from work.

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We are vulnerable: Nurses are humans and many of us are vulnerable, whether that means we have chronic health conditions and co-morbidities, or we are at risk because of age.

Nurses are also fighting amongst themselves about whether it is okay to quit the workplace now. We have to recognize that these are complex decisions; nurses are real people who have their own health issues. Getting angry about people not willing to take the risk is not productive in both the short and long term.

It’s okay to choose your life and your well-being over the “duty” or social contract to work. It’s okay to make those tough decisions, like quitting your job, and, for some folks, they may be willing to risk their license by refusing assignments where they can’t keep themselves or their patients safe, even if their board of nursing disagrees.

Many nurses will carry on, work hard, provide excellent care, and do their best.

It’s also okay to feel vulnerable and scared in these uncertain times and to question your decisions and the decisions of administrators, regulators, and leaders.

It’s okay to organize and advocate for our needs, whatever that looks like.

Always remember, you have ethics on your side.

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COVID19 and Nurses’ Concerns


Nurses are the backbone of all of the health care professions: we care for people and communities in difficult situations. We are compassionate and ethical. We put ourselves at risk daily for everything from violence from patients and families to contacting contagious diseases to post-traumatic stress from what we witness.

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Here is some of what I have read about on the social media COVID19 for nurses and healthcare providers pages that are popping up faster than dandelions.

  1. There is poor planning by, and a lack of communication from, most hospital systems, likely in part impacted by the lack of leadership at the state level. A national survey of nurses by National Nurses United found “high percentages of hospitals do not have plans, isolation procedures, and policies in place for COVID-19; that communication to staff by employers is poor or nonexistent; that hospitals are lacking sufficient stocks of personal protective equipment (PPE) or are not making current stocks available to staff; and have not provided training and practice to staff on how to use PPE properly”. https://www.nationalnursesunited.org/press/survey-nations-frontline-registered-nurses-shows-hospitals-unprepared-covid-19
  2. Personal Protective Equipment is now rationed. In inpatient settings, some nurses are asked to use just one mask/ day. An article in the New YorkTimes details how nurses are begging for PPE: https://www.nytimes.com/2020/03/05/us/coronavirus-nurses.html 
  • In the home care settings, nurses are asked or told to use one mask and one gown/ day. Obviously, this means they can’t maintain or implement proper precautions when traveling from house to house, the gown itself potentially becomes a contaminant.
  • In the home care setting, patients are canceling appointments because they view the nurses as vectors. In the long run, this could have huge implications for greater levels of care needed by these patients if they decline without proper care and guidance.

2. Most facilities do not have plans in place for the forthcoming surge in COVID19 patients.

3. The Centers for Disease Control rolled back the N-95 mask requirement and has stated that a simple surgical mask is sufficient in caring for COVID19 suspected or confirmed patients, and that may be used for extended periods while caring for multiple patients. They also have decided that reusable gowns are fine to use. https://www.fda.gov/medical-devices/letters-health-care-providers/surgical-mask-and-gown-conservation-strategies-letter-healthcare-providers

4.  Fears of getting sick themselves are rampant amongst nurses and other providers. Pregnant nurses have no idea if a COVID19 infection might affect their pregnancy. Those nurses with existing health conditions who are at risk are not sure if they should come into work, or reveal their health conditions to the workplace, or risk losing their jobs. Additionally, nurses who come home to care for elderly relatives, children, etc. are petrified of making them sick.

5. Nurses are not offered COVID19 testing, and if they have symptoms, they are often being told to use vacation, paid time off, or leave without pay, and to self-quarantine and contact the workplace in 14 days.  Those who are at risk are not identified quickly. https://www.theverge.com/2020/3/5/21166088/coronavirus-covid-19-protection-doctors-nurses-health-workers-risk

6.  Nurses may be mandated to work overtime, which can wreak havoc on stress levels and immune responses. https://www.fda.gov/medical-devices/letters-health-care-providers/surgical-mask-and-gown-conservation-strategies-letter-healthcare-providers

The CDC and NIOSH recognized years ago that working 12-hour shifts alone may be dangerous, with deteriorating performance on psychophysiological tests and an increase in risk for injuries. Poor outcomes and personal capabilities worsen with 12-hour shifts worked particularly in combination with working more than 40 hours. Working overtime obviously leads to physical fatigue, and it also increases risks for alcohol use and cigarette smoking. And there is still a lot we don’t know, such as how does working longer impact women or older workers? What about those with pre-existing or chronic conditions? What is the influence of occupational exposure?

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What can we do, and what are nurses doing?

Now is the time: we are going to have to advocate for ourselves. We also need to demand proper access to PPE, PPE training, proper testing approaches, and call for OSHA standards related to the risks we face.

We can all act as advocates locally to call for safe working conditions, and we can join forces with our national nursing organizations to continue to call for support, funding, and access to proper PPE.

Feel free to share your ideas here.

 

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.