Marissa Fratoni RN
Purpose of this paper
This paper will discuss some of the challenges faced by patients and adult users of cannabis in terms of inadequate guidance and counseling from qualified health providers, the less than clear scope of practice for dispensing agents and caregivers, and some of the negative impacts this lack of clarity presents for many of the players in the cannabis space. A discussion of the discontinuity of care between recommending healthcare providers and the medical marijuana dispensaries will be included. Recommendations for possible solutions to some of these issues and challenges will also be discussed.
The dispensary experience
It’s a common occurrence in the cannabis space — patient or adult user visits a dispensary. The product menu reads like a doctrine delivered from a foreign planet. Kush, cookies, OG, haze, indica, sativa, hybrid, oils, topicals, vapes, tinctures, edibles, flower, terpenes, vaporizers, water pipes, papers. To a cannabis naive patient, one glance at such a menu may be all things overwhelming and confusing. Realistically, a menu like this can be all things confusing for even the most experienced users, especially if they are seeking relief from symptoms. Which products help with pain? Which products work to relieve insomnia? Are there any products that can help someone experiencing anorexia related to chemotherapy treatments? These are just a few of the common medical questions that patients and adult cannabis users alike bring into the dispensaries.
For patients who registered with the Medical Use of Marijuana Program, they may have spent a short time with a recommending healthcare provider discussing what some of these terms mean. They may have come away from their recommending healthcare provider consultation with a brief guide to choosing cannabis products and have a few suggestions for choosing cannabis products jotted down. But then they enter a dispensary and their help guides from their qualified health provider are insufficient to help them negotiate the menu and make decisions that may benefit them.
Enter the dispensing agent
Also known as budtenders in other states, dispensing agents are dispensary staff members responsible for helping patients and adult users to decipher the menu by providing information about the various cannabis products. Whether or not the strain or chemovar leans sativa or indica, the lab testing results, how a product is best consumed, the terpene profile, patient experiences with the product may all be discussed in the span of a few minutes. Dispensing agents may also fulfill the patient or customer’s order, and complete the sale at the register. They are often not healthcare professionals, more often they are people with retail, customer services, and sales backgrounds.
Here’s where their role gets tricky — in order to help patients and adult users make decisions about which products to purchase based on symptoms reported, dispensing agents very often give medical advice that is far out of the realm of their skill set, training, and knowledge-base. It’s not the dispensing agent’s fault that they are in such predicaments, but the fact that the majority of dispensing agents are giving medical advice in some way, shape, or form is disconcerting from a medical and health perspective. Conveying unauthorized medical advice without a license is also a criminal offense. For the purposes of this article, we’ll stick with the risks faced by patients. There are valid risks associated with cannabis use, just as there are risks with the use of any substance, drug, or medicine. Some of these risks can certainly be perpetuated by inaccurate advice conveyed by a non-medical person, in this case, dispensing agents and caregivers.
What are some of the valid risks associated with cannabis use?
In the medical marijuana dispensaries, dispensing agents may have access to a very limited list of conditions from which the patient suffers. That’s it, there really isn’t any information regarding the patient’s health history which presents risks in itself. The unknowns about a person’s health background can be a veritable minefield in terms of keeping a person safe. Basically, how can a patient be adequately helped without such information? How can safety be prioritized? How can harm truly be reduced? From this nurse’s perspective, it’s not feasible without this sort of information. And more than this, it is really not possible without the guidance and oversight from a knowledgeable healthcare provider — one who understands cannabinoid therapeutics and conventional health and medicine practices.
For one thing, cannabis does interact with other drugs. Cannabis may impact the way most pharmaceutical medications are metabolized in the body, in some cases speeding up metabolization, in other cases slowing metabolization down. Cannabis may have a synergistic effect with medications, or it may have an antagonistic effect. In all of these cases, the risks to the person consuming cannabis with medications may range from rendering the prescribed treatment ineffective, to an experience of severe interactions that require emergency medical attention.
Another major risk — patients may think they can simply replace their prescribed medications with cannabis. And too often, unknowing dispensing agents relay anecdotes from other patients who have successfully weaned off of this medication, or that medication. This is unfortunate because no patient should wean off of any medication without the oversight and guidance from a qualified health provider as the effects of doing so may be very harmful.
A dropped ball for patients that places them at risk
As stated above, it’s not completely the fault of the dispensaries or the dispensing agents that these businesses sort of profess medical advice. Most states have developed cannabis programs that are disjointed. In Massachusetts, it’s a conflict of interest for recommending healthcare providers to have any affiliation with the dispensary businesses. On paper, this makes sense. A recommending healthcare provider who develops a relationship with specific dispensaries has the propensity to engage in questionable business practices and vice versa. However, in practice there are aspects of these restrictions that put patients at risk, mainly because the patient is provided their certification from their qualified healthcare provider then left to navigate the cannabis space on their own with only the help and guidance of the dispensary staff who are typically not qualified to help them in any medical capacity.
Per the state cannabis laws and guidance documents established in Massachusetts, recommending healthcare providers are explicitly not allowed to counsel patients at dispensaries. And because of the potential conflict of interest that is specified in the laws and guidelines, dispensary staff do not contact recommending healthcare providers on the patient’s behalf.
To better understand this issue, consider this hypothetical scenario — a patient goes to their physician with a medical problem or illness. The physician writes a prescription that will help the patient improve their symptoms and hands it to the patient. The patient then brings the prescription to the pharmacy to have it filled. The pharmacy staff experiences difficulty reading the physician’s prescription order and requires clarification to fill the order. But the pharmacy staff can’t have any contact with the prescribing physician because the physician is not allowed to counsel patients at the pharmacy. So then the pharmacy staff guesses what the patient needs, fills the order, and wishes the patient the best. No this is not something that would happen in the conventional medical system. Pharmacies regularly ask for clarifications on physician orders to maintain the patient’s safety which just makes sense.
Bottom line, the way many medical cannabis programs have been developed in part creates these issues where dispensing agents are put into situations where they are helping patients with significant medical issues because the recommending healthcare providers are not allowed to provide the continuity of care that the patients really need to make informed decisions about cannabis use. It’s the patients who get caught in the middle.
What needs to happen to improve patient safety?
Simply put, patients deserve to have oversight and guidance from qualified health providers. It would be better if the recommending healthcare providers had the opportunity to advocate for their patients as they would in conventional practice. Unethical business practices are one thing. Forced discontinuity of care for the patient is also unethical and can result in harm to the patient, which is exactly what the law promotes at this time.
Perhaps the easiest solution to this problem is to require dispensaries to hire nurses to fill these gaps. Nurses are charged with the care and safety of their patients, have a well-defined and understood scope of practice, and act as liaisons between patients and their medical teams. Nurses do exist in the cannabis space and should be involved to reduce the risks to both the patients and the dispensaries. After all, every patient deserves a nurse.
Another solution could be a standardized training program for dispensary staff. Such a program could include a well-defined scope of practice for dispensing agents, competencies to determine practice readiness, required periodic learning updates, and regular recertification requirements. In effect, the dispensing agent role should be considered that of an allied health professional with appropriate training and licensing standards.
Last but not least, the federal laws need to change, prohibition needs to end. Every healthcare provider needs to have an in-depth understanding of the endoCannabinoid System and cannabinoid therapeutics. This shift in the medical, health, and science fields would have the most profound impact in improving patient safety. As it stands, this industry and the programs that have been implemented to allow legal access to the public have remained immature and risky because of the restrictions enforced by maintaining cannabis as a federally illicit, schedule 1 substance.
What about the role of caregivers?
In Massachusetts, registered patients can identify and register two caregivers with the state. Caregivers can visit dispensaries on the patient’s behalf and transfer cannabis products to the patient from the dispensaries. Caregivers can also grow cannabis for their patients. Caregivers also run the risk of giving unauthorized medical advice, or making unsubstantiated medical claims. Such claims run rampant on the Internet and social media. To this end, it would be advantageous for the caregiver role to be well-defined with standards and scope of practice, required training, and applicable competencies. The aforementioned solutions for developing scope, standards of practice, and training protocol for dispensing agents could apply here.
It’s all about community
In closing, it’s important to note that patients and adult use cannabis users are helped by the staff at dispensaries and by qualified caregivers available in the community. There is a lot of good that happens in this cannabis space and that cannot be discounted. It’s imperative to be fair and unbiased, and realize that as wonderful as it is to see people actively improve their quality of life and heal with the use of cannabis, there are inherent risks associated with cannabis use also. There are a great deal of flaws in the way these programs were developed. For the sake of all of the participants in this burgeoning cannabis space — the patients, the adult users, the healthcare providers, the dispensaries, the caregivers — it’s time we seek functional solutions to these problems so that we may all benefit to greatest extent possible.
Marissa Fratoni RN, Holistic Nurse Mama