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    How To Start The Conversation: Avoid? Ask & Assess Advise & Act

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    PSm
    This document provides guidance for pharmacists on discussing cannabis as a therapeutic option with patients. It outlines a three-step process to have the conversation: avoid, ask and assess, advise and act. The avoid step identifies potential contraindications. The ask and assess step involves understanding the patient's knowledge, goals, and trying other treatments. The advise and act step is determining if cannabis is appropriate, providing education, and follow-up. Two case studies are presented to demonstrate applying the process. The document emphasizes an individualized approach and optimizing other treatments first.

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    How To Start The Conversation: Avoid? Ask & Assess Advise & Act

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    PSm
    63 views4 pages
    This document provides guidance for pharmacists on discussing cannabis as a therapeutic option with patients. It outlines a three-step process to have the conversation: avoid, ask and assess, advise and act. The avoid step identifies potential contraindications. The ask and assess step involves understanding the patient's knowledge, goals, and trying other treatments. The advise and act step is determining if cannabis is appropriate, providing education, and follow-up. Two case studies are presented to demonstrate applying the process. The document emphasizes an individualized approach and optimizing other treatments first.

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    This document provides guidance for pharmacists on discussing cannabis as a therapeutic option with patients. It outlines a three-step process to have the conversation: avoid, ask and assess, advise and act. The avoid step identifies potential contraindications. The ask and assess step involves understanding the patient's knowledge, goals, and trying other treatments. The advise and act step is determining if cannabis is appropriate, providing education, and follow-up. Two case studies are presented to demonstrate applying the process. The document emphasizes an individualized approach and optimizing other treatments first.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    63 views4 pages

    How To Start The Conversation: Avoid? Ask & Assess Advise & Act

    Uploaded by

    PSm
    This document provides guidance for pharmacists on discussing cannabis as a therapeutic option with patients. It outlines a three-step process to have the conversation: avoid, ask and assess, advise and act. The avoid step identifies potential contraindications. The ask and assess step involves understanding the patient's knowledge, goals, and trying other treatments. The advise and act step is determining if cannabis is appropriate, providing education, and follow-up. Two case studies are presented to demonstrate applying the process. The document emphasizes an individualized approach and optimizing other treatments first.

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    © All Rights Reserved
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    of 4

    CANNABIS FOR MEDICAL PURPOSES

    How to Start the Conversation


    How do you begin discussing cannabis as a therapeutic option with your
    patients? Use this three-step process to help guide the conversation.

    AVOID? ASK & ASSESS ADVISE & ACT

    Generally, AVOID using cannabis if your patient1: LEGEND:

    • Is under the age of 25* Cannabinoids: all therapeutic


    agents containing
    • Has a strong family history of psychosis or schizophrenia (use with cannabinoids
    caution if current or past history of anxiety or mood disorder)
    Cannabis: dried cannabis plant
    • Has a current or past cannabis use disorder or other substance use material or cannabis-derived
    disorder (e.g., alcohol, benzodiazepine, opioids) extracts with no DIN (e.g., CBD
    oil)
    • Is pregnant, planning to become pregnant or breastfeeding
    • Has a known allergy to cannabis, THC, CBD or any other cannabinoid Prescription cannabinoids:
    cannabinoid-containing
    medications with a DIN
    *Cannabis may be used with caution in situations where evidence suggests that benefits outweigh
    (e.g., nabilone, nabiximols)
    risks, e.g., use of CBD to treat children with drug resistant seizures.

    ASK & ASSESS


    General knowledge, pre-existing
    What do you know about using notions, stigma, other substance use
    cannabis? How do you feel about it? history, potential for dependence;
    determine if patient is cannabis-naïve.

    Understanding of potential benefits and


    Why do you think cannabis might be risks of cannabis for their condition; are
    an option for you, and what do you their treatment goals Specific,
    hope to achieve? Measurable, Attainable, Realistic, Timely
    (SMART)?

    Optimization of prior pharmacologic


    and non-pharmacologic therapies and
    What else have you tried for your
    potential for drug interactions.
    condition?
    (Cannabis is usually third- or fourth-line
    adjunctive therapy.)

    Is there anything else you would Comfort level and any other education
    like to know about cannabis? needs.

    ADVISE & ACT


    • Determine if cannabinoids are appropriate for this patient at this time
    • Make drug therapy recommendations
    • Provide education and counselling to the patient or their prescriber
    • Monitor therapy and follow-up with the patient
    Meet Roberta
    Roberta is a 77-year-old female with type 2 diabetes and diabetic
    neuropathic pain. She has tried many medications for pain with limited
    benefit and some side effects. Roberta’s daughter brings her to the
    pharmacy to ask some questions about cannabis.

    AVOID? There are no current contraindications to using cannabis for Roberta.

    ASK & ASSESS

    What do you know about using cannabis? Roberta is cannabis-naïve and is


    How do you feel about it? concerned about addiction.
    “I’ve never used it, but my daughter thinks I Consider further assessment of
    should try it. I already smoke cigarettes tobacco and substance use (e.g.,
    though; I don’t want to get addicted to use CAGE-AID and/or Opioid
    something else.” Risk Tool2,3)

    Why do think cannabis might be an option


    for you, and what do you hope to achieve? Roberta has no understanding
    “I don’t know what it will do, but I trust my of the effects of cannabis on
    daughter. I just want to decrease my burning her condition.
    pain and sleep better.”

    It is unclear if Roberta’s medication


    What else have you tried for your condition? regimen is optimized.
    “I am on four different medications, but
    nothing works and they make me dizzy and Consider performing a
    tired.” medication assessment

    Roberta may be more sensitive to the


    Is there anything else you would like to know effects of cannabis, particularly THC
    about cannabis? component, due to her age.
    “I’m worried I will react badly to it.”
    Consider low THC product

    ADVISE & ACT

    You carry out a medication assessment and determine that Roberta’s current pain
    medications are optimized. She is not a good candidate for opioid therapy for her pain
    because of her age, other substance use, and her concerns about addiction. You discuss the
    risks and benefits of cannabis, and recommend that she discuss a trial of a high CBD/low THC
    oil with her prescriber. You schedule a follow-up appointment with Roberta in one week, and
    smoking cessation counselling session in two weeks.
    Nabiximols has stronger evidence for the treatment of neuropathic pain than nabilone
    or cannabis but can be cost-prohibitive. Nabiximols contains THC as well as CBD and
    nabilone is synthetic THC. Neither choice is optimal when trying to limit THC exposure.
    Meet Amar
    Amar is a 36-year-old lung cancer patient with uncontrolled
    chemotherapy-induced nausea and vomiting (CINV) despite being on
    several antiemetics and trying other non-pharmacologic options. His
    doctor calls you to discuss a possible trial of cannabis or other
    cannabinoids. At your suggestion, Amar comes to the pharmacy for a
    medication assessment.

    AVOID? There are no current contraindications to using cannabis for Amar.

    ASK & ASSESS

    What do you know about using cannabis? Amar is cannabis-naïve and does not
    How to you feel about it? appear to be concerned about
    “I’ve never smoked it, but some of my stigma.
    friends do. I’ve just never been interested.”

    Why do you think cannabis might be an


    option for you, and what do you hope to Amar’s expectations of symptom
    achieve? relief are reasonable. Amar and his
    “I want to keep my food down and sleep doctor both trust your expertise.
    better. My doctor said it might work but
    we both wanted to see what you thought.”

    What else have you tried for your Upon completing a medication
    condition? assessment, you confirm that Amar
    “I’ve tried three medications so far and has already optimized other
    none of them help.” antiemetics.

    Is there anything else you would like to


    know about cannabis? Amar is skeptical but ready to try
    “Not at this point. I’m just frustrated that something for symptom relief.
    it won’t work either.”

    ADVISE & ACT

    You recommend to Amar and his doctor that the best


    option for him would be a trial of nabilone. You suggest
    that he start a dose of 1 mg twice a day the night before
    his chemotherapy cycle and his doctor writes the
    prescription. You set up an appointment for Amar to
    follow up with you a week after he starts the nabilone.

    There is some evidence for the effectiveness of


    cannabinoids as adjunctive treatment for persistent
    CINV. Of all the cannabinoids, including cannabis,
    nabilone has the strongest evidence and should be
    tried first.
    This document is only intended to provide evidence-based guidance to clinicians on
    discussing cannabinoids with their patients and should not replace clinical judgement
    based on individual patient’s needs and circumstances.
    For more information, consult CPhA’s Medical Cannabis FAQ (2017), Cannabis for Medical
    Purposes Evidence Guide (2018) and series of continuing education programs on using
    cannabis as a therapeutic agent at www.pharmacists.ca/cannabis

    References:
    1. RxTx Ottawa (ON): Canadian Pharmacists Association; c2018. CPS online: Cannabis;
    Available from: www.myrxtx.ca
    2. CAGE-AID JA Ewing. Detecting Alcoholism. The CAGE Questionnaire. 252(14): JAMA
    1905-7. 1984.
    3. Webster LR, Webster R. Predicting aberrant behaviors in Opioid-treated patients:
    preliminary validation of the Opioid risk tool. Pain Med. 2005;6(6):432

    This resource was supported in part by an unrestricted grant from Shoppers Drug Mart/Loblaw.

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