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The following course content

Introduction

In 2023, The Governor of Kentucky signed a bill legalizing the use of medical cannabis for its residents with certain medical conditions beginning January 1, 2025 [7]. This law affects the prescribing authority of both physicians and advanced practice registered nurses (APRNs). However, what we think of as “prescribing” (i.e. writing a prescription for a medication and handing it to the patient) is not the process for prescribing medicinal cannabis.

Instead, when a patient has a qualifying medical condition and a practitioner determines the patient is eligible for medical cannabis, the practitioner provides the patient with a certification through an online state registry (this “certifies” the patient’s eligibility). The patient can use the certification to obtain a registry identification card, granting them access to medicinal cannabis at dispensaries.

​According to the new Kentucky law, APRNs who seek authorization to provide these certifications must complete specialized continuing education and apply to become a Medical Cannabis Practitioner in the state.

This course will begin with the history of medical cannabis legalization in the U.S. and transition into the responsibilities of the Medical Cannabis Practitioner, including diagnosing qualified medical conditions. The course will end with an overview of clinical guidelines for treating qualifying medical conditions with medicinal cannabis.

History of Medical Cannabis Legalization

Historically, the legalization of medical cannabis did not always align with its cultural acceptance. Let’s explore the history of cannabis in the United States.

Informal Use of Cannabis

Historically, cannabis was not considered dangerous. A bag of cannabis was found buried alongside a Siberian mummy with breast cancer believed to be from 500 BCE [3]. Before the 1930s, U.S. import and export of cannabis (termed “marihuana” or “hemp” at the time) was legal, and many people bought the plant to treat a variety of ailments [15].

However, in the 1930s, a media campaign linked criminality and insanity with cannabis use [3]. States began to restrict its possession. Furthermore, the government passed the 1937 Marihuana Tax Act which placed a tax on imports and exports of cannabis, and anyone who violated the new law would be fined and imprisoned [3][19]. This changed the cultural acceptability of cannabis.

Hesitation of Medicinal Cannabis

Fast forward to the 1960s, when society began to develop an interest in cannabis again – particularly cannabis research. This prompted the U.S. to assign a formal grower of cannabis for research purposes [3]. A decade later, cannabis was deemed “not acceptable” for medical use (Schedule I drug) according to the 1970 Controlled Substance Act. Schedule I drugs are those that have a high potential for abuse and are not acceptable for medical use [21].

It took another 15 years before the U.S. Food and Drug Administration (FDA) approved the drug dronabinol (a synthetic drug modeled after a substance within the cannabis plant) for medical use, particularly to treat nausea and vomiting related to cancer. California was the first state to legalize cannabis for medicinal purposes in the late 1990s. However, the government prohibited physicians from “prescribing” medical cannabis and instead allowed physicians to “recommend” it [15].

Final Consensus on Medicinal Cannabis

The cannabis plant was identified as containing both cannabidiol (CBD) and tetrahydrocannabinol (THC). CBD is a substance in the cannabis plant that has medicinal benefits but does not cause psychoactive effects (the “high” feeling). THC is also a substance in the cannabis plant, but it’s known to cause psychoactive effects.

In September 2018, drugs containing CBD were labeled as Schedule V drugs (a significant jump from the previous Schedule I label) as long as they did not contain more than 0.1% THC [5]. Schedule V drugs have a lower potential for abuse but contain a limited number of certain narcotics [21]. In December of the same year, the 2018 Farm Bill identified the THC threshold as 0.3% for cannabis research [4].

Current Numbers

Most recently, medical cannabis has become culturally acceptable. As of September 2024, medical cannabis is legal in 47 states [17]. Of this number, 38 states have a medical-only cannabis program. Nine of the 38 states allow only CBD or products containing a low amount of THC for qualifying medical conditions. These nine states are [17]:

• Georgia
• Indiana
• Iowa
• North Carolina
• South Carolina
• Tennessee
• Texas
• Wisconsin
• Wyoming

States that do not have a medical cannabis program:

• Idaho
• Kansas
• Nebraska

How to Become a Medical Cannabis Practitioner

A Medical Cannabis Practitioner, also referred to as a Medicinal Cannabis Practitioner, is a physician or APRN who is authorized to prescribe controlled substances and provide written certifications for medicinal cannabis [9]. The journey to becoming a Medical Cannabis Practitioner in Kentucky is a four-step process that includes [9]:

1. Confirming you meet the eligibility requirements
2. Completing the continuing education requirements
3. Applying for authorization through the Kentucky Board of Nursing
4. Registering with the Kentucky Office of Medical Cannabis to access the Medical Cannabis Practitioner Authorization Registration Portal

Let’s discuss these steps in further detail.

Am I Eligible?

Although this course will prepare you for the role of Medical Cannabis Practitioner, it is important to ensure you meet the qualifications before applying for authorization. Confirm you meet the following qualifications, and you are that much closer to your new role! [8]

1. Hold an active unrestricted Kentucky license as an APRN that is in good standing.
2. Have a valid Drug Enforcement Administration (DEA) registration and a current registration certificate is on file with the board.
3. Have an active account with the Prescription Drug Monitoring Program (PDMP) with a current PDMP registration certificate on file with the board. (the PDMP is the state-based electronic database used to track prescriptions for controlled substances) [18]
4. Has not engaged in inappropriate prescribing, personally furnishing, dispensing, possessing, diverting, administering, supplying, or selling a controlled substance or other dangerous drug for which a license (to prescribe, possess, dispense, personally furnish, administer, supply, or sell a controlled substance) has been denied or restricted, or for which disciplinary action has been taken.
5. Have completed the continuing education requirements (detailed in the next section).
6. Have no ownership or investment interest in or compensation agreement with a licensed cannabis business.

Am I Meeting the Continuing Education Requirements?

Per the new law, an applicant for an initial authorization shall have completed within the immediate 12 months a one-time requirement of 6 contact hours in the following subjects [8]:

1. Diagnosing qualifying medication conditions
2. Treating qualifying medical conditions with medicinal cannabis
3. The pharmacological characteristics of medicinal cannabis and possible drug interactions
4. Indications of cannabis use disorder

Thereafter, an APRN renewing the authorization shall have obtained during the earning period 3 continuing education hours in the subjects above.

In summary, APRNs who desire to provide written certifications for medicinal cannabis in Kentucky need an initial 6 CE hours and 3 CE hours at each renewal.

How Do I Apply?

After confirming your eligibility and completing the CE requirement, you can apply for authorization through the Kentucky Board of Nursing (https://kbn.ky.gov). Take these steps to submit your initial application. The same steps apply for renewal applications.

1. Submit an “Authorization to Provide Written Certifications for the Use of Medicinal Cannabis” Initial Application or Renewal Application.
2. Submit a copy of your DEA registration certificate.
3. Submit proof of completion of the continuing education requirements.
4. Pay a nonrefundable fee of $100.

Submit all supporting documentation via your account in the Kentucky Board of Nursing Nurse Portal. Your application will be valid for 6 months. If requirements are not within this time, your application will expire, and you will need to start the process over.

How Can I Access the Authorization Registration Portal?

After receiving authorization from the Kentucky Board of Nursing, you must register for an online account with the Kentucky Office of Medical Cannabis to access the Medical Cannabis Practitioner Authorization Registration Portal (https://kymedcan.ky.gov). It is through this portal that you will provide patients with written certifications for medicinal cannabis.

What is the Process for Writing an Initial Certification for My Patient?

The State of Kentucky has outlined Professional Standards of Care that APRN Medicinal Cannabis Practitioners must follow when writing certifications for patients in the state. You must practice these standards at all times. When providing written certifications to your patient, you must perform the following tasks [8][10].

1. Establish a Practitioner-Patient Relationship
2. Use the Right Form
3. Obtain a Medical History
4. Perform a Physical Exam
5. Perform Diagnostic Tests If Needed
6. Diagnose Qualifying Medical Conditions
7. Provide Education
8. Obtain Consent
9. Include a Statement
10. Document
11. Follow Up
12. Keep Records

Let’s discuss these steps in further detail.

Establishing a Practitioner-Patient Relationship

Establish a bona fide practitioner-patient relationship with the patient. This is required before you write the certification and must occur in-person. You may also establish the relationship after receiving a referral from the patient’s primary care provider and the relationship may be maintained via telehealth. However, the relationship should not be established via telehealth.

Using the Right Form

Make sure to use a form prescribed by the cabinet (refers to the Cabinet for Health and Family Services – the commonwealth of Kentucky). Keep in mind, the certification will be issued through the registration portal.

Obtaining a Medical History

You must obtain the following basic information about the patient:

• Name
• Date(s) of office visits or treatments, and responses to treatments
• Medical history, including relevant prescription history and diagnostic results
• History of drug use, including a documented review of the patient’s current medications to identify possible drug interactions, including benzodiazepines and opioids
• Psychiatric history
• Social and family history

You should also gather information about the patient’s experience with cannabis as well as their values, preferences, needs, and knowledge related to using cannabis [15].

Performing a Physical Exam

Your examination of the patient must occur in-person for the initial certification. You must not perform a telehealth examination of the patient for the initial certification. The physical examination should be relevant to the patient’s current medical condition and should include a focused physical examination.

Performing Diagnostic Tests If Needed

You must obtain a drug screen on the patient if there is evidence or behavioral indications of addiction or drug abuse. It is within your discretion to decide the nature of the screen and which type of drug will be screened.

Diagnosing Qualifying Medical Conditions

Diagnose the patient with a qualifying medical condition for which you believe the patient is likely to receive safe and effective therapeutic or palliative benefit from the use of medicinal cannabis. You may also confirm a diagnosis if the patient has been previously diagnosed with a qualifying medical condition by another health care provider. In this case, you must review the current treatment for the qualifying condition and the patient’s response to the treatment [15].

While research about the medicinal benefits of cannabis is limited, some evidence does show a benefit to certain health conditions. Drugs that contain cannabinoids (substances found in the cannabis plant), may help improve symptoms, such as tics and sleep impairments, in patients with mental health disorders [14]. However, research suggests cannabinoids may be most helpful in treating rare forms of epilepsy and nausea and vomiting associated with cancer chemotherapy [14]. For these reasons, qualifying medical conditions have been established to help you determine which of your patients would benefit most from medicinal cannabis. Qualifying medical conditions may vary across states.

Qualifying medical conditions in Kentucky include [12]:

• Any type or form of cancer regardless of stage
• Chronic, severe, intractable, or debilitating pain
• Epilepsy or any other intractable seizure disorder
• Multiple sclerosis (MS), muscle spasms, or spasticity
• Chronic nausea or cyclical vomiting syndrome that has proven resistant to other conventional medical treatments
• Post-traumatic stress disorder (PTSD)
• Any other medical condition or disease for which the Kentucky Center for Cannabis, or its successor, determines that sufficient scientific data and evidence exists to demonstrate that an individual diagnosed with that condition or disease is likely to receive medical, therapeutic, or palliative benefits from the use of medicinal cannabis

Diagnosing patients involves using diagnostic reasoning to synthesize and analyze data from health histories, physical examinations, and diagnostic information [1]. Diagnostic reasoning is a cognitive competency under the domain of clinical reasoning that is more than simply defining a clinical problem [16].

It also involves reducing diagnostic errors (by making sure you don’t miss something) and determining the best treatment available based on the patient’s needs. Diagnostic errors are associated with poor patient outcomes and are linked to practitioners’ insufficient knowledge, data-gathering flaws, and suboptimal approaches to information processing [16]. This is why you need to develop excellent diagnostic reasoning skills as an APRN.

For example, a patient may report symptoms associated with the above qualifying medical conditions, such as loss of appetite, depression, anxiety, sleep deprivation, and mobility issues secondary to chronic pain [2]. These symptoms alone may not be considered qualifying medical conditions (as they can easily be associated with non-qualifying medical conditions). However, medicinal cannabis for chronic pain may alleviate these symptoms if they are secondary to the pain.

This is also the case for MS-related symptoms (such as sleep disorder) and PTSD-related symptoms (such as intrusion symptoms, sleep disturbance, and mood imbalances) [2]. This is why it is important to perform a thorough evaluation of the patient’s medical history as well as primary and secondary symptoms before diagnosing or failing to diagnose a qualifying medical condition. This is part of diagnostic reasoning. Your goal is to ensure the patient receives the most appropriate treatment for their condition.

When writing certifications for medicinal cannabis, you may confirm a diagnosis once you:

• Obtain a copy of the medical records or detailed written summary indicating the diagnosis
• Are satisfied that those records confirm a diagnosis of a qualifying condition
• Maintain a copy of any record or report of any Medicinal Cannabis Practitioner on which the practitioner relied for purposes of meeting the requirements in this section
• Document a plan to obtain the patient’s consent to obtain and discuss the patient’s prior medical records within 30 days of initiating a treatment. Upon receipt of the medical records, you must review and incorporate the information from the records into the evaluation and treatment of the patient. If you are unable to obtain the patient’s prior medical records despite your best efforts, you must document those efforts in the patient’s chart
• Obtain and review a Prescription Drug Monitoring Program (PDMP) report for that patient for the 12-month period immediately preceding the initial patient encounter and appropriately utilize that information in the evaluation and treatment of the patient.
• Explain treatment, alternative risks, and the benefits of medicinal cannabis with the patient (more on this in the next section)
• Obtain written informed consent from the patient for treatment
• Discuss and document the patient’s treatment with the patient’s other providers
• Meet the requirements for providing certification to patients assigned female at birth who are of childbearing potential and age (more on this in the next section)

Providing Education

Consult with the patient (or the patient's custodial parent or legal guardian responsible for providing consent to treatment if the patient is a minor child). In the consultation, explain the treatment, benefits, alternatives, possible risks, and side effects associated with medicinal cannabis, including possible interactions between medicinal cannabis and any other drug or medication the patient is taking at the time. This includes any risk to fertility, or risks to fetal harm for patients assigned female at birth who are pregnant or breastfeeding.  

Before prescribing medicinal cannabis treatment, you must recommend all patients assigned female at birth and who are of childbearing age submit to a pregnancy test. If any patient declines to take a pregnancy test, you must document the patient’s declination and the stated rationale for their decision.  

If a patient assigned female at birth is pregnant or breastfeeding, you must provide counseling. If the patient declines consultation, you must document the patient’s declination and the stated rationale for their decision. This must be completed prior to providing a written certification. 

Obtaining Consent

After thorough education has been provided, obtain written informed consent from the patient for treatment (or the patient’s custodial parent or legal guardian, if the patient is a minor child). 

Including a Statement

Before you issue the written certification, make sure it includes a statement from you certifying that: 

1. A bona fide practitioner-patient relationship exists between you and the patient. 
2. The patient has been diagnosed with at least 1 qualifying medical condition for which you believe the patient may receive medical, therapeutic, or palliative benefit. 
3. In your professional medical opinion, the patient may receive medical, therapeutic, or palliative benefits from the use of medicinal cannabis. 

Documentation

Include a documented review of whether standard medical treatment has been attempted or considered. If standard medical treatment is not attempted, you must document the reasons that standard medical treatment is not appropriate for the patient. Also document findings from your evaluation of the patient, such as medical history obtained or reported, physical exam findings, diagnostic test results, and patient declinations. Finally, record that you issued the certification in the electronic monitoring system within 24 hours of providing the patient with the certification. 

Follow Up

Be available to provide follow-up care and treatment to the patient, including physical examinations relevant to their condition to determine the efficacy of medicinal cannabis in treating their qualifying medical condition. If the qualifying condition was indicated as a terminal illness in the prior 6 months, you must confirm whether the patient’s condition continues to be a terminal illness.  

Terminate or decline to issue a new written certification if: 

• The patient no longer has the diagnosis of, or symptoms of, the qualifying medical condition 
• You are no longer authorized to issue a written certification 
• Based on your clinical judgement, the patient or caregiver is abusing or diverting medicinal cannabis 
• The patient is deceased 

Be sure to notify the cabinet in writing within 30 days the name of any patient for whom you terminated or declined to issue a written certification. 

Keeping Records

Keep all records required for the recommendation for a written certification for at least 5 years following the last office visit by the patient. The records may be kept with the patient’s other medical records.

What Happens When My Patient Needs a Renewal Certification?

You may provide subsequent or renewal certifications, including for registry identification card renewals, electronically or during a telehealth consultation [8][10]. You may renew a certification for no more than 3 additional periods of no more than 60 days each (180 days total). After that, you may issue another certification only after an in-person or telehealth examination. For renewing a registry identification card, the certification is valid for a maximum of 60 days.

What are the Limitations of My Role When Writing Certifications?

While following the above rules regarding writing certifications ensures you are practicing according to Kentucky law, limitations of your role exist. You must not [10]:

• Dispense medicinal cannabis
• Provide a written certification to a family member or for yourself

Dispensing refers to the delivery of a prescription drug or product to a patient [23]. Dispensaries are responsible for dispensing medicinal cannabis. Your role is to write the certification in the registry, which allows the patient access to a dispensary with their registry identification card.

Additionally, if you fail to renew your authorization or are otherwise unable to legally practice as a registered nurse or APRN, you are legally prohibited from practicing as or using the title of Medicinal Cannabis Practitioner until you have been reissued authorization by the Kentucky Board of Nursing.

What Happens if I Violate the New Law?

The Kentucky Board of Nursing may probate, restrict, suspend, or revoke your authorization to provide written certification for the use of medicinal cannabis and practice license for violations of the above rules [8][10]. An investigation may be made against you, and you may be required to undergo substance use evaluation or be subject to immediate temporary suspension [8].

Treating Qualifying Medical Conditions with Medicinal Cannabis

In this final section of the course, we will discuss treatment of qualifying medical conditions with medicinal cannabis as recommended by medical experts through clinical practice guidelines. Although this information is meant to guide your practice, you should follow your workplace’s policy on prescribing medicinal cannabis.

Qualifying medical conditions discussed in this section include:

• Cancer
• Chronic Pain
• Epilepsy
• Multiple Sclerosis and/or Spasticity
• Chronic Nausea and Vomiting
• Post-Traumatic Stress Disorder

Medicinal Cannabis and Cancer

The American Society of Clinical Oncology (ASCO) developed guidelines in 2024 to guide clinicians on how to use medicinal cannabis as a treatment in adult patients with cancer [3]. The organization developed the guideline after a review of multiple research studies, although the evidence is limited.

Guidelines are as follows [3]:

• The ASCO strongly recommends against using cannabis and/or cannabinoids in place of cancer-directed treatment. Cannabis/cannabinoids used as cancer-directed treatment may cause significant clinical problems (fatigue, confusion, feeling high) without good evidence of clinical benefit.
• The ASCO recommends against using cannabis and/or cannabinoids to augment cancer-directed treatment. The ACOS categorizes this recommendation as weak, meaning the undesirable effects probably outweigh the desirable effects, but appreciable uncertainty exists.
• The ASCO recommends against the use of 300 mg or more per day of oral CBD to manage symptom burden in adults with cancer due to lack of proven efficacy and risk for reversible liver enzyme abnormalities. The ACOS categorizes this recommendation as weak, meaning the undesirable effects probably outweigh the desirable effects, but appreciable uncertainty exists.

In summary, the ACOS is most certain that cannabis and/or cannabinoids should not be used in place of cancer treatments. The above recommendations are only applicable to adults who are not part of a clinical trial.

Medicinal Cannabis and Chronic Pain

An expert review panel developed “Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions 2024” to guide clinicians on how to use medicinal cannabis in adults with chronic pain [2]. Below are the panel’s recommendations.

For chronic pain alone [2]:

• The panel recommends cannabinoid-based medicines (CBM) as monotherapy, replacement, or adjunct treatment, in people living with chronic pain, for the management of chronic pain including central and/or peripheral neuropathic pain to improve pain outcomes.
• The panel recommends CBM as an adjunct treatment, for the management of chronic migraine or chronic headache, in those not achieving adequate response to other modalities. However, the panel categorizes this recommendation as weak as some patients experience headache caused by cannabis. On the contrary, the panel places a high value on CBM benefit of migraine and headache relief over the risk of adverse events (which are mostly non-threatening). To mitigate the risk of headache caused by cannabis, starting with a low dose, titrating slow, and choosing the best route for the patient’s needs is recommended.

For chronic pain among patients using opioids [2]:

• The panel recommends CBM as adjunctive treatment to opioids, for the management of chronic pain in those experiencing unsatisfactory analgesia from opioid treatment.
• The panel recommends CBM as adjunct treatment among people using moderate/high doses of opioids (>50 morphine equivalent) for the management of chronic pain and/or to increase opioid sparing.
• The panel recommends CBM as adjunct treatment for chronic pain among people using any dose of opioids who are not reaching chronic pain goals, are experiencing opioid-related adverse events, or display risk factors for opioid-related harm.

For chronic pain in patients with certain medical conditions [2]:

• The panel recommends CBM for the management of muscular and neuropathic pain in people living with HIV who are not achieving adequate response, or those experiencing adverse effects to other treatment modalities.
• The panel recommends CBM as adjunct treatment, for the management of chronic pain in people living with arthritic conditions in those not achieving adequate response to other modalities.
• The panel recommends CBM as adjunct treatment, for management of back pain, fibromyalgia pain, or other chronic pain in people with fibromyalgia who are not achieving an adequate response to standard analgesics.

For other symptoms associated with chronic pain [2]:

• The panel recommends THC-dominant cannabis for people with problematic loss of appetite in association with chronic pain, over no treatment.
• The panel recommends CBM as adjunct therapy to improve symptoms of depression in people living with chronic pain experiencing unsatisfactory results from standard treatment.
• The panel recommends CBM as adjunct therapy to improve symptoms of anxiety in people living with chronic pain not responsive to, or intolerant of, non-pharmacologic treatment.
• The panel recommends CBM as monotherapy, replacement or adjunct treatment, to improve sleep and symptoms of sleep deprivation in people living with chronic pain not responsive to, or intolerant of, other modalities or pharmacologic treatment.
• The panel recommends CBM as monotherapy, replacement or adjunct treatment, in people living with chronic pain, for mobility in those not achieving adequate response to other modalities. However, the panel categorizes this recommendation as weak because although various forms of CBM show benefits in mobility, adverse events related to the smoked form of CBM are less favorable.

In summary, CBM is recommended as an adjunct, replacement, or sole treatment for chronic pain and some pain-associated symptoms. Although no recommendations were made against the use of CBM for chronic pain, CBM is often recommended as a “last resort” treatment so-to-speak or preferred over no treatment at all. It is also important to note that CBM is recommended as an adjunct treatment for pain in patients who take opioids and never as a replacement.

Medicinal Cannabis and Epilepsy

Consider the following evidence when treating epilepsies. Medicinal cannabis has been shown to be effective in the treatment of some forms of epilepsy, including Dravet syndrome, Lennox–Gastaut syndrome, and tuberous sclerosis complex [24]:

• Darvet Syndrome

A rare, severe childhood-onset myoclonic form of epilepsy, characterized by prolonged seizures often triggered by fever or quick body temperature changes.

• Lennox–Gastaut Syndrome

An epileptic encephalopathy characterized by multiple seizures and severe cognitive impairment.

• Tuberous Sclerosis Complex

A rare genetic disease that causes benign tumors in various organs (including the brain) characterized by varying epileptic seizure types.

CBD is also commonly used as an adjunct therapy for epileptic encephalopathies with clobazam (a benzodiazepine) [13][24]. Additionally, epidiolex (a CBD oral solution) was approved by the FDA in 2018 as treatment for both Darvet syndrome and Lennox-Gastraut syndrome [22].

In pediatric populations, studies have consistently shown purified CBD’s effectiveness in reducing seizure frequency and improved quality of life in children with drug-resistant epilepsy [6]. These reported benefits have been noted in various countries. While this is not a clinical guideline recommendation, it serves as a basis for parental (or legal guardian) education and treatment options.

In summary, follow your workplace’s policy on how to treat epilepsy with medicinal cannabis. Research on this subject is limited to rare and severe forms of epilepsy.

Medicinal Cannabis and Chronic Nausea and Vomiting

The aforementioned expert panel also guides clinicians on how to use CBM to treat nausea secondary to chronic pain in adults [2]. Additionally, the ACOS makes a recommendation regarding the treatment of nausea and vomiting in adults receiving chemotherapy.

Guideline recommendations [2]:

• The panel recommends CBM for the management of HIV-related nausea, in people living with HIV. CBM is for symptom management only and should not replace the use of antiretroviral therapies.
• The panel recommends CBM as a consideration to reduce nausea in people living with chronic pain as monotherapy or adjunct treatment for those not achieving adequate response to other treatment modalities. However, the panel categorizes this recommendation as weak as it does not include cancer-related nausea. On the contrary, the panel places a high value on the benefit of CBM for nausea relief over the risk of adverse events of CBM (which are non-threatening).
• The ACOS recommends dronabinol, nabilone, or a quality-controlled oral 1:1 THC: CBD to augment the antiemetic regimen of adults with refractory nausea and vomiting who receive moderately or highly emetogenic antineoplastic agents with guideline-concordant antiemetic prophylaxis. The ACOS categorizes this recommendation as weak, meaning the desirable effects probably outweigh the undesirable effects, but appreciable uncertainty exists.

In pediatric populations, evidence has shown that synthetic cannabinoids demonstrated benefit in chemotherapy-induced nausea and vomiting when compared with conventional agents [6]. However, this is not a clinical guideline recommendation. Experts advise practitioners to consider the child’s specific condition and prognosis, and the potential benefits and risks, including drug-drug interactions [6]. Additionally, medical cannabis products may require slow titration, and administration should be tailored to the individual child and condition [6].

In summary, CBM is recommended for HIV-associated nausea in adults, but not in place of HIV treatment. CBM is also recommended for refractory nausea and vomiting in adults who receive both chemotherapy and antiemetic prophylaxis concurrently.

Medicinal Cannabis and Multiple Sclerosis and/or Spasticity

The expert panel also addressed CBM as a treatment for symptoms associated with multiple sclerosis (MS) in adults.

Guideline recommendations [2]:

• The panel recommends CBM as an adjunct treatment for pain management in people with MS who do not achieve adequate response to other modalities.
• The panel recommends CBM as an adjunct treatment, for the management of muscle spasms in people living with MS in those not achieving adequate response to other modalities.
• The panel recommends CBM as an adjunct treatment, for the management of sleep disorder in people living with MS in those not achieving adequate response to other modalities.

In pediatric populations, evidence has shown that dronabinol has been used to successfully manage spasticity in children with neurological complexities and receive palliative care [6]. This is not a clinical guideline recommendation. As aforementioned, treatment should consider the child’s specific condition and prognosis, and potential benefits and risks.

In summary, CBM is recommended for the treatment of MS symptoms in adults when other treatments are not effective.

Medicinal Cannabis and Post-Traumatic Stress Disorder

Finally, the expert panel addresses the use of CBM in the care of adults with PTSD. The U.S. Department of Veteran Affairs (VA) also recommended its clinical practice guideline titled “Management of Posttraumatic Stress Disorder and Acute Stress Disorder 2023.”

Guideline recommendations [2]:

• The panel recommends CBM to improve PTSD symptoms in people living with chronic pain not responsive to, or intolerant of, non-pharmacologic treatment [2]. PTSD symptoms include pain, intrusion symptoms, sleep disturbance, and reduced mood and quality of life. However, the panel categorizes this recommendation as weak as studies were limited to one form of cannabis – herbal. On the contrary, the panel placed a high value on the benefit of CBM for PTSD symptoms over the risks of adverse events of CBM (dry mouth, disturbance in attention and memory, and the potential for the patient to use CBM for non-medical purposes).
• The VA recommends against the use of cannabis or its derivatives to treat PTSD due to limited evidence [20].

In summary, CBM is favored for treatment of PTSD symptoms when non-pharmacological treatments are not effective (although it depends on the form of cannabis used). It is important to note that both guidelines showed insufficient evidence as the reason for its recommendation.

To conclude this entire section, your primary goal in treating patients with medicinal cannabis is to achieve therapeutic effects while maintaining the patient’s safety. Clinical practice guidelines can help guide your practice when treating qualifying medical conditions as a Medical Cannabis Practitioner in Kentucky. However, as mentioned earlier, follow your workplace’s policy on prescribing medical cannabis.

Conclusion

This course has provided you with a detailed look into the role of the Medical Cannabis Practitioner, including what it takes to fulfill this role and how to diagnose and treat patients with cannabis per Kentucky law and within your APRN scope of practice. Further details on the new rules surrounding APRN medical cannabis prescribing can be found under the following Kentucky law:

“Title 201 | Chapter 020 | Regulation 067: Professional Standards for Medicinal Cannabis” (https://apps.legislature.ky.gov/law/kar/titles/201/020/067).

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