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Good Practice: Legalization of Cannabis

Legalization of cannabis possession by adults over 18 came into effect in Canada in 2018. Since then, physiotherapists have voiced questions and concerns about their roles and responsibilities when treating patients who use cannabis. In this article we will address some important issues physiotherapists need to consider and provide answers to some of the questions that have been asked.

What do we know about cannabis and its use in Canada?

The use of cannabis in Canada is not new, nor is it limited to a small, specific population. According to Stats Canada, in 2017 an estimated 4.9 million Canadians aged 15 – 64 used cannabis for medical and non-medical purposes.2 In Alberta the per capita usage of cannabis, 24.1 grams, was third highest in Canada and 25.1% of that was prescribed for medical reasons.2

Cannabinoids (the chemicals in cannabis that react with neuro receptors to produce the desired effects) can be ingested, inhaled, vaporized or applied externally. When the drug is delivered by inhaling or vaporizing the effects can be very rapid, often starting within minutes and peaking within 15-30 minutes. When ingested through edible products the effects may take 60 – 90 minutes to start to take effect and effects can last for several hours.1

Central nervous system (CNS) effects

Cannabinoids act on the CNS, producing effects ranging from feelings of euphoria and the sense of mellowing out, to more negative psychotropic effects such as hallucinations, confusion, paranoia, or panic reactions.3
Of concern for physiotherapists are some of the short-term impairments that may be experienced. These may include:

  • Difficulties with cognition, memory, and alertness
  • Coordination and balance difficulties leading to increased risk of falls or other accidents
  • Impairment of ability to think and slowing of reaction time when driving, working, or other activities requiring rapid mental and physical reactions3

Although there is limited evidence related to long-term effects with chronic use, there are reasonable concerns that some CNS functions related to mood and behavior may be adversely affected.3

Medical uses

There is still considerable controversy about whether medical cannabis is effective. Anecdotal reports and case studies have generated interest in the use of this intervention in treating pain, inflammation, spasticity, and other problems seen commonly in physiotherapy practice.3

A 2018 systematic review of systematic reviews for medical cannabinoids looked at the effects of medical cannabinoid use on pain, nausea and vomiting, spasticity and possible harms from use.4 The review concluded that “there is reasonable evidence that cannabinoids improve nausea and vomiting after chemotherapy. They might improve spasticity (primarily in multiple sclerosis). There is some uncertainty about whether cannabinoids improve pain, but if they do, it is neuropathic pain, and the benefit is likely small. Adverse effects such as dizziness, sedation, confusion and feeling high are very common, meaning that benefits would need to be considerable to warrant trials of therapy.”4

What is the Physiotherapist’s Role?

Despite the results of the 2018 systematic review, the stats on use tell us that there is a high probability that physiotherapists are or will be treating clients who have, are or will be using cannabis. Understanding what this means in practice is important to every physiotherapist. Providing information about and managing challenging situations arising from cannabis use (including issues of impairment and consent) are key roles for physiotherapists.

Education

Physiotherapists are not authorized to prescribe cannabis or any other drug, and are cautioned against recommending any medications, including cannabis. However, they may provide reliable resources and refer patients to physicians to determine if a prescription for medical cannabis is appropriate.

Patients may ask questions related to prescription or recreational use to help manage symptoms such as pain, inflammation, or spasticity. All these symptoms may be related to identified rehabilitation goals. Physiotherapists need to be aware of the options that are available for patients considering medical cannabis and where patients can find additional reliable information. As with other medications, physiotherapists are advised to develop collaborative relationships with prescribing practitioners such as physicians, or nurse practitioners rather than providing advice about cannabis use.

Helping patients monitor the affects of using cannabis for decreasing or controlling their symptoms is also a role physiotherapists can play. Using reliable pain scales, asking about symptoms and suggesting the use of a personal diary to track patient progress are all useful strategies to help patients to objectively determine if their treatment is working.

“Clinicians should also be aware that cannabis can produce untoward effects on cognition, coordination, balance, and cardiovascular and pulmonary function and should be vigilant for any problems that may arise if patients are using cannabinoids during physical rehabilitation.”3 It is important to recognize signs of impaired judgment/function that will affect performance or safety before, during and after treatment and consider how this will affect the individual’s ability to drive, return to work, or function safely in the community.

Monitoring for signs of mood or personality changes, depression, despondency, decreased motivation and delusions or hallucinations, are important roles a physiotherapist can take.3 Identifying these issues when they arise, documenting them and making a referral to the physician or other health-care provider to determine the root cause of these changes would be appropriate steps to take.

Finally, physiotherapists should also be aware of the Canadian and Alberta legislation related to legalization of Cannabis. Useful information can be found from the Alberta Government at: https://www.alberta.ca/cannabis-legalization-in-canada.aspx

What questions has the College of Physiotherapists of Alberta been asked?

Here are some of the questions physiotherapists have asked and the answers provided:

  1. Is it appropriate to treat a patient who has used medical cannabis prior to their appointment?

Part of a comprehensive history would include asking about prescription medication, non-prescription medication, and herbal medications/vitamins/recreational drug use. This information will help the physiotherapist plan an appropriate treatment program and monitor patient progress. Allowing the patient to feel confident to include cannabis use when answering is important to ensure a complete medical history has been obtained. This may not occur at the first visit but if there is an indication of use, probing questions related to frequency of use, mode of consumption, and reported effects may be appropriate.

If a patient had used cannabis immediately prior to treatment, it may mask pain, cause a lack of coordination, or have other effects. This would impact treatment planning and delivery. The physiotherapist should act and adjust their plans accordingly. This is consistent with the patient who presents to clinic immediately after taking a dose of any prescription pain medication.

If the patient appears impaired, then the clinician would need to act according to the clinic’s usual protocols for managing an impaired patient. This would again be consistent with the response if an intoxicated patient attended clinic, or a patient had taken a prescription medication prior to their treatment and was impaired.

2. Do we require any additional documentation from the patient about their cannabis use?

Asking about prescription medication, non-prescription medication, and herbal medications/vitamins/recreational drug use (including cannabis) has always been an appropriate component of a comprehensive history and should be documented accordingly.

3. Are patients who use cannabis allowed to drive home following an appointment? Or if someone shows up too high for an appointment what is the procedure?

Alberta has made changes to the impaired driving laws related to alcohol and drug impaired driving offences and sanctions. These came into effect April 9, 2018. Information about these changes can be found at: https://www.alberta.ca/impaired-driving-law-changes.aspx

The Government of Canada has good information on driving while impaired by a drug at: https://www.canada.ca/en/health-canada/services/substance-abuse/talking-about-drugs/driving-impaired-drug.html

From a physiotherapy perspective, the expectations will be the same or substantially similar to when someone attends an appointment intoxicated. As stated in the Managing Challenging Situations Guide,6 if a patient attends a visit intoxicated and the physiotherapist turns them away, and the physiotherapist is aware that the patient is intending to drive, the physiotherapist may report this to local authorities by calling 911, RID, or Curb the Danger.

In Canada it is against the law to drive while impaired by alcohol and/or drugs. Section 21 of the Canadian Criminal Code identifies that an individual is party to an offence if the person “does or omits to do anything for the purpose of aiding any person to commit it.” Section 60 of the Alberta Traffic Safety Act provides protection for physicians or other health-care providers to report impaired drivers and ensures the confidentiality of the individual making the report.7

The Managing Challenging Situations resource5 provides guidance about what to do in cases where an ethical, moral, or legal imperative leads to a decision to contact the authorities. The physiotherapist must use their judgment to determine whether to report their concerns. In this situation the physiotherapist needs to balance the potential consequences of not reporting the situation and the risk of being party to a criminal offence against the serious nature of breaching a patient’s privacy and act accordingly.

In these circumstances the test to determine if breaching patient confidentiality is justified is as follows:

  • The physiotherapist perceives that there is a clear risk of harm to the patient or any other clearly identifiable individual.
  • The danger poses a risk of serious bodily harm or death.
  • The danger is imminent (i.e., “a sense of urgency must be created by the threat of danger”).

When all three requirements are met, legislation allows a breach of privacy without patient consent for the purpose of alerting the appropriate authorities.

4. Can a person who is using cannabis provide consent for treatment?

Ultimately that comes down to the physiotherapist’s judgment of whether the individual is impaired or not and is no different from any other situation where it appears that the individual’s ability to provide consent may be impaired.

As stated in The College of Physiotherapists of Alberta’s Informed Consent Practice Guideline,8 “the patient must have the ability to appreciate the nature and consequences of the consent decision.” Consent is ongoing and is treatment specific. Some treatments come with more risk that others. If a physiotherapist has concerns that the patient does not appreciate the nature and consequences of the consent decision, regardless of the reason, they should not seek or accept consent for the specific treatment proposed. This will impact the treatment plan and the approach the physiotherapist will take.

In summary, the College of Physiotherapists of Alberta’s perspective is that cannabis be treated in much the same way as alcohol or prescription pain medications. Although the substance is different, the effects and issues of impairment and consent are largely the same.

It is important that individual physiotherapists educate themselves on the topic to provide current and accurate information to their patients within the scope of practice for the profession and to deal with issues of impairment appropriately. In addition to the sources cited in the article, here are a few other relevant and useful links from the Alberta and Canadian Government to guide learning.

  1. Government of Canada: (2013) Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids. Available at: https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-use-marijuana/information-medical-practitioners/information-health-care-professionals-cannabis-marihuana-marijuana-cannabinoids.html Accessed May 7, 2018.
  2. Statistics Canada (2018) Provincial and Territorial Cannabis Economic Accounts, 2017. Available at: http://www.statcan.gc.ca/daily-quotidien/180430/dq180430b-eng.htm Accessed May 1, 2018.
  3. Ciccone CD. Medical marijuana: just the beginning of a long, strange trip? Phys Ther. 2017 February; 97 (2):239–248. https://doi.org/10.2522/ptj.20160367. Accessed May 7, 2018.
  4. Allan MG, Ramji J, Perry D, Ton J, Beahm NP, Crisp N, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Can Fam Physician 2018 February; 64 (2) e78-e94. Accessed May 16, 2018.
  5. Allan MG, Finley CR, Ton J, Perry D, Ramji J, Crawford K, et al. Systematic review of systematic reviews for medical cannabinoids. Can Fam Physician 2018 February; 64 (2) 111-120. Accessed May 16, 2018.
  6. Physiotherapy Alberta College + Association (2016). Managing Challenging Situations Resource Guide. Available at: https://www.physiotherapyalberta.ca/files/guide_managing_challenging_situations.pdf Accessed May 7, 2018.
  7. Province of Alberta. (2018) Traffic Safety Act http://www.qp.alberta.ca/documents/Acts/t06.pdf Accessed May 8, 2018.
  8. Physiotherapy Alberta (2017) Practice Guideline: Informed Consent. Available at: https://www.physiotherapyalberta.ca/files/practice_guideline_informed_consent.pdf Accessed May 8, 2018.

Page updated: 20/04/2022