Can too much weed kill you?

 

The idea for this post came from a Facebook friend who indicated they were concerned about the US’s recent push to legalize marijuana, particularly in light of the chances of death from an overdose. Myself and another ED colleague had never heard of a death resulting from THC. So off to research I went.

Scouring the search engines I could find no credible evidence to say overdosing on marijuana has, in fact, been attributed to a death. Having too much marijuana can cause a number of unwanted conditions within the body which can make you VERY uncomfortable:

  • Temporary feelings of paranoia, fear and anxiety
  • Shortness of breath
  • Pupil dilation
  • Vomiting and/or nausea
  • Fast heart rate
  • Shaking that is hard to control, feeling cold
  • Disorientation or hallucinations
  • Hangover

But these symptoms are also common with other illicit and legal drugs, such as alcohol. Studies have shown that a person would have to receive a massive amount of THC, the active high-producing ingredient in marijuana, to die from it- this would equate to pounds being used at a time. Very unlikely.

So marijuana is harmless?

Not so fast! The question is whether you can die from a single overdose of marijuana. But just like other chemicals that humans used for pleasure marijuana can have serious effects which could indirectly lead to death. It is these items I think many are talking about when they discuss the dangers of marijuana consumption.

A report from Colorado USA where marijuana is legal has found that traffic fatalities with drivers showing marijuana in their system at the time of the accident rose by 154%! Hospital presentations were also mentioned as increasing due to marijuana consumption, however the evidence was not clear that marijuana definitely had an impact. School suspensions from marijuana use were also mentioned.

Marijuana also has shown long-term health affects in terms of memory and brain function. There can also be secondary effects from smoking the drug and there are associated birth defects when women who are pregnant use marijuana.

The bottom line…

The actual THC in marijuana can kill you if consumed in large enough quantities. However, obtaining and using those quantities will either land you in jail for a very long time or be practically impossible. There are no known attributed cases to anyone dying from consumption of marijuana.

However, there are dangers in misuse of marijuana. As with all other chemicals consumed by individuals to obtain a euphoric state marijuana can alter a person’s functioning and cause health concerns. Therefore, any use of this or any other substance must be done so with full knowledge of the effects. And there it goes without saying a careful review of current laws on consumption in your area.

Should it be legal?

The eternal debate in modern society. Like other legal substances marijuana has very negative side-effects both short and long term, however that has not stopped tobacco and alcohol from remaining legal. Some would argue that it is a ‘gateway’ drug and could lead to greater abuse. However we do not know the numbers of individuals who use marijuana and never progress to harder drugs, so how can we really know? Like alcohol marijuana can impair a person’s driving and other complex and fine motor skills. So policies and laws would need to be put in place outlining legal limits on consumption and operation.

There is growing credible evidence that marijuana is beneficial to relieving pain and other neurological symptoms. Therefore, I think it’s use as a medical alternative to stronger and harsher medications is welcomed. Especially if those with severe and chronic pain can be helped. These individuals are often struggling, and if allowing this avenue can bring relief then I am all for it.

As for the rest of us, I still don’t know. I will state for the record I have never used marijuana. I can see both sides of the debate, and I guess as I have gotten older my views have become more complex. While once very much against the idea now I am leaning toward society’s choice. There are some distinct advantages to legalizing marijuana.

  • Once legal safe limits on consumption can be placed.
  • Regulations on growing, processing, and distribution can be instated and ensure a safe product.
  • There will be a decreased demand from law enforcement agents in going after marijuana users and dealers.
  • Marijuana use can be taxed leading to revenue.
  • Legalization may also spark increased interest in investigating other medicinal properties.

So I guess I am on the legalizing side of the debate. I also can see the arguments with those who wish to uphold the laws against marijuana use. However, I do feel that they will be fighting a loosing battle in years to come.

References

Herb.com: Marijuana Deaths: How Many Are There?

Huff post: Here’s How Many People Fatally Overdosed On Marijuana Last Year

New Health Guide: Can You Overdose On Marijuana?

Family Council: Number of Deaths Caused by Marijuana Much More than 0

National Institute on Drug Abuse: What is marijuana?

 

 

 

Do we need RNs in nursing homes? The NSW government doesn’t think so

 

It seems that every day I keep being reminded of issues facing the ‘premature death’ debate in Residential Aged Care Facilities (RACFs). An article today again raised this issue on a matter that had gone under my radar, that the New South Wales (NSW) minimum legislative ruling regarding a registered nurse to be on duty in a RACF 24 hours a day seven days a week had been abolished. I must say as a registered nurse, healthcare worker, former aged care registered nurse and aged care manager I was appalled.

A little background

The NSW Public Health Act 2010 superseded the NSW Public Health Act 1991. Section 104 of the 2010 act stated that a nursing home (their definition) MUST be staffed by a registered nurse at ALL times. This act was intended to ensure that RACF residents who were needing what was formerly known as high care would be taken care of by registered nurses. When this act was passed the Commonwealth Aged Care Act of 1997 was in-place and defined what was considered as high and low residential aged care.

Changes to federal funding legislation

In 2013 the Living Longer, Living Better initiative was passed by the Federal Government. This initiative did several things, but the key factor in this initiative was to eliminate the distinction between high and low residential aged care. Essentially, the government, for all intents and purposes, said that every elderly RACF resident only needed basic care, eliminating the complex health care component. This jeopardized the Public Health Act’s nursing home definition, and therefore potentially removed the requirement for registered nurses to be rostered in RACF homes 24 hours a day. However, in July of 2014 the NSW government publishes an amendment upholding section 104 and continuing to require a registered nurse in RACF homes. This amendment was only an interim measure which expired in Demeber 2015.

NSW government inquiry into RACF care

On the 25th of June 2015 the NSW government begins an inquiry entitled “Registered nurses in New South Wales nursing homes“. The inquiry is finished and the report released on the 29th of October 2015. In it the committee makes several very important distinctions about the role of registered nurses within RACFs:

3.2 For many inquiry participants the administration and management of medication in aged care facilities by registered nurses was considered essential to ensure residents’ health and safety.

 

3.4 Leichhardt Council expressed similar concern about unqualified or inappropriately qualified staff administering medications, particularly Schedule 8 drugs, as it could lead to adverse health outcomes for residents.67

 

3.12 The ability of registered nurses to clinically assess the health status of residents was another important role highlighted by stakeholders

 

3.15 The Combined Pensioners and Superannuants Association asserted that the assessment skills and expertise of registered nurses were particularly critical in aged care facilities, as – unlike hospitals – there is generally no immediate access to a doctor and in situations where a resident’s health deteriorates rapidly, a registered nurse can be at hand to make a clinical judgement about the appropriate course of action.

 

3.18 A number of inquiry participants highlighted the fact that registered nurses have the necessary skills training and experience to provide end-of-life care as a reason to mandate their continuous presence in nursing homes.

 

3.26 There was general consensus that aged care staff and enrolled nurses can undertake the personal care needs of residents with dementia, however, some inquiry participants pointed out that registered nurses are still required to administer certain medications (as already discussed throughout this chapter) and manage more challenging behaviours.

 

3.33 Numerous stakeholders noted that the supervision of enrolled nurses and aged care staff is a key accountability for registered nurses in residential aged care facilities.

 

3.37 Registered nurses also supervise aged care workers. NSW Health’s Employment of Assistants in Nursing (AIN) in NSW Health Acute Care dictates that ‘an AIN will work within a plan of care under the supervision and direction of a registered nurse when providing aspects of nursing care’.

A number of groups, such as the Australian College of Nursing (ACN), submitted statements of support for the committee recommending keeping registered nurses within RACF. The highlighted concerns that although the federal government had eliminated the high and low care qualifiers in funding nursing home residents were requiring more skilled care due to their chronic conditions. Additionally, the ACN response highlighted the committee’s evidence that assistants in nursing (AINs) and enrolled nurses (ENs) needed in-person supervision as per the requirements withing their scope of practice.

NSW government refuses to take action

However, in April of 2016 the NSW government disagreed with the committee’s findings and overturned the amendment to the Public Health Act. In an article the then health minister Jillian Skinner stated that RACF facilities were regulated by the federal government, and therefore a NSW specific requirement would constitute double regulation.

The Shooters and Fishers party, led by R.L. Brown introduced an amendment to the Public Health Act 2010 which replaced the term nursing home with a definition more appropriate to the Living Longer, Living Better initiative. This would then bring the Public Health Act of 2010 current and uphold section 104 requiring 24 hour seven day a week registered nurse coverage. The bill was passed by the upper house in May of 2017 and voted down by the lower house on the 11th of May 2017.

What does mean for RACF residents?

Within nursing homes it is often, particularly in the evening/night and weekend hours, that the registered nurse serves as the in-charge for the facility. This means they are ultimately responsible for all care and function of the facility. It is during these times that rates of pay, due to penalties, is highest for registered nurses. So it stands to reason that this is the period where a registered nurse would not be rostered on.

But who will clinically assess a resident’s need for analgesia, and would a RACF allow a non-licensed AIN to administer schedule eight medications such as Endone or Ordine? If a resident falls in a facility during these hours who is going to make the clinical assessment of whether that resident is safe to be lifted, and whether that resident should be sent to hospital? If a resident shows signs of aspiration (coughing after swallowing, difficulty breathing during meals, etc.) on a Saturday morning and no registered nurse is rostered on until Monday morning, will that resident not eat for the weekend? I know these are extreme examples, but they are common within aged care facilities.

Registered nurses within facilities also handle administrative and safety tasks. They are often required to fill sick-calls during their shifts. Registered nurses are also seen as fire wardens and trained to respond to fire alarms if needed. Who is going to undertake these jobs if the registered nurse is absent? I know these are extreme cases, but currently there is NO legislative requirement for registered nurses to be rostered within aged care facilities at ANY time. It is the discretion of the facility to decide when to roster on a registered nurse. I wonder if families of loved ones in aged care facilities would be made aware of periods when a registered nurse was not employed, and how would they feel about this?

What does this mean for the hospital and greater acute health system?

From personal experience and common sense if a registered nurse is not available in an aged care facility if a resident is requiring as needed (PRN) medication an ambulance is called. An issue with aspiration, which could be assessed by the registered nurse, would need to be undertaken by the local hospital who would be the closest access to registered nurses. Any changes in a patient’s condition would require transfer to hospital as there would be no registered nurse on premesis to assess their condition and contact the resident’s medical representative.

This means increased workload on the ambulance service and emergency departments. In a period where the number of ambulance call-outs and emergency presentations is rising do we need a further burden on our health system? And it isn’t fair for the residents themselves. Transferring a elderly person, particularly one with dementia, to hospital can lead to disorientation and further complications in their treatment leading to longer stays in hospital.

Call to action!

Jillian Skinner stated in her 2015 statement that she would encourage federal adoption of the mandatory 24 hour registered nursing requirement through the Council of Australian Governments. NSW through their own inquiry found critical evidence that registered nurses provide an invaluable link to improving a resident’s health and well-being in aged care facilities. Every clinical representative body can attest to the need for trained clinical registered nurses to be on-duty at all times in aged care facilities.

There needs to be action on this subject, not just debate and fact-finding. The evidence is overwhelming for the need for minimum clinical supervision in aged care facilities. We need lawmakers to listen to their constituents and put into place minimum standards.

References

NSW Public Health Act 2010- http://www.legislation.nsw.gov.au/inforce/e20f1d11-6a0d-ec9a-fe79-d31ae57c52c3/2010-127.pdf

Workingcarers.org.au: Living Longer Living Better changes that might affect working carers-  http://www.workingcarers.org.au/index.php/work-n-care/reports/1467-living-longer-living-better-changes-that-might-affect-working-carers

NSWNMA: Timeline of events – registered nurses in NSW nursing homes-  http://www.nswnma.asn.au/wp-content/uploads/2013/09/Timeline-of-events-registered-nurses-in-NSW-nursing-homes.pdf

Legislative Council: Registered nurses in New South Wales nursing homes- https://www.parliament.nsw.gov.au/committees/DBAssets/InquiryReport/ReportAcrobat/5821/Report%2032%20-%20Registered%20nurses%20in%20New%20South%20Wales%20n.pdf

Australian College of Nursing: ACN submission inquiry into RNs in NSW nursing homes-  http://ACN_submission_inquiry_into_RNs_in_NSW_nursing_homes.pdf

Sydney Morning Herald: NSW Government abandons 24/7 nursing in aged care homes-  http://www.smh.com.au/nsw/nsw-government-abandons-247-nursing-in-aged-care-homes-20160430-goium1.html

Talking Aged Care: NSW registered aged care nurses on duty 24/7- https://www.agedcareguide.com.au/talking-aged-care/nsw-registered-aged-care-nurses-on-duty-24-7

NSW Legislature:  Public Health Amendment (Registered Nurses in Nursing Homes) Bill 2016-  http://www.legislation.nsw.gov.au/bills/84bb3a65-4581-4187-a2b8-90a8d6e7c659

Healthy one day, sick the next- the issue of Diagnosis Creep

 

An article by Hugo Wilcken in the Medical Journal of Australia InSight page turned me onto the discussion over ‘Diagnosis Creep’. Essentially this is coined as a negative term for the change in definitions of diseases which causes an increase in those diagnosed with that disease which prior to the change would be otherwise considered as not having it. An example would be osteoporosis where in 2008 a new definition was adopted and instantly changed the affected population of women from 21% to 72%! Similarly changes to definitions have created ‘pre-‘ conditions in the diseases of diabetes and hypertension. Wilcken contends that what makes these changes diagnosis creep is that they do not offer health benefits as the treatments do not successfully aid to overall health or well-being.

Some factors have been forwarded to explain diagnosis creep. One such idea is that of the ‘pre’ classification of diseases. Therefore, you may not clinically have the disease, but you are at risk of contracting it. Another theory is that the expert panels who decide on what clinical factors are needed to lead to a diagnosis are made up of clinicians who specialize in their field. These experts, in order to be able to treat effectively, tend to be more inclusive than exclusive when re-examining factors and therefore lessen the threshold for diseases.

Then there is the nasty side of diagnosis creep. There seems to be a pervasive concern that pharmaceutical companies have a wayward hand in expanding the population with certain diseases in order to increase sales of medications for that disease. The MJA InSight article discusses this as ‘Big Phrama’ and contends that some ‘expert panel’ members are sponsored by pharmaceutical companies- leading to potential conflicts of interest. A similar argument was made in an article in The Conversation in 2016.

No matter what the reasons diseases are being re-defined to include more patients an article in the Australian Prescriber magazine sums up the reason for this post:

Health professionals should be more aware, and patients and the public better informed, about the controversy surrounding many contemporary definitions of disease. Diagnostic criteria are not set in stone – they are regularly changed, often with the best of intentions, but are also often rigorously challenged because of the potential for unintended harms.

In Australia the issue has been seen as serious enough that the NPS group has developed an entire campaign entitled “Choose Wisely” to inform and attempt to tackle the need for certain tests, treatments and procedures. Readers of this blog can also follow the Choose Wisely campaign on Twitter at @ChooseWiselyAU.

Before the MJA article I had not known about diagnosis creep, nor the controversy surrounding it. However, the issue does make sense. All healthcare professionals should be conscious of how and why patients are being diagnosed with diseases and what treatments are being given. While I do recognize the need for disease management and appropriate medications I also recognize that we can easily over-medicate and the elimination of any unneeded treatment would be valuable, particularly in the elderly. I applaud the works of Wilcken and the NPS at serving as a checks-and-balance system in this most important area.

References

MJA InSight: Diagnosis creep: the new problem in medicine

The Conversation: Resisting expanding disease empires: why we shouldn’t label healthy people as sick

Australian Prescriber: Caution! Diagnosis creep

NPS Medwise: Choosing Wisely Australia

Coroner asks NSW health privacy rules be relaxed to fight terrorism

A report by SKY news has indicated that the Coroner Michael Burns in investigating the Lindt Cafe siege has found the Personal Information Protection Act and the Health Records Information act were too stringent and did not allow ASIO investigators to have information needed. Coroner Burns has asked the NSW government to review the privacy legislation through his findings. The Sydney Morning Herald, reporting on the findings stated that “Mr Barnes says the government should consider whether NSW Health should more readily share information so that “fixated lone actors”  can be identified and monitored earlier.

However, reviewing the coroner’s report the findings aren’t so clear. Monis did visit several General Practitioners (GPs) who referred him to psychiatrists. Monis did, on one occasion, see a psychiatrist (through a private practice) who diagnosed him with mild depression. He was also seen by the Cantebury mental health team over a period of 16 months. However, according to the coroner’s report Monis was felt to have a personality condtion and not a psychiatric disorder. Additionally, Monis was felt to have manipulated the system to present him as a person with mental instability for some reason.

While the report is obviously a summary of the information gained at the inquest I wonder what good the health information would be in assisting ASIO or any other agency in identifying and removing Monis from the streets prior to the Lindt cafe siege? He appeared to be using the system for his own gains. Monis saw at least 10 GPs within the community, all who I would presume to be in private practice; and therefore not within the confines of the NSW Health system regarding privacy and information sharing. I am wondering how ASIO would be able to know that Monis had seen so many private practitioners and that he failed to follow-up on psychiatric referrals?

I, like many of my countrymen and women, do not want to see terrorist attacks in Australia as occurred in the Lindt cafe siege and in other horrific attacks around the world. And I would be prepared to assist authorities if it was needed. But unless there could be a reasonable explanation as to what benefit would be gained from relaxing the two privacy legislative bills in regards to apprehending potential ‘lone actors’ and preventing terrorist attacks then I fail to see how this would provide benefit over cost to the general public?

NSW Health takes privacy very seriously, and that is a welcome position in my book as a healthcare practitioner and patient. While I am not completely opposed to relaxing privacy legislation I do think we owe it to the general public to have an open discussion regarding what we as that public would be prepared to give up in terms of our privacy for the safety of others. By relaxing privacy legislation, particularly in mental health situations, you risk potential patients staying away from treatment in order to protect their privacy.

Yes, it is a slippery slope. But I am willing to take that slide if there would be real benefit and recognized limits on who the information is shared with and how it will be used. The public has a right to be involved in any discussion.

Your thoughts?

References

Coroner’s report into the Lindt Cafe siege

Sky news report on the findings

Sydney Morning Herald: Lindt inquest: Mistakes cannot be papered over, coroner Michael Barnes finds

 

 

Privacy concern or valuable tool: all Aussies can have an e-health record, would you?


The ABC network has written that with a new surge in federal funding the My Health Record project looks to provide all Australians with the ability to have an electronic health summary. This is a follow-on from other E-health projects trying to establish similar results. While I can understand the apprehension noted by some with regards to privacy and sharing of health information from a healthcare worker’s perspective it is a great leap forward.



In my history as a registered nurse I remember the days before electronic health records. The nature of our health system in Australia means that an individual can present at numerous public and private health institutions without any ability of those institutions knowing prior medical treatment. This is a safety concern for the patient at worst and could potentially prolong the time for effective treatment in the least.


With the implementation of the local electronic health record if I am looking after a patient who has visited another health facility within the same area, state, or even nationally connected the doctor and I can see previous treatments and tests, allowing for more accurate diagnosis and treatment. Expanding this nationally would allow those visiting or recently moved to the area to have better quality care by allowing information sharing.


It is also better for the GP. Now general practitioners must rely on discharge summaries for information about hospital treatment. However, with the electronic record the GP could access more complete information from hospital visits, aiding in their continuation of care at home. A GP could also review and place information for patients on the record in case they travel or are too sick to speak for themselves, vital information which could save their life.


There is always a potential for abuse of the system. However, I would trust that the powers-at-be would design safeguards to prevent unauthorized information sharing of electronic health records. I, for one, will be happy to welcome this advancement in Australian healthcare. According to the ABC report individuals would be allowed to ‘opt out’ of the program.

ABC news: Everyone to have a digital health record