Digital Repository Doctoral Projects Spring 2022 Medical Cannabis Education for Providers to Improve Patient Outcomes Stacie Egan Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Egan, S. (2022) Medical Cannabis Education for Providers to Improve Patient Outcomes Weber State University Doctoral Projects. https;//dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Medical Cannabis Education for Providers to Improve Patient Outcomes by Stacie Egan A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 29, 2022 April 29. 2022 _______________________________ Stacie Egan, DNP, MSN, APRN, FNP-C ______________________________ Date April 29, 2022 _______________________________ Kristy A. Baron, PhD, RN _______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director ______________________________ Date April 29, 2022 ______________________________ Date Note: This form and paper must be submitted by the program director. MEDICAL CANNABIS EDUCATION FOR PROVIDERS Table of Contents Abstract ........................................................................................................................................... 4 Medical Cannabis Education for Providers to Improve Patient Outcomes .................................... 5 Background and Problem Statement ........................................................................................... 5 Stigma and Medical Cannabis ................................................................................................ 6 Barriers to Recommendation and Patient Access ................................................................... 7 Diversity of Population and Project Site ..................................................................................... 7 Significance for Practice Reflective of Role-Specific Leadership ............................................. 7 Literature Review and Framework ................................................................................................. 8 Framework .................................................................................................................................. 8 Search Methods ........................................................................................................................... 9 Synthesis of Literature ................................................................................................................ 9 Chronic Pain and Cannabis Use ............................................................................................ 10 Patient Communication and Understanding ......................................................................... 11 Impact of Utilizing Medical Cannabis .................................................................................. 12 Prescriber Attitudes and Education about Medical Cannabis ............................................... 13 Description ........................................................................................................................ 13 Medical Cannabis Education ............................................................................................ 13 Benefits of Education .................................................................................................... 14 Effective Delivery Model ............................................................................................. 14 Discussion ................................................................................................................................. 16 Implications for Practice: Medical Cannabis Education for Providers ..................................... 17 Project Plan ................................................................................................................................... 17 Project Design ........................................................................................................................... 17 Data ....................................................................................................................................... 18 Information ........................................................................................................................... 18 Knowledge ............................................................................................................................ 18 Wisdom ................................................................................................................................. 19 Needs Assessment of Project Site and Population .................................................................... 19 Cost Analysis and Sustainability of Project .............................................................................. 19 Project Online Access ............................................................................................................... 20 Project Outcomes ...................................................................................................................... 20 Consent Procedures and Ethical Considerations....................................................................... 21 Instrument to Measure the Effectiveness of Intervention ......................................................... 21 Gap Analysis ............................................................................................................................. 22 MEDICAL CANNABIS EDUCATION FOR PROVIDERS SWOT Analysis ........................................................................................................................ 22 Strengths ............................................................................................................................... 22 Weaknesses ........................................................................................................................... 22 Opportunities......................................................................................................................... 23 Threats................................................................................................................................... 23 Project Implementation ................................................................................................................. 23 Interventions ............................................................................................................................. 23 Alignment of Intervention and Project Outcomes .................................................................... 25 Project Timeline ........................................................................................................................ 26 Project Evaluation ......................................................................................................................... 26 Data Maintenance and Security ................................................................................................ 26 Data Collection and Analysis.................................................................................................... 26 Findings..................................................................................................................................... 28 Strengths ............................................................................................................................... 29 Weaknesses ........................................................................................................................... 29 Quality Improvement Discussion ................................................................................................. 29 Translation of Evidence into Practice ……………………....................................................... 30 Implications for Practice and Future Scholarship ..................................................................... 30 Sustainability......................................................................................................................... 31 Dissemination ....................................................................................................................... 32 Conclusion ................................................................................................................................ 32 References ..................................................................................................................................... 33 Appendix A ................................................................................................................................... 39 Appendix B ................................................................................................................................... 40 Appendix C ................................................................................................................................... 41 Appendix D ................................................................................................................................... 47 Appendix E ................................................................................................................................... 48 Appendix F.................................................................................................................................... 49 Appendix G ................................................................................................................................... 50 Appendix H ................................................................................................................................... 51 Appendix I .................................................................................................................................... 52 Appendix J .................................................................................................................................... 56 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 4 Abstract Medical cannabis can address many difficult-to-treat diseases, including chronic pain syndromes. Despite the legalization of medical cannabis, many medical providers lack knowledge about clinical risks and benefits, appropriate cannabis dose and form, and types of patients and conditions that benefit from a cannabis recommendation. Comprehensive provider education can increase patient access to medical cannabis. Purpose: The DNP project was designed to confidently prepare providers to recommend cannabis for appropriate patients in a clinic. Methodology: The project offered medical cannabis education to providers at a multi-specialty physician-owned clinic during monthly grand rounds. A pre-and post-survey was given to participants to evaluate learning. Survey items reflected a 5-point Likert scale to assess the perceived degree of efficacy of medical cannabis. Results: After the implementation, participants showed an increase in the following areas: 20% indicated that cannabis was a legitimate therapy, 13.4% selected that cannabis should be offered to patients, 46.6% agreed that cannabis could effectively treat symptoms, and 20% thought that cannabis could effectively replace or reduce opioid use in patients with chronic pain. The survey results supported the project outcome that effective medical cannabis education can change provider attitudes about recommending medical cannabis. Implications for Practice: For best patient outcomes, providers have an opportunity to recommend cannabis, offering benefits and applications over current medications, such as opioids with a lower safety profile and higher addiction and overdose potential. Keywords: medical cannabis, provider education, cannabis legalization, chronic pain, patient access to medical cannabis MEDICAL CANNABIS EDUCATION FOR PROVIDERS 5 Medical Cannabis Education for Providers to Improve Patient Outcomes In the United States, deaths related to opioid overdose have increased by 132% over the past decade. By 2017, opioid overdose deaths numbered more than 630,000, which exceeds the number of U.S. deaths in World War I and World War II combined (Larkin & Madras, 2019). This opioid public health disaster was fueled by the pharmaceutical industry, which failed to warn of the risks of opioids and misrepresented opioids as safe alternatives to treat pain (Haffajee & Mello, 2017). Despite the U.S. opioid crisis, medical providers often prescribe opioids to treat chronic pain conditions, with a lack of evidence that long-term opioid treatment is effective. Opioids also have a significant addiction risk and overdose potential (Kissin, 2013). Medical cannabis may be an alternative for treating chronic pain and other medical diagnoses. Lynch and Ware's (2015) systemic review found medical cannabis useful for numerous disease states, including chronic pain. Many of these studies demonstrate the benefits of medical cannabis for treating chronic pain, sleep disturbances, muscle stiffness, and spasticity. Medical cannabis is a safe and effective alternative for patients currently prescribed medications like opioids and may have fewer side effects and a decreased addiction potential (Kissin, 2013). Background and Problem Statement For many patients, medical cannabis is an essential recommendation for the effective treatment of chronic pain syndromes, multiple sclerosis, seizure syndromes, Crohn's and ulcerative colitis, post-traumatic stress disorder, autism, and terminal illnesses (Utah Department of Health: Center for Medical Cannabis, 2020). A lack of scientific research and education to validate the efficacy of medical cannabis has created barriers for patients and prescribers (Wan et al., 2017). Effective medical cannabis education can increase provider knowledge, identify appropriate patients, and improve medical cannabis access. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 6 Wan et al. (2020) believe there are three steps to increase medical cannabis access for patients. First, research is needed to increase knowledge about medical cannabis and the interactions between cannabis and the human cannabinoid system. Second, patient outcomes need to be collected to corroborate research and to understand patient experience with medical cannabis. Third, the research and patient outcomes must be utilized to create cannabis education. Medical cannabis products can be made based on cannabis research that addresses specific patient conditions and offers providers cannabis forms and doses appropriate for individual medical needs. These steps may increase access to medical cannabis, improving patients' quality of life with difficult treatment conditions. In March 2020, medical cannabis became available for Utah patients when a qualified medical provider (QMP) recommended it. To qualify, medical providers can take a four-hour course and apply for certification to legally prescribe medical cannabis. Medical cannabis recommendation is limited to specific medical conditions and patients (Utah Department of Health: Center for Medical Cannabis, 2020). Stigma and Medical Cannabis The stigma surrounding medical cannabis is a barrier to patient access and is related to the history of cannabis in the United States. The medical cannabis stigma stems from the social and political history of cannabis prohibition. More nonusers of cannabis exist in the U.S. than users, and social policies prevent, restrict, or punish users and distributors. Implementation of controls and interventions such as regulation, incarceration, treatment, prevention, and taxation discourage the use of cannabis (Adrian, 2015). The medical cannabis stigma results from negative connotations associated with cannabis as a recreational drug and criminal penalties imposed for the use and distribution of cannabis (Bottorff et al., 2013). MEDICAL CANNABIS EDUCATION FOR PROVIDERS 7 Barriers to Recommendation and Patient Access Lack of medical cannabis education is a barrier to the recommendation and patient access. Szaflarski et al. (2020) examined attitudes and knowledge of cannabis use in a sample of U.S.-based providers finding correlations between medical cannabis recommendation knowledge and provider attitudes. Provider education and workplace policies supporting medical cannabis resulted in higher knowledge and favorable attitudes about recommending medical cannabis for appropriate patients. Diversity of Population and Project Site The project's education cohort included 164 medical providers of all specialties at Ogden Clinic in Ogden, Utah. The training was conducted at face-to-face ground rounds for all clinic providers. Additional training was delivered through online modules. Ogden Clinic providers with further educational needs can request scheduled face-to-face consultations with the DNP leader. Medical cannabis recommendation support documents, including patient disclosures, are also available online. Significance for Practice Reflective of Role-Specific Leadership This DNP project aimed to improve medical cannabis access for patients by increasing the number of Ogden Clinic QMPs. The DNP post-master's leadership role was essential to the success of this project. DNP leadership skills were used, including collaboration, team building, and effective communication among stakeholders, the DNP leader, and other project team members. These skills supported project outcomes of educating providers to increase patient access to medical cannabis and improve patient outcomes. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 8 Literature Review and Framework The Iowa model was chosen to identify and implement an educational program for medical providers to increase provider knowledge and patient access to medical cannabis. In addition, literature was reviewed to gather evidence-based research supporting the recommendation of medical cannabis. An educational program was created based on the literature review. The DNP leader and a multi-disciplinary team implemented the medical cannabis educational program. Framework The Iowa model guided the DNP project using seven steps allowing the DNP leader to identify a knowledge-based or problem-based trigger (Buckwalter et al., 2017). This project used the Iowa model to evaluate the lack of cannabis use to improve patient outcomes, where an evidence-based practice change may be warranted. This problem was a priority in that it can help address alternate ways to treat pain besides prescribing opioids, thereby reducing factors that fuel the opioid epidemic. The model led the DNP student to form a multi-disciplinary team to help develop, evaluate, and implement the change through medical cannabis education. The multidisciplinary team aimed to gather and critique pertinent evidence-based research related to the problem and determined that the evidence is scientifically sound. Brown (2014) states that when using the Iowa model, the determination of the soundness of scientific evidence is based on (a) consistent findings to support the change, (b) the type and quality of the studies, (c) the clinical relevance of the findings, (d) the number of studies with similar sample characteristics, (f) the feasibility of implementing the results into practice, and (g) the risk-benefit ratio. After showing adequate research existed, the DNP project lead implemented medical cannabis education into a pilot practice, which evaluated the change's effectiveness so that the MEDICAL CANNABIS EDUCATION FOR PROVIDERS 9 team could make necessary adjustments to the implementation on a smaller scale. The evidencebased practice implementation was successful in the pilot practice, so the change can be implemented on a larger scale and eventually be implemented in the organization (Brown, 2014). The Iowa model was valuable because it evaluated the problem-based trigger of the lack of medical cannabis education. Thus, many providers are not prescribing medical cannabis, limiting patient access to medical cannabis and qualified providers. The Iowa model allowed the implementation of medical cannabis educational materials, increasing provider knowledge and patient access to medical cannabis (Brown, 2014). Search Methods The data were collected through a literature search to retrieve studies on the efficacy of cannabinoids in treating chronic pain and other chronic disease states. Moreover, a literature search was conducted to retrieve studies on medical cannabis education and provider knowledge of medical cannabis. The databases searched were PubMed, CINAHL (EBSCO), and Academic Search Premier (EBSCO). The search retrieved all articles assigned the headings cannabis, cannabinoids, cannabidiol (CBD), marijuana and delta-9-tetrahydrocannabinol (THC), cannabis education, and medical provider education. Synthesis of Literature A search of the literature identified several themes related to medical cannabis. Themes include medical cannabis for treating chronic medical conditions, patient selection and education, provider attitudes about medical cannabis, and considerations when recommending medical cannabis to patients. The following section outlines the themes and explores an effective medical cannabis educational delivery model for providers. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 10 Chronic Pain and Cannabis Use In primary care, the most treated qualifying condition is chronic pain. Medical providers often prescribe opioids to treat chronic pain conditions, despite lacking evidence that long-term opioid treatment of chronic nonmalignant pain is effective. However, evidence shows opioid treatment carries a significant risk of addiction and overdose potential (Kissin, 2013). Bradford et al. (2018) state that from 2000 to 2015, mortality related to opioids increased by almost 320%. Additionally, in states where medical cannabis is legal, there were decreases in the use of both opioid and non-opioid pain medications. Maharajan et al. (2020) recognize that chronic pain syndromes affect more than 15% of the U.S. population. Chronic pain syndromes are often undertreated, and many patients live in pain, impacting their quality of life, personal relationships, work, and overall health. Many of these patients have no option but to turn to opioids to relieve their pain, despite the adverse side effects and the risk of an opioid overdose. Opioids are often used to treat chronic pain, including neuropathic pain. However, the potential exists to use combinations of opioids and medical cannabis to treat pain effectively, allowing chronic pain patients to use lower doses of opioids for pain control or eliminating the need for opioids, which results in less overdose risk. Cannabis has addiction potential, but it is lower than other substances, including opioids, nicotine, and alcohol, making it a better choice for treating pain (Maher et al., 2019). Lynch and Ware's systematic review (2015) shows that medical cannabis is helpful for numerous disease states and chronic pain. Many of these studies demonstrate the benefits of medical cannabis for treating sleep disturbances, muscle stiffness and spasticity, and chronic pain management. Medical cannabis is a safe and effective alternative for patients currently prescribed medications like opioids and may have fewer side effects and addiction potential. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 11 State laws that establish access to medical cannabis may change overdose mortality related to opioids, and there is a need for effective and safer alternative treatments like medical cannabis (Corroon et al., 2017). Moreover, evidence supports the use of cannabinoids to treat chronic pain and spasticity. Other benefits include treatments for nausea and vomiting, weight loss in HIV infection, sleep disorders, and Tourette syndrome (Isaac et al., 2016). The Australian Government Department of Health Therapeutic Goods Administration (2017) conducted a meta-analysis of randomized studies using medicinal cannabis to treat noncancer chronic pain. Researchers concluded that medicinal cannabis treatment resulted in 30% and 50% reductions in pain scores and a measured reduction in patient-reported pain intensity ratings compared to placebo. Because of its safety profile and effectiveness, cannabis should be considered a first-line agent to treat patients with qualifying medical conditions. Patient Communication and Understanding In the United States, cannabis is legal in 36 states and the District of Columbia. Recreational cannabis is legal in 15 states and the District of Columbia. The remaining states, including Utah, have legalized cannabis for medical use only (ProCon.org, 2021). A concern exists that the legalization of marijuana may make patients feel that the risks associated with marijuana use are minimal. Patient and community education is vital to increase awareness of the risk of medical cannabis use, especially related to children (Ulrich & Valdez, 2017). Although cannabis has a better safety profile than opioids, it is not without risk. When prescribing any medication, providers should consider the risk-benefit ratio and ensure informed consent while closely monitoring safety and side effects (Glickman & Sisti, 2020). Prescribers of medical cannabis must discuss risks with patients before prescribing. In states like Colorado, where medical cannabis has been legal since 2000, the dangers of cannabis MEDICAL CANNABIS EDUCATION FOR PROVIDERS 12 are becoming evident. Since the legalization of cannabis in Colorado, children's unintentional ingestion and the intentional use of cannabis by teens and young adults have increased (Ulrich & Valdez, 2017). Studies suggest a higher risk of cannabis use disorder in younger people (Allan et al., 2018). Additionally, available data suggest that adolescent cannabis exposure can increase the risk of cannabis addiction and psychiatric disorders in later life (Wilsey et al., 2015). Providers prescribing to pediatric patients must educate patients and their parents about the potential side effects and long-term impact of medical cannabis use in children and young adults. Patients and prescribers need to be mindful of the risk of cannabis to children and the importance of storing medical cannabis as they would any other prescription drug. Furthermore, providers and patients must also consider the mental and physical impacts of medical cannabis. Patients must be educated about the risk of impairment while using medical cannabis and the importance of not driving under the influence of medical cannabis. In Colorado, motor vehicle accidents were 25% more likely to be caused by marijuana users than drivers with no evidence of marijuana use (Ulrich & Valdez, 2017). Impact of Utilizing Medical Cannabis A qualitative study by Mercurio et al. (2019) surveys medical cannabis cardholders (n = 25) about the use of marijuana for medical purposes. Researchers compare medical cannabis to currently prescribed medications and the substitution of medical cannabis for other medicines. The study also considers how patients' perceptions of medical cannabis policy impact use. Moreover, the findings suggest that some providers and patients prefer medical cannabis to other prescription medications because they perceive it to address disease-related symptoms without side effects or adverse reactions that often accompany many prescription medications. The study MEDICAL CANNABIS EDUCATION FOR PROVIDERS 13 illustrates a perception by patients that medical cannabis is safer and less addictive than opioids when considering drugs to treat chronic pain. Prescriber Attitudes and Education about Medical Cannabis Description. To increase access to medical cannabis for patients who would benefit, providers need an education that focuses on the benefits of medical cannabis compared to the medications they currently prescribe their patients. Benavides et al.'s (2020) survey of physicians and nurse practitioners (n = 105) identifies that medical providers want foundational information about medical cannabis. Providers feel they do not have the necessary knowledge to recommend cannabis safely and lack information about dosing and developing treatment plans. They also believe that cannabis plays a role in treating pain and suggest further research. Less than 45% of providers would feel comfortable recommending cannabis to patients because of a perceived knowledge deficit and the stigmatization of medical cannabis use related to cannabis being both an illegal substance and a therapeutic drug among the public and providers (Bottorff et al., 2013). These issues make it vital for providers prescribing medical cannabis to know state and federal laws, as there is a conflict between them (Jarvis et al., 2017). Szaflarski et al. (2020) show that healthcare providers recognize medical cannabis as potentially beneficial for a patient, but that lack of knowledge makes them hesitant to recommend it. Effective medical cannabis education can address the growing patient demand for medical cannabis. Medical Cannabis Education. Sinclair (2016) discusses cannabis research over the past decade that cannabis reacts with the endocannabinoid system in the human body and provides a wide range of therapeutic properties ranging from treating chronic pain to ulcerative colitis. Despite this research, there is a lack of information in current medical education curricula about MEDICAL CANNABIS EDUCATION FOR PROVIDERS 14 medical cannabis to treat specific conditions. This lack of curriculum relates to medical cannabis not being federally legal and only legal in some states. Insufficient educational material may be an obstacle to the recommendation of cannabis and thus limit patient access to medical cannabis. Creating a curriculum for practice that can transform medical providers' attitudes and prescribing habits is challenging but essential. Without changing provider attitudes and prescribing patterns, patients may lack access to medical cannabis and providers who have the knowledge and confidence to recommend treatment. One way to effectively alter providers' current practices is to consider compelling arguments for changing their perspectives. Benefits of Education. Medical cannabis education resources are vital for providers wanting to recommend it, thereby reducing stigma and improving patient access. Provider education, including program design, development, and content delivery, are necessary for any organization wishing to create medical cannabis education for providers (Avorn & Soumerai, 1983). An effective medical cannabis education curriculum focuses on pharmacological concepts and existing knowledge (Ware & Ziemianski, 2015). This curriculum provides a framework for medical providers to understand and identify appropriate medical cannabis forms and doses for qualified patients. Educating physicians about medical cannabis can remove the stigmas surrounding the drug and may improve access for patients. When designing a medical education curriculum for providers, the first consideration must be educational materials and concerns about state laws and how they apply to specific providers and patients. Educators must also consider an effective delivery model that appeals to all types of medical providers. Effective Delivery Model. Educational delivery models remain essential in support of medical cannabis use. Allen et al. (2007) discuss a provider outreach delivery model. Similarly, MEDICAL CANNABIS EDUCATION FOR PROVIDERS 15 Avorn and Soumerai (1983) found that in-person education is effective. Conversely, Noh et al. (2019) found evidence to support self-directed learning with online support. Offering a variety of delivery models addresses the learning styles and time limitations found among providers. Each delivery can be discussed using past studies about drug education for providers, which can be applied to the recommendation of medical cannabis. A randomized controlled trial of providers (n = 435) by Avorn and Soumerai (1983) found that personal educational visits combined with mailed "unadvertisements" reduced providers' prescribing of targeted drugs by 14% to less expensive but more effective medications, compared with the control group. A decrease in drug cost was noted between the two groups related to reimbursement for these drugs, resulting in substantial savings. No such change was seen in physicians who received mailed print materials only or in the control group. As this study showed, printed materials alone do not impact prescriber practices, and brief oneto-one educational outreach visits help impact prescriber knowledge and prescription practices (Avorn & Soumerai, 1983). One way to achieve personal educational visits is through a model studied by Allen et al. (2007). In a mixed-methods study using two methods to collect data, a questionnaire and a semistructured telephone survey, Allen et al. (2007) found factors impacting participation (n = 869), such as the relevance of topics and materials delivery. They also discovered that physicians prefer physician educators over non-physician educators. Another critical factor was the quality of handout materials, emphasizing brief, graphic print materials. Researchers suspected that time would be a deterring factor, but this did not prove enough of a barrier to prevent participation (p < 0.004). Whereby Allen et al. (2007) and Avorn and Soumerai’s (1983) studies focused on MEDICAL CANNABIS EDUCATION FOR PROVIDERS 16 personal educational visits, Noh et al.'s study (2019) examined self-directed education programs using blended coaching, as desired by participants. A study by Noh et al. (2019) (n = 91) examined self-directed learning programs using blended coaching, which means online with the option of face-to-face for clarification. This method can be applied to healthcare education for medical providers. This study's researcherdeveloped learning programs improved self-directed learning competency and promoted clinical practice satisfaction (p = 0.003). Learners appreciated self-directed learning materials with online or face-to-face instruction if desired (n = 44). Evidence showed that various delivery models exist to educate providers on prescribing drugs (Allen et al., 2007; Avorn & Soumournai, 1983; Noh et al., 2019). This evidence can be used in educating providers about recommending medical cannabis. Discussion The evidence supports educating providers about recommending medical cannabis to address chronic pain and other chronic diseases that are difficult to treat. Medical cannabis has a better safety profile than opioids and can be an effective treatment for chronic pain with less risk of addiction or overdose. Significantly lower state-level opioid overdose mortality rates are associated with legalized medical cannabis (Bachhuber et al., 2014). Additionally, non-opioid analgesic medications should be considered another tool for providers to treat chronic pain conditions (Maher et al., 2019). Although research supports medical cannabis recommendations by providers, evidence shows a lack of provider knowledge, which decreases provider confidence in recommending medical cannabis to patients. This lack of medical cannabis education may impact patient access to this treatment. Limitations may be related to medical cannabis classification as a Schedule I, MEDICAL CANNABIS EDUCATION FOR PROVIDERS 17 which has resulted in a lack of scientific research on cannabis in the United States (Bostwick, 2012). As a result, this classification has limited research examining the medical benefits of cannabis and educational curriculum implementation that can prepare medical providers to recommend medical cannabis for appropriate patients. Implications for Practice: Medical Cannabis Education for Providers Medical cannabis education is lacking for providers, which may negatively impact patient access to this treatment (Szaflarski et al., 2020). Medical providers have an obligation and ethical responsibility to their patients to find safer alternative treatments, including medical cannabis, for difficult-to-treat medical conditions with few current effective therapies. Access to providers who are educated about and feel comfortable recommending medical cannabis is essential for patients. The evidence outlined in the literature review synthesis supports the need for medical cannabis education for providers. Provider-to-provider medical education is effective when delivered in a hybrid delivery system that incorporates blended face-to-face and online learning (Noh et al., 2019). The DNP project implementation of a medical cannabis educational program for providers may improve providers' knowledge and comfort with recommending cannabis, thus improving patient access to medical cannabis and promoting positive patient outcomes. Project Plan Project Design The DNP project was a quality improvement project designed to educate medical providers at Ogden Clinic. The data, information, knowledge, and wisdom, building blocks of the DIKW model was used to implement medical cannabis education (Aukett, 2019). The data and information provided via the project education gave providers the knowledge and wisdom to MEDICAL CANNABIS EDUCATION FOR PROVIDERS 18 correctly identify patients who may benefit from medical cannabis, further improving access to this treatment. Data A search of the literature identified several themes related to medical cannabis. Themes included medical cannabis for treating chronic medical conditions, patient selection and education, provider attitudes about medical cannabis, and considerations when recommending medical cannabis to patients. The data provided consistent evidence to support the implementation of medical cannabis education for providers. This education was necessary for any organization that promotes provider recommendations (Avorn & Soumerai, 1983). Information Information collected by the DNP leader and project team was delivered to Ogden Clinic providers through an established continuing education program. The program included monthly meetings and was in a grand round format allowing providers to earn continuing education credits. The education consisted of information to support providers in the safe recommendation of medical cannabis, thus increasing access to medical cannabis for Ogden Clinic patients. Providers also had continued access to the training and support documents via the Ogden Clinic Intranet. Knowledge Benavides et al. (2020) found that medical providers lacked foundational information about medical cannabis. Providers wanted the knowledge to prescribe cannabis safely, information about dosing, and assistance in developing treatment plans. The knowledge gained through the DNP project medical education allows providers to recommend and prescribe medical cannabis. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 19 Wisdom Matney et al. (2011) stated that wisdom is the use of the appropriate knowledge to manage and solve the problems of humans. The DNP project intervention aimed to provide the knowledge needed to lead to increased provider wisdom. Improved provider wisdom might result in the recommendation of medical cannabis for patients while acknowledging its use as an effective treatment of chronic conditions that were previously inadequately addressed through prescription medications. The knowledge would benefit patients as providers learn alternative options to deliver the best care to them. Needs Assessment of Project Site and Population The DNP project participants comprised of 164 medical providers from various specialties at Ogden Clinic in Ogden, Utah. Participants included medical doctors, nurse practitioners, and physician assistants. Project stakeholders included Ogden Clinic Administration and the Board of Directors, Ogden Clinic Providers, and Ogden Clinic patients. Medical cannabis education could benefit participants and stakeholders by increasing QMPs, thus improving patient access to medical cannabis. This project could help the Ogden Clinic Administration and Board of Directors by expanding the population of patients seeking care from Ogden Clinic providers, thus increasing Ogden Clinic revenue. Cost Analysis and Sustainability of Project The project budget included investing time for the DNP leader, Ogden Clinic staff, IT team; the printing of deliverables; and catering for the Grand Rounds educational presentation (see Appendix A). The overall cost of the project was low. The DNP leader adapted educational materials as needed to promote the project's sustainability. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 20 Project Online Access The project was available on the Ogden Clinic Intranet for any medical provider requesting additional medical cannabis education. As Utah state cannabis laws evolve, medical cannabis education could be modified by the DNP nurse leader. Ketron (2019) stated that when a DNP student graduates, their project is not sustained. The DNP nurse leader was involved in continuing education to ensure sustainability by adapting educational materials for specific providers and specialties and ensuring that medical cannabis education was available to all those who would like to recommend medical cannabis to their patients. Project Outcomes The short-term outcomes or goals of medical cannabis education for providers were to provide foundational information about medical cannabis recommendations and the benefit of medical cannabis over current treatment options. Benavides et al. (2020) found that medical providers lacked foundational information about medical cannabis, which may hinder the recommendation of medical cannabis. Providers have wanted to prescribe cannabis safely, learn about appropriate dosing, and desire assistance in developing treatment plans. The knowledge gained through the project's medical education may allow providers to feel confident recommending medical cannabis. Short-term outcomes were measured by pre-and post-surveys gauging provider attitudes and knowledge about medical cannabis before and after the educational presentation. The project's intermediate and long-term outcomes were to increase the number of QMPs at Ogden Clinic so that patients have access to medical cannabis, improving patient outcomes. The overarching goal of Ogden Clinic was to meet the ever-changing healthcare needs of patients and provide access to quality healthcare (Ogden Clinic, 2021). Medical cannabis has MEDICAL CANNABIS EDUCATION FOR PROVIDERS 21 been a healthcare solution for many patients with difficult to treat chronic conditions. Access to QMPs at Ogden Clinic reflected the predominant outcome of the DNP project and the organization. Intermediate and long-term project success could be measured by increasing numbers of QMPs at Ogden Clinic. Consent Procedures and Ethical Considerations The Weber State University Institutional Review Board determined that the DNP project met the standard of a quality improvement activity. Providers who participated in the medical cannabis educational presentation and online educational activities anonymously submitted preand post-education surveys, thus supporting participant confidentiality. The survey responses were stored on a password-protected computer. In addition, the results of this survey were reported using aggregate data, keeping responses anonymous and confidential. Instrument to Measure the Effectiveness of Intervention Pre- and post-surveys measured in-person and online education outcomes to determine if program educational goals were met. These surveys evaluated provider knowledge and attitudes about medical cannabis education. At the same time, an increasing number of QMPs could measure provider willingness to prescribe medical cannabis at Ogden Clinic before and after training. The instrument used to measure the effectiveness of the intervention was an open-access survey developed by Philpot et al. (2019), and they permitted use with appropriate credit and acknowledgment of changes. The survey consisted of questions about medical cannabis knowledge and recommendation for patients with qualifying medical conditions. Data from survey results were used to improve future educational content. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 22 Gap Analysis Analysis of the strengths, weaknesses, opportunities, and threats (SWOT) was performed (see Appendix B). Before the educational presentation, less than 10% of Ogden Clinic providers were recommending cannabis. More Ogden Clinic providers were needed to be QMPs to improve patient access to medical cannabis. The DNP project aimed to provide medical cannabis education to improve provider knowledge about and comfort in recommending medical cannabis to appropriate patients. SWOT Analysis Strengths Project strengths included the clinical experience and medical cannabis knowledge of the DNP student, who also had the support of the Ogden Clinic nurse educator and physician project consultant in developing medical cannabis education for providers. The project could benefit patients of Ogden Clinic through an increased number of QMPs and access to medical cannabis for difficult-to-treat chronic conditions. Another strength of the project was publishing the educational presentation and materials on the Ogden Clinic Intranet so that all providers have access to the information. Weaknesses Weaknesses included the miscalculation of time by the DNP student regarding how long it would take to become a medical cannabis expert. The student also underestimated the time required to create the educational PowerPoint presentation and support materials for providers and patients. Additionally, the time constraints of Ogden Clinic providers impacted their ability to attend the educational presentation. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 23 Opportunities Practical education allowed providers the information and comfort required to recommend and prescribe medical cannabis. An increased number of QMPs at Ogden Clinic could result in improved patient access to medical cannabis, enhanced patient care, and improved results for patients of Ogden Clinic. In addition, patient access to medical cannabis could increase treatment options for difficult to treat conditions to benefit patients and providers. Threats Potential stigma related to medical cannabis use could affect the number of Ogden Clinic providers who choose to become QMPs. The stigma surrounding medical cannabis could affect both provider and patient comfort with medical cannabis use. Providers might also be hesitant to recommend medical cannabis because of the extra time needed to educate patients and approve medical cannabis applications. Project Implementation Interventions The DNP project intervention was a medical cannabis education class for providers at Ogden Clinic. The DNP student created the project to improve the providers' knowledge and comfort in recommending medical cannabis for appropriate patients. The project intervention aimed to improve patient access to medical cannabis, resulting in the best outcomes for patients with difficult to treat medical conditions which currently have limited treatment options. The medical cannabis intervention developed by the DNP student informed providers about choosing appropriate patients, medical cannabis types and delivery options, cannabis safety, and patient education. This educational presentation included PowerPoint slides, patient handouts, and provider support materials. The presentation was presented at Ogden Clinic's MEDICAL CANNABIS EDUCATION FOR PROVIDERS 24 monthly grand rounds continuing medical education class. The PowerPoint slides were reviewed and approved by Ogden Clinic's nurse educator and the physician project consultant before the educational presentation (see Appendix C for the Medical Cannabis Provider Education PowerPoint Slides.) The presentation showed medical cannabis recommendations, including a provider guide to effectively recommend medical cannabis to patients. The educational presentation consisted of evidence-based information about medical cannabis, medical diagnoses, and patient conditions that may benefit from medical cannabis. The PowerPoint presentation contained photographs of the different forms of medical cannabis available in Utah. It also showed appropriate medical cannabis strains and delivery methods for qualifying medical conditions. Handouts distributed to the participants at the educational presentation and posted on the Ogden Clinic Intranet included the following:  Criteria for Medical Cannabis identify medical conditions that qualify for this treatment in Utah. Providers discuss current medical conditions with patients to see if they are eligible for medical cannabis under the Utah Medical Cannabis Act (see Appendix D).  Information for Patients and Designated Caregivers About Medical Cannabis educates patients about Utah laws regarding cannabis. It also informs patients about the risks of using medical cannabis (see Appendix E).  Medical Cannabis Patient Note Discloser is created for the patient visit note. It shows that the patient qualifies for medical cannabis under the Utah Medical Cannabis Act. It also outlines documentation that the provider discussed Utah law regarding medical cannabis and the risks and benefits (see Appendix F). MEDICAL CANNABIS EDUCATION FOR PROVIDERS  25 Medical Cannabis Application Process is created by the DNP student for patients applying for medical cannabis cards in Utah. The process outlines applying for the card, meeting with the medical cannabis pharmacist, and scheduling clinic follow-ups (see Appendix G).  Utah Qualified Medical Provider handout educates providers about becoming a QMP in Utah by showing providers the process of applying and outlining necessary provider education (see Appendix H).  Pre- and post-survey evaluates provider knowledge and attitudes before and after the educational presentation (see Appendix I). Alignment of Intervention and Project Outcomes The DNP project met short-term outcomes of presenting medical cannabis education to providers. Szaflarski et al. (2020) found correlations between medical cannabis knowledge, provider education, and comfort in recommending medical cannabis. Medical cannabis education could result in more favorable attitudes about recommending this treatment. The medical cannabis education intervention met proposal outcomes by presenting provider-centered education that delivered appropriate education, preparing providers to recommend medical cannabis safely and effectively. The interactive presentation provided a question-and-answer session following the PowerPoint allowing providers to discuss medical cannabis questions and concerns to help providers feel more confident recommending medical cannabis. Long-term outcomes were met by making medical cannabis education available to providers desiring additional knowledge on the Ogden Clinic Intranet. The DNP nurse educator has planned to update medical cannabis PowerPoint and support materials as Utah state laws and MEDICAL CANNABIS EDUCATION FOR PROVIDERS 26 provider needs change and evolve. This educational program can help providers in all specialties to recommend medical cannabis, which can improve long-term patient access to cannabis. Project Timeline The DNP student developed a Gantt chart to support project planning. The chart specifically outlined dates and interventions. The process helped the student plan for time to complete the project, attain necessary resources, and meet project deadlines (see Appendix J for Gantt Chart). Project Evaluation A grand rounds educational presentation at Ogden Clinic in Ogden, Utah, was offered to all Ogden Clinic providers. Fifteen providers voluntarily attended the educational presentation and completed pre-and post-educational surveys. Survey items reflected a 5-point Likert scale to evaluate a perceived degree of effectiveness of medical cannabis. The 16-item survey addressed provider characteristics and knowledge about cannabis, attitudes and beliefs about medical cannabis as therapy, and specific disease and symptom control with cannabis. Data Maintenance and Security Project data were secured on a password-protected computer. Moreover, Qualtrics data were secured on a password-protected website with two-step verification. Project data were also available on the Ogden Clinic Intranet through the password-protected Ogden Clinic virtual private network. Data Collection and Analysis The Qualtrics website did not work with the Ogden Clinic presentation software. Because of this situation, paper pre- and post-surveys were distributed to participants before the educational presentation. Survey results were input into Qualtrics by the DNP student. The pre- MEDICAL CANNABIS EDUCATION FOR PROVIDERS 27 and post-survey questions were the same (see Appendix I). The beginning of the survey showed participant characteristics (see Table 1). Table 1 Participant Characteristics Gender - Female - Male Provider Licensure - MD/DO - NP/PA - Other Provider Specialty - ENT - Family Medicine - Gastroenterology - Urology - PT QMP - Yes - No N % 4 11 26.7 73.3 5 9 1 33.3 60 6.7 1 11 1 1 1 6.7 73.3 6.7 6.7 6.7 7 8 46.7 53.3 Note: N = 15. QMP refers to Qualified Medical Provider Clinician attitudes about the legitimacy of medical cannabis as a medical therapy in general and beliefs regarding overall effectiveness were assessed. Providers were also asked about the perceived difficulty they felt in enrolling and maintaining patients on medical cannabis therapy through the state program (see Table 2). The survey assessed provider beliefs about how effective medical cannabis is as a medical therapy for pain, seizures, nausea, vomiting, appetite, anxiety, depression, insomnia, weight loss, and tics. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 28 Table 2 Results of pre-and post-survey questions Align titles below with the last two columns Strongly Agree % Somewhat Agree % Neither % Somewhat Disagree % Strongly Disagree % Legitimate therapy 46.7 (66.7) 33.3 (20.0) 20.0 (13.3) 0 (0) 0 (0) Cannabis should be offered 13.3 (26.7) 60 (60) 13.3 (13.3) 13.3 (0) 0 (0) Significant interactions 26.7 (13.3) 33.3 (33.3) 33.3 (33.3) 6.7 (20.0) 0 (0) Effectively treat symptoms 6.7 (53.3) 53.3 (46.7) 20.0 (0) 0 (0) 0 (0) Patients benefit 6.7 (13.3) 20.0 (40.0) 26.7 (46.7) 46.7 (0) 13.3 (0) Replace or reduce opioids 0 (20.0) 40.0 (73.3) 40.0 (6.7) 13.3 (0) 6.7 (0) Difficult to become QMP 20.0 (13.3) 26.7 (26.7) 40.0 (20.0) 6.7 (33.3) 6.7 (6.7) Note: To see the complete survey, see Appendix I. Post-survey results are in parentheses. Findings In general, the survey showed that providers at Ogden Clinic believe that medical cannabis is legitimate medical therapy. The educational presentation improved provider knowledge about the benefits of medical cannabis for patients with state-designated qualifying conditions, the ease of becoming a QMP, and the benefits of medical cannabis for pain instead of MEDICAL CANNABIS EDUCATION FOR PROVIDERS 29 opioids. The survey showed that accurate information about the potential for drug interactions needs to be addressed more in-depth to deal with provider concerns. Strengths The strength of this project was in the varied characteristics of the providers (see Table 2). The diverse provider backgrounds allowed the DNP student to examine the attitudes and beliefs of providers with different educations, experiences, and patient populations. The educational presentation effectively taught that cannabis could treat symptoms associated with medical conditions, benefit patients with chronic illnesses, and reduce or replace opioids in patients with chronic pain. Weaknesses Two weaknesses were identified in the project implementation. The educational material was ineffective at communicating that medical cannabis could safely be used with many medications without significant interactions. The small number of providers who attended the Grand Rounds presentation was also a project weakness. A more substantial number of participants would provide more data for the DNP student to evaluate the intervention and make necessary changes to improve the educational presentation. Quality Improvement Discussion The project aims to create medical cannabis educational and support materials for providers at Ogden Clinic, with the end goal being increased access to medical cannabis for patients. The effectiveness of the intervention is measured by pre-and post-surveys gauging provider attitudes and knowledge about medical cannabis before and after the educational presentation. The study results are similar to a previous survey by Szaflarski et al. (2020), showing that healthcare providers recognize medical cannabis as potentially beneficial for a MEDICAL CANNABIS EDUCATION FOR PROVIDERS 30 patient. Still, that lack of knowledge makes them hesitant to recommend it to their patients. Providers wishing to become QMPs, want to prescribe cannabis safely, learn about appropriate dosing, and develop effective treatment plans for their patients, which are implications for practice. Translation of Evidence into Practice Research supports medical cannabis recommendation by providers, but a lack of provider knowledge decreases provider confidence in recommending medical cannabis to patients (Szaflarski et al., 2020). A lack of medical cannabis education in curricula and organizations may impact patient access. The knowledge gained through effective medical cannabis education can change provider attitudes about recommending medical cannabis, increasing access for patients. Project findings can be helpful to any provider or organization wanting to increase the number of providers who are QMPs. Evidence supports educating providers about recommending medical cannabis to address chronic pain and other chronic diseases (Lynch & Ware, 2015). With a better safety profile than opioids, medical cannabis can be an effective treatment for chronic pain with less risk of addiction or overdose than opioids. The educational presentation supports this finding, and providers surveyed indicate that they felt more comfortable replacing opioids with cannabis after the presentation. Providers surveyed are also more supportive of cannabis being an effective therapy and that cannabis can be beneficial for patients (see Table 2). Implications for Practice and Future Scholarship The findings of the DNP project show that most providers believe that medical cannabis can benefit their patients, but they do not have the practical knowledge of how to implement medical cannabis into current practice. Practical education allows providers the information and MEDICAL CANNABIS EDUCATION FOR PROVIDERS 31 comfort required to recommend medical cannabis. Medical providers who recommend medical cannabis can improve patient access to medical cannabis, enhance patient care, and provide safer alternative treatments for patients currently treating chronic pain with opioids. In addition, patient access to medical cannabis can increase treatment options for difficult-to-treat conditions. Sustainability The DNP project is created to be sustainable after implementation. Sustainability is possible because of Ogden Clinic’s emphasis on continuing medical education for providers. The Ogden Clinic Intranet is a repository of past educational presentations that providers have access to, including a recording of the DNP student presenting at Ogden Clinic grand rounds and medical cannabis patient and practice support materials. Materials created by the DNP student were evaluated by the Ogden Clinic Board of Directors and sent to legal for evaluation and approval. Ogden Clinic providers recommending medical cannabis could use the following forms: Criteria for Medical Cannabis (see Appendix D), Information for Patient and Designated Caregiver (see Appendix E), Medical Cannabis Patient Note Disclosure (see Appendix F), and Medical Cannabis Application Process (see Appendix G). As medical cannabis practice laws evolve, the DNP student can support project sustainability by updating medical cannabis information. Support material can also be created to meet provider and patient needs through communication with providers and patients. The DNP student can also present educational presentations at the monthly Ogden Clinic grand rounds to educate providers about changes to cannabis prescribing laws and new research findings. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 32 Dissemination Medical cannabis education for providers is not only needed at Ogden Clinic. Throughout northern Utah, many providers are eligible to become QMPs who are not taking the opportunity to do so. Making the educational presentation available to different organizations can expand medical cannabis access for patients seeing providers outside of the Ogden Clinic system. Presenting to DNP students at local universities, where medical cannabis education is lacking in the current curriculum, can be an effective way to increase provider education and patient access. The educational presentation can also be adapted for other organizations providing medical cannabis education. Conclusion The development of effective medical cannabis education ensures that patients have access to providers who support cannabis treatment for chronic pain and other qualifying medical conditions. Lack of provider education is detrimental to patients and limits effective treatment for many chronic diseases. The educational intervention indicates that provider attitudes have changed about medical cannabis. Participants show through the survey that they learned through evidence medical cannabis is a safe, effective treatment that can benefit their patients. The results of this project are consistent with the literature, confirming that there is a need for provider education. MEDICAL CANNABIS EDUCATION FOR PROVIDERS 33 References Adrian, M. (2015) What the history of drugs can teach us about the current cannabis legalization process: Unfinished business. Substance Use & Misuse, 50(8), 990-1004. DOI: 10.3109/10826084.2015.1013725 Allen, M., Ferrier, S., O'Connor, N., & Fleming, I. 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The Clinical Journal of Pain, 31(12), 1087-1096. 38 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 39 Appendix A Figure Medical Cannabis Education Budget Item NP Time Cost $300.00 Staff Time $48.00 IT time $82.00 Printing $24.00 Catering $270.62 Total $724.62 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix B Gap Analysis Tool 40 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix C PowerPoint Presentation Slides 41 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 42 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 43 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 44 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 45 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 46 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix D 47 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix E 48 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix F 49 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix G 50 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix H 51 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix I 52 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 53 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 54 MEDICAL CANNABIS EDUCATION FOR PROVIDERS 55 MEDICAL CANNABIS EDUCATION FOR PROVIDERS Appendix J 56