Meet the experts: Portugal Experience

By Soraia Tomás

With a degree in Nursing from Escola Superior de Enfermagem de Coimbra in 2015, Soraia Tomás worked in the intensive care unit of cardiothoracic surgery and lung transplantation in Lisbon. She currently works at the Spine Center, a spine surgery service and a general surgery intensive care unit at Hospital da Luz in Coimbra, where she lives. An enthusiast in the field of Medicinal Cannabis, she is a member of the scientific board of the Portuguese Observatory of Medicinal Cannabis, has attended conferences in this field (Portugal Medical Cannabis, Cannabis Europe, and CannX, CannabMed among others) and has obtained a graduate degree in GMP's for Medicinal Cannabis, a course held by the Portuguese Observatory of Medicinal Cannabis in partnership with the Military Laboratory of Chemical and Pharmaceutical Products and the Faculty of Pharmacy of the University of Lisbon. President of the General Assembly of apcanna - the Portuguese Association for Information on Cannabis, which holds PTMC (Portugal Medical Cannabis) project, she also provides counseling and nursing supervision to medicinal cannabis patients through Kalapa Clinic.

This series of chronicles describes the personal experience of a Medical Doctor who prescribes medical cannabis in his/her country. Each article is narrated in the first person and reports the subjective experience of each expert.

A Portuguese Cannabis Nurse

I started my professional career as a nurse in 2015, a year full of changes at both a professional and personal level. I performed nursing functions in several areas, including general medicine internment and intensive care of cardiothoracic surgery and lung transplants. Later, I joined the nursing team of the Spine Center, a service dedicated to spine surgery and the intensive care unit team of general surgery, where I am currently active. During this journey, both as a nursing student, intern and later health professional, I realized that to be a Nurse is to be a highly qualified professional, who uses her technical, social, ethical and cultural skills for the well-being of people, families and communities. It is also knowing how to put into practice "caring for others", not only in the technical aspects required, but above all, with the skills that allow me to implement a holistic approach to patient care .

After finishing my degree, I was confronted with my grandfather's cancer diagnosis, which led to a whirlwind of emotions, namely the fear of treatment and its side effects, as well as the panic caused by the uncertainty of its effectiveness. This situation led me to research for alternative therapies and from this search came the possibility of treatment or relief of symptoms associated with the disease using the cannabis plant. Although an effective treatment solution, at the time it was still illegal in Portugal and very stigmatized.

My research intensified, despite the few resources existing at that time. I found that although it was already legal in some countries and there were reports of several successful cases, the knowledge of the Portuguese medical and nursing community was almost non-existent and it would therefore be difficult to obtain the necessary support.

The changing cannabis legislative framework worldwide

Fortunately, in recent years, interest in using cannabis to treat a variety of conditions has resurfaced. This interest has culminated in the amendment of the legislation to allow its use for medicinal purposes in the most diverse countries. Most notable in the European Union are Germany, Italy, Netherlands, Czech Republic and more recently, Portugal.

Scientific evidence has revealed the therapeutic value of cannabinoids in several pathologies and symptoms, namely in the prevention of nausea and vomiting induced by chemotherapy, improvements in spasticity and pain, reduction of the frequency of epileptic seizures, and much more.

In Portugal, Law no. 33/2018 was passed on July 18 and its regulation by Decree-Law no. 8/2019 of January 15, established the legal framework for the use of medicines, preparations and substances based on the cannabis plant for medicinal purposes. This meant in addition to drugs containing cannabinoids as the active ingredient, prescription and dispensation of preparations and substances based on cannabis, namely containing the leaves and juices flowered or fruited, oil and other standardized extracts or preparations extracted obtained from the plant were allowed. The prescription is by way of a special medical prescription and is exclusive dispensed in pharmacies. The legislative changes regarding medicinal use highlight the need for a correct and comprehensive understanding of its properties.

Ethics and Deontology of the Nurse

As a nurse, and according to the ethical and deontological code of nursing, I have duties to the community. I am responsible for promoting health and responding appropriately to the needs in nursing care. Not only knowing the needs of the population and community in which I am professionally involved, but also participating in the search for solutions to identified health problems and collaborating with other professionals in programs that respond to their needs. I also believe i have a duty to provide as much information to patients as possible, provide resources and respect their rights to choose their course of treatment.

The nurse has the duty to seek, in every professional endeavour, the best practices, maintain continuous updating of his knowledge and to use the technology in a competent way, not forgetting the permanent and in-depth training in human sciences.

The deontological principles associated with my professional practice and personal experience have led me to intensify my defense of those who intend to undergo cannabinoid therapy and, as a member of apcanna, to develop projects dedicated to the dissemination, education and training in medicinal cannabis to health professionals and the general public, thus promoting excellence in professional practice and safe and effective access to cannabinoid therapies.

The lack of training, information and available "medicines"

Despite the legislative change in Portugal, there is a huge void in education and training of health professionals and the population in general, and it is personally frustrating to deal with the lack of knowledge inherent to this plant. Although it is legal, the access to this plant, with so many therapeutic benefits, is still denied. There is no authorization from the competent authorities for the introduction of products based on the cannabis plant in the Portuguese market, which prevents its prescription and monitoring by health professionals.

There is a growing demand for cannabinoid therapy from patients of all social classes, who have found in it the therapeutic potential necessary for the relief of a myriad of mental and physical conditions.

It is controversial how people continue to purchase cannabis-based products on their own initiative and without medical supervision, which carries risks of drug interactions and other possible adverse effects. Products are acquired through questionable means, without any control in terms of quality, safety and effectiveness.

Currently, I provide counseling to medicinal cannabis patients and besides providing reliable information based on studies with scientific evidence, I also make an initial screening of patients, later referring them to doctors specialized in cannabinoid therapies. During this work I have noticed that this therapy is sought after for the treatment of several medical conditions, from multiple sclerosis, rheumatoid arthritis, epilepsy, autism, fibromyalgia, chronic pain, depression and anxiety, among others. I recognize that cannabis does not represent a cure for all pathologies, however it can be the help that many needs in relieving symptoms and improving their quality of life.

A successful case with OsteoArthritis

I worked with a patient with osteoarthritis, diagnosed 10 years ago, whose conventional treatments had failed. The intense pain culminated in a severe reduction of mobility, insomnia, increased appetite and weight gain, hormonal imbalance, anxiety and depression, consequently drastically reducing quality of life. One of the main reasons for her fear and anxiety at the beginning of her treatment was the dialogue with the doctor who treated her about medical cannabis. At the time, her doctor did not know or support a treatment based on the cannabis plant, due to lack of knowledge and possibly the inherent stigma.

At first contact, I provided reliable information, carried out an initial screening and then referred the patient to doctors specialized in cannabinoid-based therapies. With an adequate medical and nursing follow-up, after the beginning of the treatment the inflammation inherent to this pathology was controlled and consequently the pain complaints decreased. The two hours of sleep were replaced by 8/9 hours of repairing sleep. There was also a control of appetite, weight loss and consequently improved mobility. This evolution in the state of health allowed this user, previously dominated by the sedentary nature associated with her condition, to start walking about three hours a day. There was an improvement in hormonal levels, thus reducing the symptoms associated with anxiety and depression triggered by this sequence of events. Her social life was re-established and the quality of life drastically improved.

Anxiety and Depression

Another successful case, related to cannabinoid treatment, was that of a young woman diagnosed with anxiety and depression, whose panoply of anxiolytics, benzodiazepines and antipsychotics left her in a state of apathy and general disinterest for life. The patient revealed problems of insomnia, loss of appetite and consequently weight loss, isolation, and a very limited social life, in addition to stating that she had no reason to live and presented daily suicidal ideation.

After an adequate initial screening and subsequent referral to a specialized physician in the area, it was possible to reduce, safely and without risk of interactions, the entire load of medication she was on. Slowly this young woman came back to life, she returned to daily exercise and adopted a healthy diet. The satisfaction with her physical self-had positive consequences on her amorous life and she went back to college, a dream that had remained in standby as a consequence of the isolation previously described. Happiness was once again present in her daily life and no more suicidal thoughts were reported after the start of treatment with cannabinoid therapy.

The experience of the animals, my Jack

The benefits of this plant are not restricted to humans, but also to animals, since all vertebrates have an endocannabinoid system, and especially dogs, which have much more receptors than humans.

In my personal sphere, this year I was confronted with the cancer diagnosis of Jack, my four-legged best friend. At the age of seven and always a very happy dog, he began to show signs in early 2020 of severe respiratory difficulty when subjected to moderate effort, nausea and vomiting, loss of appetite and consequent weight loss. After two consultations in the veterinary hospital of the city where I live, two chest x-ray and several blood tests, he was diagnosed with metastatic lung cancer. We returned home with a bunch of medication (powerful anti-inflammatories, antibiotics and gastric protectors) and very slim prospects for a complete recovery. Knowing the benefits that the cannabis plant could offer and being aware of my limitations, I sought medical attention in this area. I did not find that support in my country, but after getting in touch with some cannabis experts, I met Elena Battaglia, an Italian veterinary doctor, specialist in cannabinoid therapy, who after the first contact was immediately available to follow Jack's treatment. A difficult journey that requires time, dedication and love, but in which fantastic results were obtained. Currently Jack has regained his appetite, as well as his normal weight, and is again an active dog, running, jumping and playing.

The Nurse has the ethical obligation to help the Patient

The cases described above are only three successful stories, out of several that appear daily, not only in Portugal, but all over the world. For this reason, it is crucial to have health professionals, namely nurses, familiar with the different constituents of this plant, its applicability, as well as with the ethical and legal issues related to its prescription.

For 18 consecutive years, nursing has been classified as the profession in which the highest level of trust is placed by patients and, as such, suffers from the professional obligation and ethics to live up to our reputation. I have made the decision to advocate and monitor patients seeking relief from this plant for their most diverse symptoms and for the first time in my career as a nurse I feel that I am really helping people, promoting quality of life and fulfilling my duty on a professional and personal level. I want to fight for the basic human right of safe and effective access to cannabinoid-based therapy, and currently each of us has his own personal experience that has led him to defend the use of this plant. The cases reported are, in some cases, "miraculous" in the eyes of patients, who had already lost hope. As a matter of fact, all patients have the right to have someone to accompany and defend them in this struggle.

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