Christy Rapoza, RN, BSN, SAFE - Introduction & Philosophy



Clinical Question Paper

Christy Rapoza

Ferris State University

Abstract

This paper is the result of research done after applying the PICO method to determine a question in an area of interest. The methodology in which data was collected will be explained as well as the level of evidence assigned to each article. Each article utilized in this research will be critiqued for their findings. It will be determined whether or not this research can be integrated into patient care and the impact it will have on personal and professional values.

Clinical Question Paper

The Research in Nursing syllabus (2014) states “The purpose of this assignment is to reflect how nursing knowledge is disseminated for use in personal use and professional practice” (p. 11). This reflection is done through research using the PICO method. Articles researched will be analyzed for their significance to nurses and possible incorporation into patient care.

Clinical Question

The PICO method is an acronym often utilized when writing a clinical question. This can help the researcher decide on the right question to ask to solve a problem. Nieswiadomy, (2012) defines the letters in the acronym as follows “P= Patient or population, I= Intervention or interest area, C= Comparison intervention or current practice, [&] O= Outcome(s) desired” (p. 282).

The PICO question that was chosen and researched was, Does medical marijuana use reduce self-reported pain scale ratings compared to opioid analgesic use in chronic pain patients? This problem was chosen because working in the Emergency Department (ED) there has been an increase in the number of patients coming in using marijuana for pain management instead of opioid analgesics. This elicited the question on whether one was safer and more effective than the other for the treatment of chronic pain.

Methodology

To research this information searches were conducted using four different databases. These databases were: CINAHL, PUBMED, AHRQ, and Cochrane Review. The following is the results used from each database to answer the PICO question:

• CINHAHL: 71 results with 90% relevant

Keywords: Marijuana therapy for pain

• PUBMED: 99 results with 60% relevant

Keywords: Marijuana therapy for pain management

• AHRQ: 57 results with 0% relevant

Keywords: Marijuana, pain, opiods

• Cochrane Review: 4 results with 75% relevant

Keywords: Marijuana therapy for pain management

Multiple searches were done trying to find research on this topic, with the above choices having the most relevancies to the topic of choice. Unfortunately, none of the research found was nursing research.

Levels of evidence are a quick way to let researchers know the quality of the data in a particular article. However, research with an evidence level of 1, does not guarantee that it will be the best or most appropriate choice for your research criteria (Burns, P., Rohrich,R., & Chung, K., 2012). Melnyk,& Fineout-Overholt (2011) list the seven levels of evidence as:

Level 1 - Systematic review & meta-analysis of randomized controlled trials; clinical guidelines based on systematic reviews or meta-analyses, Level 2 - One or more randomized controlled trials, Level 3 - Controlled trial (no randomization), Level 4 - Case-control or cohort study, Level 5 - Systematic review of descriptive & qualitative studies, Level 6 - Single descriptive or qualitative study, and Level 7- Expert opinion

Discussion of Literature

After multiple database searches, three articles were chosen as the best to answer the PICO question. These articles were critiqued to determine their purpose, study methodology, level of evidence, and ultimately their findings on the subject.

Article 1

Article one, Therapeutic Benefits of Cannabis: A Patient Study by C. Webb & S. Webb. The purpose of this study was to determine the therapeutic benefits of marijuana. The sample size for this study was a 100 patients utilizing medical marijuana. These patients were given a survey when they came in for their yearly re-certification for marijuana use. This is a relatively small study which was conducted over eight months. Unfortunately nowhere does it list how many marijuana patients they have in total utilizing marijuana (i.e. in the 4 months that they didn’t hand out surveys did they miss 100 patients or just 10?

The results from this study showed that marijuana is a very safe and effective medication for the treatment of chronic pain, with 64% of patients self-reporting a decrease in pain (Webb, C. & Webb, S., 2014). It also showed the added therapeutic benefit of decreased anxiety in 50% of patients and insomnia in 45% of their patients (Webb, C. & Webb, S., 2014). The level of evidence for this study was a four, as this is a case controlled study (Melnyk & Fineout-Overholt, 2011).

Article 2

Article two, Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials by M. Lynch & F. Campbell. The purpose of this study was to determine the potential role of marijuana in the treatment of chronic pain. This was a review of 18 trials conducted between 2003 and 2010 involving a total of 766 patients. Lynch & Campbell, (2011) state "The quality of the trials was very good with a mean score of 6.1on the 7 point modified Oxford scale".

The results from this study showed that marijuana is an effective and safe medication for the treatment of chronic pain. Many of the trials also reported patients with improved sleep (Lynch & Campbell, 2011). The level of evidence for this study was five, as this is a systematic review of qualitative studies (Melnyk & Fineout-Overholt, 2011).

Article 3

Article three, Systematic Review and Meta-analysis of Cannabis Treatment for Chronic Pain by E. Martín-Sánchez, T. Furukawa, J. Taylor, & J. Martin. The purpose of this study was to determine if marijuana is an effective treatment for the management of chronic pain or if it is potentially harmful to the patients. This was a systematic review and meta-analysis of 18 double-blind randomized controlled trials comparing marijuana use vs. placebo use among patients with chronic pain.

The results from this study showed marijuana is effective for chronic pain however there is the possibility of becoming addicted to it. The level of evidence for this study was one, as this is a systematic review & meta-analysis of randomized controlled trials (Melnyk & Fineout-Overholt, 2011).

Based on these articles I would recommend incorporating marijuana into the collection of medications for chronic pain patients. I would not discontinue the use of opioids as many of the articles did not directly compare the two. They only noted how marijuana had additional benefits that opioids did not. None of these articles were nursing research. In the future I would look for nurses to do research on this topic, especially with relevance to side effects and addiction. Also, only one of the articles had the patients use the 0-10 pain scale before and after treatment as a way to determine the effects of marijuana use. I would also expect to see more research done using the pain scale in the future.

Significance to Nursing

White & O'Sullivan, (2012) state "Combining teamwork and collaboration, the Quality and safety Education for Nurses (QSEN) program reaffirms that nurses must 'function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care'" (p. 177). This might be hard with patients utilizing marijuana for their chronic pain; personal values have the potential to influence professional values. There is still the belief, especially since marijuana is still illegal in many states, that marijuana is a harmful illegal drug with no medicinal benefit. Nurses need to work together, as more and more patients are being treated with marijuana, they need to make sure these patients are not being stereotyped simply as "potheads" and are receiving the appropriate care that is needed. Patients who feel that they cannot communicate with their nurse will likely not participate in their care.

There is also the need for nursing research in regards to marijuana use. The significance of using sources which are distinct for nursing is that they are meant to guide quality patient based care. Without current nursing research there is only medical research to guide patient care.

Conclusion

Using the PICO method to help determine a research question resulted in demonstrating the need for nursing research in regards to marijuana use for chronic pain patients. The medical research used for this paper all state that marijuana is a safe and effective treatment for the management of chronic pain.

References

Burns, P., Rohrich,R., & Chung, K. (2012). The Levels of Evidence and their role in Evidence-Based Medicine. Plast Reconstr Surg. 128(1), 305–310. Retrieved from

Lynch, M.D. & Campbell, F. (2011). Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. BJCP 72(95), 735-744. Retrieved from

Martín-Sánchez, E., Furukawa, T.A., Taylor, J. & Martin, JLR. (2009). Systematic Review and Meta-analysis of Cannabis Treatment for Chronic Pain. Pain Medicine 10 (8), 1353-1368. Retrieved from

Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.

Nieswiadomy, R. M. (2012). Foundations of nursing research (6th ed.). Boston: Pearson.

Ursuy, Peggy (2014). Research in Nursing Syllabus. Ferris State University.

Webb, C.W. & Webb, S. M. (2014). Therapeutic Benefits of Cannabis: A Patient Study. Hawaii Journal of Medicine & Public Health 73 (4), 109-111. Retrieved from

White, K. & O'Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANA's Scope and Standards in Practice and Education. Silver Spring: MD

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