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Official websites use. Share sensitive information only on official, secure websites. This article is distributed under the terms of the Creative Commons Attribution 4. Although medicinal cannabis is prescribed for conditions such as pain, epilepsy, nausea and vomiting during cancer treatment, evidence about associated adverse side effects is still evolving. Because adverse events AEs might impact the performance of workers, it is important to consider their implications on workplace health and safety WHS. This study aimed to map the types and prevalence of the AEs associated with medical cannabis and articulate how those events could impact WHS. Of 1, papers identified from the initial search, 31 met the inclusion criteria and were analyzed. Acute and chronic pain was the most prevalent disorder under review. Adverse events associated with the use of medicinal cannabis could increase workplace risks, including decreased alertness and reaction times, increased absenteeism, reduced ability to safely drive or operate machinery and an increased probability of falling. Focused research into the risk to workers and workplaces from the use of medical cannabis and related human performance impairment is urgently warranted. Keywords: medical cannabis, adverse events, occupational health and safety, safety management. Studies have encouraged pharmaceutical applications, while restrictions on the use, production, and distribution of cannabis endure due to its listing as a narcotic drug Aguilar et al. Adverse events can differ for each patient due to their age, underlying health conditions, gender, weight, patient compliance, interaction with other medications, food or vitamins, and overall health U. Cannabis use can lead to clinical impairment of psychological, cognitive, and physiological functioning American Psychiatric Association, Research has demonstrated the significant impact of tetrahydrocannabinol THC cannabis on reaction time, motor co-ordination, ability to judge Arkell et al. However, these studies mainly focused on cannabis for recreational use. Despite acknowledgment of the potential adverse effects of cannabis, research into the potential AEs has not yet matured Arnold, , and there seems to be a dearth of long-term high-quality studies to confidently clarify patient safety aspects MacCallum et al. Moreover, there is no globally accepted definition of impairment associated with medicinal cannabis and no agreement on how to measure its occurrence Eadie et al. Yet, being cognizant of the adverse effects of medical cannabis and the probable impacts on human functioning is critical for workplaces. Under workplace health and safety WHS legislation in most countries, employers must provide a safe working environment while workers must also declare anything that could decrease their ability to work safely undertake work in a safe manner or threaten the health and safety of themselves and others affected by work activities Government of Canada, Hence, there is an urgent need for occupational health OH providers and, in general, OH nurses, to support workplaces in making sure workers are fit for duty, and both workers and employers meet their legal obligations to avoid causing harm to others. This is particularly relevant for those taking medication, such as medicinal cannabis, due to adverse side effects and the subsequent risk of impairment. As a first step toward addressing this gap, the current scoping review of systematic reviews and meta-analyses maps the types and prevalence of the AEs associated with medical cannabis and articulates how those events could impact WHS. This research contributes to the knowledge of medicinal cannabis by providing quality synthesis of current evidence to inform WHS policy and practice. This study could influence the review of existing policies and WHS legislation, including OH staff and employer responsibilities, return-to-work and rehabilitation programs, and worker compensation schemes. Time efficiency was gained through the identification of relevant systematic reviews and meta-analyses. The search strategy was completed under the guidance of a medical librarian and was peer-reviewed by all authors of this article. As the use of medicinal cannabis is an emerging topic and requires timely access to evidence, the literature search was limited to the period between and March The abstracts and titles of the remaining entries were initially screened by the first author VO and classified into the groups of Excluded, Included , and Maybe. The first author randomly selected 30 of the screened articles from within those three groups and split them into three sets for moderation by the rest of the authors PM, AS, and NK. Each author reviewed 10 articles, and any discrepancies were resolved through discussion and consultation. After establishing confidence in the reliability of screening, VO and PM independently screened all abstracts. Discrepancies from this screening were resolved through consensus between the two researchers, leading to the exclusion of articles and inclusion of publications for eligibility assessment. After retrieving the full texts of the articles, an additional moderation was undertaken by randomly assigning 10 papers to PM, AS, and NK for eligibility. Following the resolution of discrepancies through consultation and the achievement of consensus, VO assessed all articles. This step resulted in the exclusion of 86 articles. Figure 1 presents the literature screening flow. The data extracted from each systematic review and meta-analysis study included information about the year and country of publication, aims of the review, specific populations examined, number of original papers analyzed, and key findings associated with AEs of medicinal cannabis. During the review of the studies, the research team noticed it was unclear what criteria the authors of each paper followed to classify an adverse event as serious. Excluding easily recognizable serious events like death , a life-threatening medical event , and suicidal behaviors , the classification of events as serious or not was not consistent in the data. For example, disorientation and urinary tract infection were classified as serious in one study Mohiuddin et al. Next, as the terms used to describe AEs varied across studies, an additional review of all events was undertaken by VO and PM. During this process, all similar terms were grouped together. Any discrepancies were resolved through consultation and consensus. Moreover, the lowest and highest percentages of participants who experienced AEs were recorded. Finally, to yield an overall picture per article, we calculated the average percentages of the participants who experienced the AEs, identified within each publication. The principal aim of all 31 studies was to review the efficacy and safety of medicinal cannabis across a range of disorders. In addition, only one study Hindley et al. The studies were not examined to investigate occupational settings nor the potential interactions and effects of additional prescribed medication on medicinal cannabis. The rest included a range of administration routes, such as capsules and intramuscular injections Gazendam et al. Cannabis doses were not comparable across any of the studies. The third most frequently reported AE across 16 studies was a dry mouth , while vomiting and fatigue were reported across 14 studies each. In total, 12 studies identified SAEs, all of them regarding participants experiencing pain. The most frequently reported SAEs were urinary tract infection, pneumonia, fracture from fall due to dizziness , and suicidal ideations. The greatest incidence of SAEs i. The least reported incidents of SAEs were in the study that focused on subjects with chronic pain Nugent et al. Of the 12 systematic reviews that identified SAEs, only five noted percentages of individuals affected Figure 3. After grouping the AEs reported with different names, sedation presented the highest incidence, with 53 referenced times across the original articles Table 2. The events reported only once were death, rash, sweating, social stigma, and cancer. A range of AEs is attributed to the use of medicinal cannabis, which relates to implications of the physical, cognitive, and physiological states of individuals. Interestingly, there are significant differences in the percentages of affected individuals reported per original research that was considered in the systematic reviews and meta-analyses included in this study. For example, body size is a key influence on the response of drugs in the system Higgs et al. This is due to bigger frames having a larger vascular system; therefore, the same concentration of a drug will be diluted in a larger blood volume. Indeed, fat-soluble drugs, such as THC, would be absorbed into the body fat, and their period of action would be longer for a person who is obese as opposed to a person who is lean Le, Age is a further pharmacokinetic factor Higgs et al. In addition, kidneys are less effective at excreting drugs into urine, and the liver becomes smaller and less efficacious. In general, AEs can differ for each patient due to their age, underlying health conditions, gender, weight, patient compliance, interaction with other medication, food or vitamins, and overall health FDA, Therefore, while there is a considerable range of AEs that can arise from taking medicinal cannabis, how to manage and accommodate these safely, especially during work activities, can be a challenging proposition for both the employer and the worker. Apart from the obligations of employers to provide a healthy and safe working environment, workers are also required to be fit for their role to minimize any risk to self or others and to perform their duties safely Commonwealth of Australia, The findings from this scoping review show that workers who have been prescribed medicinal cannabis could experience a broad spectrum of AEs, which in turn can cause impairment in their functioning. Depending on the type of cannabinoid, the route of administration and the tolerances of the individual, such effects have the potential to jeopardize WHS. Due to the lack of consistency in terminology and classification of serious AEs, the following sections focus on the most frequent of the AEs listed in Table 2 , which have been categorized for the purposes of this study. Although the grouping of events, irrespective of reported severity level, serves the scope of this study, they should still be viewed with caution due to the inconsistencies and variability the authors observed in the way those events and their prevalence were reported across the publications analyzed. Furthermore, the possible effects of the less frequent events listed in Table 2 should not be underestimated as their incidence can vary across individuals, as discussed above. Notably, the coexistence of more than one of those AEs in individuals and their interactions can increase the cumulative risks of negative consequences within workplaces and beyond. Similar terms used across the studies were fatigue, somnolence, tiredness, drowsiness, sleepiness , and lethargy. Indeed, sedation can influence the ability to remain alert and focused, lead to reduced reaction times when responding to a situation, and impact the decision-making capacity Phillips et al. While there is a difference between the sensation of nausea being discomfort and the urge to vomit, and vomiting being the final forced action, they are often described together and can range from mild to severe U. National Library of Medicine, Although mild symptoms can be unpleasant they can be easily managed. Those symptoms can cause impairments within the workplace. For example, it has been reported that dehydration in the workplace resulted in impaired decision-making and cognitive capacity and created risk of poorer work performance and increased preventable errors Lamaire et al. In addition, weakness and dizziness can increase the risk of injury to worker due to an increased likelihood of a fall, possibly resulting in bone fractures Velayudhan et al. Moreover, dehydration can also cause headaches that impact work efficiency, reduce productivity, and require short-term absence from the workplace Simic et al. Although we could not identify dizziness-related publications specifically for WHS, referred effects of this adverse event on the employment and daily living activities has previously been identified San Filippo, These included an increased risk of injury due to a fall, inability to drive due to safety concerns and reduced capacity to concentrate and process tasks San Filippo, Such effects can impact productivity levels, inflict additional costs for businesses and threaten workplace safety. The fourth most frequently reported adverse effect was euphoria. This is the sensation frequently associated with smoking marijuana cigarettes for recreational purposes Alcohol and Drug Foundation, Participants also described this sensation as feeling high and feeling drunk. Decreased reaction times Phillips et al. At BAC 0. As in several countries, the BAC limit for safe driving is 0. The findings of this research are constrained by several limitations. As a scoping review, this study did not include a quality assessment of the publications analyzed. Another limitation is the lack of investigation and synthesis of dosage, type of cannabinoid and route of administration. This was beyond the scope of this study and many of the papers included did not specifically mention synthesis of dosage, type of cannabinoid and route of administration. This would have been advantageous to derive the magnitude and duration of each adverse event and generate more tangible results for implications on WHS. In addition, it is noted that the synergistic effects of drug-to-drug interactions, especially between cannabidiol and conventional pharmacotherapies, can amplify adverse effects Arnold, A final limitation relates to the subjective responses of the participants of the original research and the lack of clinical data. Nevertheless, although we believe the limitations stated above did not threaten the objectives of this study, they reflect research gaps and could constitute opportunities to standardize future studies on the AEs of medicinal cannabis. Risks associated with the adverse effects in the context of WHS discussed in this study include, lower levels of alertness, reduced reaction times, increased absenteeism, decreased ability to safely drive or operate machinery and an increased probability of falling. Therefore, the AEs and their ramifications must be considered and proactively addressed to ensure a healthy and safe work environment. This will require a multidisciplinary approach with critical input from OH staff, including OH nurses, as they are in an ideal role to work alongside the workplace in assessing the risk of impairment connected to safety-sensitive roles Phillips et al. However, well-defined policies will need to be established and implemented to guide best practice as this contentious topic continues to evolve. With advancements in the use of medicinal cannabis for chronic health conditions and an aging global workforce with greater access to medicinal cannabis to manage pain and disability, a more comprehensive understanding of the implications of the effects of medical cannabis to WHS is critical. Further high-quality research is recommended with a focus on medicinal cannabis and AEs that impact WHS, including measurements of the intensity and duration of human functioning impairments associated with medicinal cannabis. We identified a number of potential risks associated with the adverse events from the use of medicinal cannabis. From an occupational health and safety perspective, the adverse events and their ramifications must be detected and proactively addressed. Occupational health staff are in an ideal place to operate in concert with the workplace in assessing the risk of impairment connected, in particular, to safety-sensitive roles. Author Contributions: All authors were involved in the conception and design. Primary author was involved in the literature search, and all authors were involved in the extraction and selection of articles for inclusion. The primary author scripted the initial draft. All authors were involved in the subsequent revisions and preparations of the review prior to submission. Availability of Data and Materials: The author confirms that all data generated or analyzed during this study are available from the primary author. As a library, NLM provides access to scientific literature. Workplace Health Saf. Find articles by Nektarios Karanikas. Find articles by Adem Sav. Patricia Murphy , PhD 2 Independent researcher. Find articles by Patricia Murphy. Issue date Sep. Open in a new tab. Similar articles. 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