AJN REPORTS
Medical Marijuana: A Hazy State of Affairs for Nurses Few clear rules exist to guide prescribing and patient education.
M
edical marijuana is quickly becoming a part of life for many patients in certain states across the country, but its continuing out law status with federal authorities means nurses must tread carefully around this rapidly evolving issue. Lawmakers and voters have approved the legal ization of marijuana, or cannabis, for medicinal use in only 22 states and the District of Columbia, with most of the changes taking place in the last six years. Beginning this year, recreational use of marijuana is allowed in two states, Colorado and Washington. But nurses are caught in a difficult position. Yes, medical marijuana may be legal according to the laws of a state, but at the federal level the drug re mains a Schedule I controlled substance—the same designation the U.S. Drug Enforcement Administra tion (DEA) gives lysergic acid diethylamide (LSD) and heroin. The agency considers Schedule I drugs to have “no currently accepted medical use and a high potential for abuse.” This dichotomy creates a tension between pa tients wanting to use marijuana for certain condi tions and traditional medical providers fearful of backlash from law enforcement or federal agencies. Advocates for medical marijuana say few hospitals will let patients use marijuana in any form, including “edibles,” on their campus and that hospital physi cians typically don’t recommend medical marijuana for their patients. (Because of the DEA ban, prescrip tions for medical marijuana are not written. Instead, physicians—and, in some states, NPs—will issue a recommendation for its use.) Advocates also report that few nursing schools touch on the topic in their curricula. Some nurses in states that have legalized medical marijuana report a slow but growing acceptance of the drug by the medical establishment, although oth ers are exercising caution in order to avoid conflict with employers, federal authorities, or state boards of nursing. “Everyone is waiting to see what happens. It’s like the Wild West,” said Shayne Mason, BSN, RN, PMHNP, a psychiatric mental health NP who teaches [email protected]
Christine Emerson, CPNP, spoke before the New York State Assembly Health Committee on Medical Marijuana during a hearing last year in Buffalo, New York. Emerson was one of more than two dozen speakers invited to testify before the committee about proposed legislation that would authorize the use of medical marijuana in New York. Photo by Charles Lewis / Buffalo News / Associated Press.
at the University of San Francisco School of Nursing and Health Professions. “We need help as educators and practitioners.” Mason works in a psychiatric emergency clinic that doesn’t provide medical marijuana recommen dations, but many of his patients use the drug, either purchased illegally or through the recommendation of another provider. Some patients, including chronic pain sufferers, appear to have benefited from mari juana, at least on the surface, he said. Still, he feels awkward discussing the subject with his nursing stu dents for fear he might be seen as endorsing the use of marijuana. AJN ▼ August 2014
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Vol. 114, No. 8
19
AJN REPORTS
THE LEGAL LANDSCAPE
Such a go-slow approach for nurses is wise, said au thor, nursing legal consultant, and AJN contributing editor Edie Brous, JD, MS, MPH, RN. Nurses in states where medical marijuana is legal need to familiarize themselves with the specific laws in their state and be aware that the state nursing board’s reaction to the law is important. Of particular concern are home care nurses who may be exposed to secondhand smoke, which could trigger a positive result on a drug test. In 2009, the Delaware Board of Nursing reprimanded a nurse in one such episode, but the action was later overturned by a judge. “Even if it’s legal at the state level, that doesn’t mean that the nursing board has caught up,” Brous said. Medical marijuana has not emerged as a medical drug therapy through the usual process. It didn’t come from large clinical trials with results published in peer-reviewed medical journals. Instead, this has been a grassroots effort, with advocates winning vic tories for legalization in state legislatures or on state initiative ballots.
for Cannabis Nursing,” which took place in May at a conference on medical marijuana in Portland, Or egon. An information sheet on its Web site (http:// bit.ly/Uhmw9l) discusses a number of important as pects of medical marijuana: indications, routes, ad verse effects, dosing, contraindications, and talking points for patient teaching. Too often, fear leads nurses and other health care professionals to shy away from medical marijuana as a research topic or as an issue to discuss with patients, Mathre said. Hospital and school leaders are fearful of jeopardizing federal funding. Frontline nurses are afraid of being seen as marijuana advocates, a designa tion that could hurt promotion opportunities or lead to a drug test.
WHERE DO WE GO NOW?
Despite these fears, nurses are learning to navigate the gray legal area of medical marijuana use. Nurses faced similar legal and social constraints decades ago when working with women seeking contraceptive in formation, said Deborah Burger, RN, copresident of
Nurses in states where medical marijuana is legal need to familiarize themselves with the specific laws in their state and be aware that the state nursing board’s reaction to the law is important. The result is a patchwork of marijuana laws across the country. Some states, like California and Colo rado, have established a legalized marijuana dispen sary system to allow patients to purchase cannabis products. Other states have simply decriminalized use of the drug by certain patients but haven’t set up a means to purchase it. Exactly who qualifies for medi cal marijuana also differs from state to state. Cali fornia leaves that up to the physician. Other states require a specific diagnosis, such as cancer, glaucoma, or chronic pain.
ENTER NURSES
“The good news is that laws are being passed,” said Mary Lynn Mathre, MSN, RN, CARN, a founder of the American Cannabis Nurses Association (ACNA). “But health care professionals are scared to deal with it.” The ACNA is trying to change those attitudes. ACNA members are trying to bring a level of profes sionalism to the subject, rather than jokes about the munchies or Cheech and Chong movies, including hosting a daylong program called “Core Curriculum 20
AJN ▼ August 2014
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Vol. 114, No. 8
both the California Nurses Association and National Nurses United. “Federal law equates cannabis and marijuana with heroin. From a medical perspective that is just ludicrous,” Burger said. It prevents us, she said, from “taking a really honest look at how medi cal marijuana can be used.” When San Francisco mental health NP Kimber leigh Cox, DNP, MSN, received her formal training, the use of marijuana was covered under substance abuse—not discussed as a possible therapy. But a de cade of working for a nonprofit agency serving men tally ill and chemically dependent homeless adults taught her its potential benefits, particularly from a harm-reduction perspective. For example, smoking marijuana may be less risky in the short term for a patient who has been frequently hospitalized for her oin or alcohol abuse, she said. “It’s not [realistic] and doesn’t make sense to wait for some future, funded research trial to yield better information,” said Cox, an assistant professor at the University of San Francisco. Prescribed or not, she said, “marijuana is here already, in our communities, in our patients’ lives.”—John Welsh ▼ ajnonline.com
Medical Marijuana: A Hazy State of Affairs for Nurses Few clear rules exist to guide prescribing and patient education.
M
edical marijuana is quickly becoming a part of life for many patients in certain states across the country, but its continuing out law status with federal authorities means nurses must tread carefully around this rapidly evolving issue. Lawmakers and voters have approved the legal ization of marijuana, or cannabis, for medicinal use in only 22 states and the District of Columbia, with most of the changes taking place in the last six years. Beginning this year, recreational use of marijuana is allowed in two states, Colorado and Washington. But nurses are caught in a difficult position. Yes, medical marijuana may be legal according to the laws of a state, but at the federal level the drug re mains a Schedule I controlled substance—the same designation the U.S. Drug Enforcement Administra tion (DEA) gives lysergic acid diethylamide (LSD) and heroin. The agency considers Schedule I drugs to have “no currently accepted medical use and a high potential for abuse.” This dichotomy creates a tension between pa tients wanting to use marijuana for certain condi tions and traditional medical providers fearful of backlash from law enforcement or federal agencies. Advocates for medical marijuana say few hospitals will let patients use marijuana in any form, including “edibles,” on their campus and that hospital physi cians typically don’t recommend medical marijuana for their patients. (Because of the DEA ban, prescrip tions for medical marijuana are not written. Instead, physicians—and, in some states, NPs—will issue a recommendation for its use.) Advocates also report that few nursing schools touch on the topic in their curricula. Some nurses in states that have legalized medical marijuana report a slow but growing acceptance of the drug by the medical establishment, although oth ers are exercising caution in order to avoid conflict with employers, federal authorities, or state boards of nursing. “Everyone is waiting to see what happens. It’s like the Wild West,” said Shayne Mason, BSN, RN, PMHNP, a psychiatric mental health NP who teaches [email protected]
Christine Emerson, CPNP, spoke before the New York State Assembly Health Committee on Medical Marijuana during a hearing last year in Buffalo, New York. Emerson was one of more than two dozen speakers invited to testify before the committee about proposed legislation that would authorize the use of medical marijuana in New York. Photo by Charles Lewis / Buffalo News / Associated Press.
at the University of San Francisco School of Nursing and Health Professions. “We need help as educators and practitioners.” Mason works in a psychiatric emergency clinic that doesn’t provide medical marijuana recommen dations, but many of his patients use the drug, either purchased illegally or through the recommendation of another provider. Some patients, including chronic pain sufferers, appear to have benefited from mari juana, at least on the surface, he said. Still, he feels awkward discussing the subject with his nursing stu dents for fear he might be seen as endorsing the use of marijuana. AJN ▼ August 2014
▼
Vol. 114, No. 8
19
AJN REPORTS
THE LEGAL LANDSCAPE
Such a go-slow approach for nurses is wise, said au thor, nursing legal consultant, and AJN contributing editor Edie Brous, JD, MS, MPH, RN. Nurses in states where medical marijuana is legal need to familiarize themselves with the specific laws in their state and be aware that the state nursing board’s reaction to the law is important. Of particular concern are home care nurses who may be exposed to secondhand smoke, which could trigger a positive result on a drug test. In 2009, the Delaware Board of Nursing reprimanded a nurse in one such episode, but the action was later overturned by a judge. “Even if it’s legal at the state level, that doesn’t mean that the nursing board has caught up,” Brous said. Medical marijuana has not emerged as a medical drug therapy through the usual process. It didn’t come from large clinical trials with results published in peer-reviewed medical journals. Instead, this has been a grassroots effort, with advocates winning vic tories for legalization in state legislatures or on state initiative ballots.
for Cannabis Nursing,” which took place in May at a conference on medical marijuana in Portland, Or egon. An information sheet on its Web site (http:// bit.ly/Uhmw9l) discusses a number of important as pects of medical marijuana: indications, routes, ad verse effects, dosing, contraindications, and talking points for patient teaching. Too often, fear leads nurses and other health care professionals to shy away from medical marijuana as a research topic or as an issue to discuss with patients, Mathre said. Hospital and school leaders are fearful of jeopardizing federal funding. Frontline nurses are afraid of being seen as marijuana advocates, a designa tion that could hurt promotion opportunities or lead to a drug test.
WHERE DO WE GO NOW?
Despite these fears, nurses are learning to navigate the gray legal area of medical marijuana use. Nurses faced similar legal and social constraints decades ago when working with women seeking contraceptive in formation, said Deborah Burger, RN, copresident of
Nurses in states where medical marijuana is legal need to familiarize themselves with the specific laws in their state and be aware that the state nursing board’s reaction to the law is important. The result is a patchwork of marijuana laws across the country. Some states, like California and Colo rado, have established a legalized marijuana dispen sary system to allow patients to purchase cannabis products. Other states have simply decriminalized use of the drug by certain patients but haven’t set up a means to purchase it. Exactly who qualifies for medi cal marijuana also differs from state to state. Cali fornia leaves that up to the physician. Other states require a specific diagnosis, such as cancer, glaucoma, or chronic pain.
ENTER NURSES
“The good news is that laws are being passed,” said Mary Lynn Mathre, MSN, RN, CARN, a founder of the American Cannabis Nurses Association (ACNA). “But health care professionals are scared to deal with it.” The ACNA is trying to change those attitudes. ACNA members are trying to bring a level of profes sionalism to the subject, rather than jokes about the munchies or Cheech and Chong movies, including hosting a daylong program called “Core Curriculum 20
AJN ▼ August 2014
▼
Vol. 114, No. 8
both the California Nurses Association and National Nurses United. “Federal law equates cannabis and marijuana with heroin. From a medical perspective that is just ludicrous,” Burger said. It prevents us, she said, from “taking a really honest look at how medi cal marijuana can be used.” When San Francisco mental health NP Kimber leigh Cox, DNP, MSN, received her formal training, the use of marijuana was covered under substance abuse—not discussed as a possible therapy. But a de cade of working for a nonprofit agency serving men tally ill and chemically dependent homeless adults taught her its potential benefits, particularly from a harm-reduction perspective. For example, smoking marijuana may be less risky in the short term for a patient who has been frequently hospitalized for her oin or alcohol abuse, she said. “It’s not [realistic] and doesn’t make sense to wait for some future, funded research trial to yield better information,” said Cox, an assistant professor at the University of San Francisco. Prescribed or not, she said, “marijuana is here already, in our communities, in our patients’ lives.”—John Welsh ▼ ajnonline.com
