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Few clear rules exist to guide prescribing and patient education.
Medical marijuana is quickly becoming a part of life for many patients in certain states across the country, but its continuing outlaw status with federal authorities means nurses must tread carefully around this rapidly evolving issue.
Lawmakers and voters have approved the legalization 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 remains a Schedule I controlled substance-the same designation the U.S. Drug Enforcement Administration (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 patients wanting to use marijuana for certain conditions 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 physicians typically don't recommend medical marijuana for their patients. (Because of the DEA ban, prescriptions 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 others 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 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 recommendations, 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 marijuana, at least on the surface, he said. Still, he feels awkward discussing the subject with his nursing students for fear he might be seen as endorsing the use of marijuana.
Such a go-slow approach for nurses is wise, said author, 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 victories for legalization in state legislatures or on state initiative ballots.
The result is a patchwork of marijuana laws across the country. Some states, like California and Colorado, have established a legalized marijuana dispensary 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 medical marijuana also differs from state to state. California leaves that up to the physician. Other states require a specific diagnosis, such as cancer, glaucoma, or chronic pain.
"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 professionalism to the subject, rather than jokes about the munchies or Cheech and Chong movies, including hosting a daylong program called "Core Curriculum for Cannabis Nursing," which took place in May at a conference on medical marijuana in Portland, Oregon. An information sheet on its Web site (http://bit.ly/Uhmw9l) discusses a number of important aspects of medical marijuana: indications, routes, adverse 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 designation that could hurt promotion opportunities or lead to a drug test.
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 information, said Deborah Burger, RN, copresident of 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 medical marijuana can be used."
When San Francisco mental health NP Kimberleigh Cox, DNP, MSN, received her formal training, the use of marijuana was covered under substance abuse-not discussed as a possible therapy. But a decade of working for a nonprofit agency serving mentally 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 heroin 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
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