Medical Marijuana: Understanding the Six Principles of Essential Knowledge

As more states continue to pass legislation for various levels of marijuana use, you need to understand what you can and can't do. Discover the six principles of essential knowledge in this article. Nurses Announcements Archive

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You enter the exam room to get Jane checked in before she sees the Cardiologist for her annual visit. As you’re reviewing her meds, Jane pulls out a medical marijuana card. She tells you that she takes it for chronic pain caused by Fibromyalgia, but that it hasn’t been working quite as well lately. Jane starts asking you questions about dosages and if you think she can increase what she is currently taking. She also tells you that she is getting ready to go on a trip to Kansas to visit a childhood friend and asks if she can take her marijuana with her there. Jane has lots of general questions about how the drug works. You silently think to yourself that you’re not prepared to answer her questions.

Medical Marijuana Overview

If you’re not sure what you need to know about medical marijuana and your patients, you’re not alone. As several states continue to develop and pass legislation and others change laws, it can be challenging to stay up-to-date. The National Council of State Boards of Nursing published the National Guidelines for Medical Marijuana. Here are the essentials you need to know when caring for a patient using cannabis or other medical marijuana drugs.

Current State of Legalization

Marijuana is currently classified as a Schedule I Controlled Substance by the Drug Enforcement Agency (DEA) which prohibits physicians from prescribing cannabis, pharmacies from dispensing it, and limits the amount of research that can be done about the long term effects and benefits. While the federal government doesn’t provide guidelines for use, many state medical marijuana laws do.

Currently, thirty-three states and the District of Columbia, Puerto Rico and Guam have comprehensive medical marijuana laws. Another thirteen states allow for the use of low tetrahydrocannabinol (THC), high cannabidiol (CBD) products for medical use. The federal government under the Obama administration discouraged prosecution of people who distribute or use cannabis for medicinal purposes. However, this was rescinded in January of 2018, and federal prosecutors are now encouraged to decide which cases to prosecute.

Principles of a Medical Marijuana Program (MMP)

States create their own MMP rules for their jurisdiction. These rules vary from one state to the next. However, there are a few general concepts that exist regardless of the state:

Health providers do not prescribe the drug

Physicians certify that the patient has a qualifying condition under state law

Qualifying conditions and the certifying process are described in each MMP, including the type of healthcare provider that can certify a qualifying condition

Pharmacies do not dispense medical marijuana products

Each state gives provisions for dispensaries that can sell the drug to those with a medical marijuana card

Once a patient has a physician who will certify a qualifying condition, they can register with the MMP and then obtain cannabis from an authorized cannabis dispensary. Administration is generally limited to the patient or their designated caregiver. Some states allow employees of a hospice provider, nurse, or home health aide to act as a designated caregiver.

Endocannabinoid System Overview

Did you know that you have a body system named after cannabis? The endocannabinoid system is made up of a series of cannabinoid receptors that lie deep in cell membranes. You have naturally occurring endocannabinoids in your body that trigger this system. Plant substances like marijuana can trigger it as well. Endocannabinoids stimulate your system, promoting balance or homeostasis. The most well-known cannabinoids are tetrahydrocannabinol (THC), cannabidiol, (CBD), and cannabinol (CBN).

Pharmacology of Cannabis

Because marijuana remains illegal under federal law, there is a limited amount of research available to help you better understand the use, indication, and dosage of the drug. Placebo-controlled trials that have been done have determined a few conditions that medical marijuana can help. A current list of qualifying conditions include:

  • Nausea and vomiting caused by chemotherapy
  • Body wasting related to some severe chronic illnesses
  • Pain caused by cancer or rheumatoid arthritis
  • Chronic pain associated with fibromyalgia
  • Neuropathies resulting from HIV/AIDS, diabetes, or multiple sclerosis (MS)
  • Muscle spasticity from MS or spinal cord injuries

As with all drugs, medical marijuana can cause some side effects. However, it’s important to note that a few of the side effects are desired for some patients. For example, if you have a patient who is experiencing weight loss and body wasting, medical marijuana might be prescribed for its ability to increase the appetite. Potential side effects include:

  • Sleepiness
  • Rapid heart rate
  • Decreased blood pressure
  • Dry mouth and eyes
  • Increased appetite
  • Hallucinations
  • Paranoia
  • Anxiety
  • Decreased urination

Safety Considerations for the Patient

It’s essential you fully understand your facility policy for patients taking medical marijuana. The only people with the authority to administer the medicine is either the patient or their designated caregiver, so you should not give the drug.

As with any other medications, medical marijuana must be kept in a locked area out of reach of children and others in the patient's room. Drug disposal should be done following the DEA Disposal Act.

Approaching the Patient

Social acceptance of the use of these products is still evolving, and scientific evidence continues to be obtained. Nurses are expected to provide care without personal judgment. Consider your own biases about the use of medical marijuana for pain and other conditions. However, regardless of your personal opinions, you must remain non-judgemental and understanding of the patient’s decision and right to use the drug.

Have you had any personal experience caring for those with a medical marijuana card? Share your experiences below to get the conversation started.

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Great overview, thank you!! I don’t have experience with it but dispensing has just started here and some patients are asking about it. This article gives me a quick overview and a direction for more info.

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Very informative article.

Working in a state with legalized recreational use, my biggest issue in the NICU/peds world has been breastfeeding moms who use THC. It is highly fat-soluble, so it bioaccumulates and becomes even more concentrated in the fat-ladened breastmilk. A recent study found that THC is still detectable in breastmilk a week after use, so it isn't really possible to 'pump and dump' like people sometimes do with alcohol.

It's wild to me how some moms are insistent that they wouldn't use THC during pregnancy or smoke around the baby because it seems irresponsible, but they don't seem to process that giving them breastmilk with THC is basically feeding them an edible.

There isn't any formal data available on breastfeeding and THC (yet). However, given the numerous studies linking fetal THC exposure to cognitive deficits and behavioral problems, compounded by the degree of bioaccumulation that occurs in breastmilk fat, it does not seem like this will end well. If THC does turn out to be harmful in breastmilk, a whole slew of kids will risk lifelong cognitive and behavioral issues just to have acted as guinea pigs. The whole thing has me shaking my head.

I'm all for freedom of choice. However, when it puts a child's wellbeing at risk, I have to bite my tongue.

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One element is missing from this piece and that is that there is little evidence at all for effectiveness of "medical" marijuana.

From the Alberta College of Family Physicians:

https://www.acfp.ca/wp-content/uploads/tools-for-practice/1510681044_tfp199mmandpainfv.pdf

https://www.acfp.ca/wp-content/uploads/tools-for-practice/1511480622_tfp200harmsmmfv.pdf

https://www.acfp.ca/wp-content/uploads/tools-for-practice/1512754221_tfp201medcanotherfv.pdf

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Specializes in Pediatrics.

Thanks you very much for shedding some light on this. Talk about brand-new territory--a schedule I drug that is available at the state level! I'm not sure we've ever encountered that as nurses.

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Specializes in School Nursing.

One of my family members just started in the last few weeks and has already decreased amounts of RXs (including opioids ) he's been on. This article address so many of the questions he had and that people ask him. So many of the "quick info" type articles aren't very quick.

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Just now, LikeTheDeadSea said:

One of my family members just started in the last few weeks and has already decreased amounts of RXs (including opioids ) he's been on. This article address so many of the questions he had and that people ask him. So many of the "quick info" type articles aren't very quick.

Glad your family member is feeling better. I don't think these scientifically based papers are motivated by the desire that people don't do well. But basing rational treatment plans on anecdotal evidence is a radical departure from accepted practical medical practice. I suppose one question these family practice physicians would ask is "does the long term risk of trading known, studied and predictable medical therapy for smoking marijuana worth the (apparent) short term benefit?"

It's a legitimate question and I'm glad someone is asking it.

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Specializes in Workforce Development, Education, Advancement.
On 2/20/2019 at 2:26 PM, BarrelOfMonkeys said:

Great overview, thank you!! I don’t have experience with it but dispensing has just started here and some patients are asking about it. This article gives me a quick overview and a direction for more info.

BarrelOfMonkeys - So glad this was helpful!

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Specializes in Workforce Development, Education, Advancement.
On 2/20/2019 at 5:12 PM, adventure_rn said:

Very informative article.

Working in a state with legalized recreational use, my biggest issue in the NICU/peds world has been breastfeeding moms who use THC. It is highly fat-soluble, so it bioaccumulates and becomes even more concentrated in the fat-ladened breastmilk. A recent study found that THC is still detectable in breastmilk a week after use, so it isn't really possible to 'pump and dump' like people sometimes do with alcohol.

It's wild to me how some moms are insistent that they wouldn't use THC during pregnancy or smoke around the baby because it seems irresponsible, but they don't seem to process that giving them breastmilk with THC is basically feeding them an edible.

There isn't any formal data available on breastfeeding and THC (yet). However, given the numerous studies linking fetal THC exposure to cognitive deficits and behavioral problems, compounded by the degree of bioaccumulation that occurs in breastmilk fat, it does not seem like this will end well. If THC does turn out to be harmful in breastmilk, a whole slew of kids will risk lifelong cognitive and behavioral issues just to have acted as guinea pigs. The whole thing has me shaking my head.

I'm all for freedom of choice. However, when it puts a child's wellbeing at risk, I have to bite my tongue.

adventure_rn,

You raise some valid points. I hadn't thought about the implications of breastfeeding moms. Do you notice any anecdotal side effects in these infants? Just curious. I might have to research this. ? I'm a nerd! LOL Thanks for sharing!

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Specializes in ER.

Marijuana is legal in my state, so people are more open about it.

Your article doesn't mention cannabis induced hyperemesis, a very real side effect. Also, addiction to marijuana and the high it produces is another danger.

I also strongly believe that marijuana can exacerbate tendencies towards mental illness.

It does improve ones guitar playing, at least in ones own mind...

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one issue in my state is that as a nurse here, you can't work and be on medicinal THC/CBD low dose yourself, and that's with having your card. Apparently, because hospitals receive federal monies, and only the state approves you loose your job because of the federal side of this. I a RNgot approved for its use and lost my job. I had to apply through the state to get my card so I was shocked that I was not told anything of possible job loss. So, long story, I lost my job, on the back of a raise at that for the use of medical THC/CBD.

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The same identical thing happened to me exactly. I still can't get a job because my last job said I have to go to IPN, which I am still apart of now. I would love to help out in the current crisis, but no luck.

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