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Let’s face it: we have a lot to learn about safely recommending cannabis (marijuana) to our patients.
Cannabis has been used for centuries in the treatment of medical conditions. Cannabis has been recommended for appetite, anxiety, depression, sleep, and migraines. However, the stigma associated with cannabis as a recreational drug has created challenges to the legitimacy and social acceptance of cannabis for medical purposes in the United States.
At the federal level, marijuana is still illegal. In fact, the U.S. government classifies cannabis as a drug with no accepted medical use. The U.S. Drug Enforcement Agency (DEA) maintains that marijuana is a schedule I controlled substance—the same class as LSD, heroin, and ecstasy. In August 2016, the DEA again declined (for the sixth time) to change the status of marijuana. To date, the U.S. Food and Drug Administration has not approved cannabis for treatment for cancer or any other medical condition.
Regulation of marijuana is different at the state level. Laws have been passed in 28 states and the District of Columbia legalizing the possession, use, and/or sale of marijuana. Some laws include specific indications for the use of cannabis for medical conditions (http://bit.ly/1LZS4Ya) and requirements for dispensaries selling cannabis. Given that more than half of the states have some legalization of marijuana, ethical issues arise related to inequities in access to cannabis for the treatment of medical conditions, as well as legal problems related to trafficking across state lines.
There are two main types of marijuana plants (i.e., indica and sativa), as well as some hybrid types. Marijuana contains more than 60 active ingredients called cannabinoids. The two most commonly used cannabinoids for medical purposes are cannabidiol and tetrahydrocannabinol. Cannabinoids activate the endocannabinoid system and can be administered by many routes: oral, topical, sublingual, and rectal, or they can be inhaled as smoke or vapor.
Every nurse is looking for evidence- based guidelines, particularly for medications. To date, no evidence-based guidelines exist for the route of administration or dosing of cannabis. It is generally recommended that providers use a “low and slow” approach (a patient-determined, self-dosing model) to determine how cannabis affects an individual patient. Producers (marijuana growers) often recommend a starting dose. Little information exists about the effects of cannabis on cancer treatments. A small but growing amount of evidence does exist about the interactions of cannabis with other medications.
Nurses recognize the need to address the use of cannabis to treat symptoms and medical conditions. In 2010, the American Cannabis Nurses Association (http://americancannabisnursesassociation.org) was organized to advance the practice of cannabis nursing. Their goal is to educate nurses about the uses of cannabis to treat medical conditions so nurses can educate and advocate for their patients.
Clinical trials are desperately needed to establish dosing, safety, and indications for the use of cannabis in the treatment of symptoms and medical conditions. In addition, little information has been published about the issues of polypharmacy when cannabis is added as a treatment during cancer therapy. Research studies are limited because only one site in the United States, the University of Mississippi, has approval to use research-grade cannabis for studies.
Before we recommend cannabis to our patients, we need more information. Oncology nurses need further education about the indications and effects of cannabis. We need to promote research to develop dosing guidelines that promote the safe use of cannabis in oncology care. Nurses need to advocate at the policy level so that patients have access to the appropriate cannabinoid for their symptom or condition.
About the Author(s)
Lisa Kennedy Sheldon, PhD, APRN, AOCNP®, FAAN, is the chief clinical officer at the Oncology Nursing Society in Pittsburgh, PA, and an oncology nurse practitioner in the Cancer Center at St. Joseph Hospital in Nashua, NH. The author takes full responsibility for the content of the article. No financial relationships relevant to the content of this article have been disclosed by the editorial staff. Kennedy Sheldon can be reached at firstname.lastname@example.org.