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How to Better Understand the Clinician Role with Cannabis in Hospice

Updated: Apr 3, 2019



How can it be Illegal and Legal at the same time?

If you haven’t noticed, there is an ongoing societal repeal of cannabis prohibition. Whether the federal government approves is “yet to be determined.” Nevertheless, it is obvious that the American people see the potential merit in this new, or should I say, “old” drug and they will not stop pushing for approval. It is, indeed, an “old” drug. In the mid 1800s, Cannabis was  listed in the US Pharmacopoeia (USP) as an effective treatment for pediatric seizures. Cannabis was also USP listed as a treatment for many conditions for which it is in use today: as an anti-emetic, anxiolytic and especially pain. After listening, watching and reading, I am confident that these uses are valid. Based also on my own experience as a hospice nurse, caring for patients who have tried cannabis for those uses, has convinced me of the efficacy of the drug for these uses.


Cannabis is not currently listed in the USP, but there is a reason for that. It is federally illegal. Why? Cannabis was black-listed in the US in the early 20th century and shortly thereafter became banned globally. If being listed with the DEA as a schedule I drug wasn’t bad enough, the “War on Drugs” has all but eliminated our ability to even study it.


Let me reiterate: Cannabis is federally illegal. According to federal law you cannot grow it, you cannot transport it, you cannot sell it and you certainly cannot possess or use it; but that is federal law. So how do the states get away with it? Well, in 2009 President Obama (via Attorney General Eric Holder) came along and said that the federal government “would not interfere” with those states which were testing the waters with medical marijuana, so the entrepreneurial American spirit kicked into high gear.

In 2014, Dr. Sanjay Gupta risked his credibility when he debuted “Weed,” the story of the successful use of cannabis in the treatment of a young girl with previously intractable seizures. That,  I believe, is when Americans began to really change their opinions on cannabis.


Without federal interference, each state has been allowed to set up its own agencies to govern, grow, distribute and use “medical marijuana.” In most states with a medical marijuana program (and dispensaries/apothecaries in place) they have also initiated legal “recreational” use, meaning anyone over 21 can purchase it.


Nonetheless, cannabis is still listed as a Schedule I substance, which is listed as “no currently accepted medical use in the US, a lack of accepted safety under medical supervision, and a high risk for abuse.”

Based on growing evidence for low abuse potential, combined with reported efficacy of treatment for nausea, intractable seizures, anorexia and treatment for pain, I believe it is time that we “Re-schedule” or “De-schedule” cannabis. We could request that the DEA change cannabis from Schedule 1 to perhaps, Schedule IV. Or we could find ourselves voting on De-scheduling cannabis, which would remove it from the DEA list altogether.


Regardless of whether or not you live in a state with a legal cannabis program, cannabis education is a clinical obligation. The American Nursing Association position statement includes support for “reclassification” and for our responsibility as nurses to educate patients on the potential uses for the drug. If you can wade through the complex American Medical Association position statement (which still clings to the Schedule 1 law), the position statement repeatedly calls for rescheduling, researching, testing or trials.


It may be “legal” in your state, but make no mistake, cannabis is still federally illegal. When it comes to being a clinician, always protect your livelihood! You are going to have to learn about it before you recommend anything and understand your State specific licensure requirements/limitations in regard to administering cannabis.


As a clinician, you will inevitably be asked, “Where can I get cannabis, or CBD, or even a medical marijuana card?” I wish there was a simple answer. Instead, each of us is obligated to, at the very least, know the laws of our individual states. You may have heard, “Now legal in 30 states” or the figurative description: “a legal state.” You may have already seen some of the colorful maps indicating “medical only,” or “recreational,” or “ CBD only.” Some states recognize cannabis in a role as a “medical only” state, with the allowance for growth and sale in and by apothecaries or dispensaries to people with a medical MJ card. Some states say “CBD only,” but do not indicate where to get CBD, nor does the state have any regulations to test or analyze CBD. This leads me to the next area of concern for the clinician: CBD may recently have gone mainstream, but where are our patients buying it and is it verified as safe?

The quest for state-specific cannabis information, can, in and of itself, be daunting. For example, in Washington, DC, it is legal to recreationally smoke marijuana, but not to grow it, dispense it, transport it, buy it, or sell it. In a situation like that, a clinician certainly cannot answer the patient’s question about obtaining cannabis, without recommending that the patient do something illegal. So what about going to one of the “legal” states and bringing some home? Well, in some of the “medical only” states with apothecaries or dispensaries, one would need a medical card. Some states will not issue a medical card unless you are a resident. If you are not too confused to read further, I will say, that many I have talked to have purchased cannabis in recreational states (where anyone over 21 can buy) and brought it home. Mind you, I did not recommend how to get it home. Assuming you know that transport over the state line (by any method) would be breaking federal law, here is another wrinkle: Los Angeles International Airport just made a public, published statement that they would NOT stop you from boarding the plane with cannabis (unless it exceeds the state quantity limit).


Some of the best sources for finding current state law include starting at one place that leads you to your state specific legislature. I frequently use Procon.org. There you will find summaries of legality, possession limits, etc., and they seem to stay as current as possible. It is a challenge to keep up with the changes, but as I said earlier, I believe we are obligated to do so.


What do you tell someone about how to dose it, or recommend it for specific conditions?

Today, about the best you can do to learn use, dosing and side effects of cannabis, is to find a credible “Budtender.” That’s what they call the folks standing behind the counter at legal states’ “dispensaries” or “apothecaries.” That interaction with a Budtender can range from enlightening to perplexing, or even humorous. In our prohibition infancy, cannabis is touted to treat everything from acne to the common cold, making some people think it is just plain snake oil! However, the anecdotal evidence for cannabis’ ability to help with pain, nausea, and seizures is enough to keep one searching.


My personal favorite is Grace, a Budtender from Oregon. Grace has a bachelor’s degree in a medically related field and has become, for all intent and purposes, a “pharmacist of cannabis!” Grace can certainly attest to the numerous maladies from which people seek relief—and to the apparent efficacy of the drug. Grace can tell you which product is more potent or less potent. She can also show you the different formats by which you can ingest the drug and can cite you the onset, intensity, duration and interactions that are currently being reported. I am always amazed by her experiences; like the recluse PTSD victim who ceased SSRIs and Thorazine for cannabis and became socially functioning again. She also tells of a formerly wheelchair-bound patient who now uses her walker because the cannabis allowed her to endure physical therapy. Grace’s advice though, is still conservative: “We do not recommend any one product or method of delivery for any condition.” Grace also states cannabis use has a “highly individual response” and that the best rule of thumb is to “start low and go slow.” Although you may find those quotes frustrating, her approach to conservative “recommendation” or “dosing” is excellent advice for any clinician. As for now, Grace states, “We are challenged to recommend what is not well researched.”

Without interference of the FDA, today’s infinitely-stronger cannabis has at least been quantified, and to the credit of the demanding American people, cannabis has become labeled with a milligram strength. This should give the consumer some guidelines of their own.


As a clinician, how can I educate myself further on cannabis?

I have found numerous “courses” on the endocannabinoid system, all for pay and few for CE credit. The American Cannabis Nurses Association recommends: TCMI Medical Cannabis Curriculam for Nurses. They also list other online resources:


District of Columbia Center for Rational Prescribing provides information about medications and other therapeutic options to physicians and healthcare professionals. It has three modules on medical cannabis that are available for CME credit (payment required) or free-of-charge in PDF format.Medical Cannabis: An Introduction to the Biochemistry & PharmacologyMedical Cannabis: Evidence on EfficacyMedical Cannabis: Adverse Effects and Drug InteractionMedical Cannabis Institute – Offering a large variety of courses including many presentations from the National Clinical Conferences on Cannabis Therapeutics sponsored by Patients Out of Time.Medicinal Cannabis and Chronic Pain Project – A project of the University of Washington Alcohol & Drug Abuse Institute.


Susan Tyner-Pritchett, RN BSN CHPN

Susan has been a hospice nurse for 10 years practicing in multiple southeastern states. She was a presenter at the 2018 Cannabis Science Conference on the topic of hospice medications with a concern for the opioid use and end of life issues.

stpritchett@gmail.com

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