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 lea