Groundbreaking, Comprehensive, Vital: The National Nursing Guidelines for Medical Marijuana
In July 2018, NCSBN published its “National Nursing Guidelines for Medical Marijuana” as a supplement to the Journal of Nursing Regulation (JNR). The supplement is currently available free-of-charge. It is the first comprehensive compendium of evidence and guidelines of its kind.
Marijuana, also known as cannabis, is a psychoactive drug from the Cannabis plant and is used for medical or recreational purposes. The history of its use goes back to 2900 BC. By the mid-1800s, marijuana was sold legally in pharmacies in the U.S. “Cannabis,” as it was called then, was an ingredient in products found in American homes. Its path to illegalization between the early 1900s and the late 1930s is a complex one. The term “marihuana” was introduced to the U.S. by Mexican immigrants following the Mexican-American War and the Mexican Revolution. The smoking of marijuana by minorities was seen as a threat, fueled by xenophobia, propaganda and dubious claims about addiction, violence and overdoseage. Criminalization of its use spread across the country. By 1931, 29 states had outlawed it. The prohibition of alcohol was repealed in 1933, and the U.S. was in the middle of the Great Depression. Activists and bureaucrats turned their focus to marijuana. By 1937, its use was regulated and largely prohibited by the Marihuana Tax Act of 1937, which the American Medical Association opposed.
Because of the prevailing negative public mindset toward marijuana, it was classified a Schedule I drug in the U.S. in 1970 under the Controlled Substances Act, prohibiting its use for any purpose. Schedule 1 drugs are defined as having no current accepted medical use and a high potential for abuse. Other Schedule I drugs include heroin and LSD. This federal restriction has limited exploration into marijuana’s potential medical use, effectively tying the hands of researchers. Its use in medical conditions has occurred largely through experimentation, and evidence of its efficacy is largely anecdotal. Very little has been published that serves as a guide to caring for patients that use marijuana.
More recently, public opinion has moved in favor of consideration of marijuana for specific indications, and states have taken their own actions to legalize marijuana for medical and recreational use. Oregon was the first state to decriminalize marijuana in 1973. More recently, in 2012, Colorado and Washington legalized recreational use. Seven states currently allow the recreational use of marijuana, and as of November 2018, 33 states -- plus Guam, Puerto Rico, and the District of Columbia -- have legalized the medical use of marijuana.
U.S. public opinion on the legalization of marijuana has changed significantly since the Controlled Substances Act of 1970 was passed. More than 60 percent of Americans recently polled by Pew Research said that marijuana should be legal, up from 12 percent in 1969. The same study found that Americans differ in their opinion on marijuana legalization based on their generation. Legalization is favored by 39 percent of the Silent Generation (people born between the mid to late 1920s and the early to mid-1940s), 54 percent of Baby Boomers (early to mid-1940s to the early 1960s), 63 percent of Generation X (early to mid-1960s to the early 1980s), and 74 percent of Millennials (early 1980s to the early 2000s).
Because of the rapid and sweeping change in societal attitudes toward marijuana, and the increasing use and legalization of medical and recreational marijuana, the NCSBN Board of Directors (BOD) recognized that nurses were unsure of their responsibilities in the care of patients who may use marijuana. Without scientifically rigorous, statistically reportable evidence-based on patient populations, nurses will face increasing challenges concerning medical marijuana.
The NCSBN BOD formed and appointed a committee in September of 2015 called the Regulatory Implications of Legal Cannabis Committee, charged with exploring the trends and issues related to marijuana use and nursing regulation. Building on the work of the Legal Cannabis Committee, and to address the lack of guidelines available to nurses caring for individuals using marijuana, in 2017 NCSBN formed and appointed members to the NCSBN Marijuana Regulatory Guidelines Committee.
The committee was charged with developing model guidelines for the advanced practice registered nurse (APRN) certification of a qualifying condition under state requirements, model guidelines for APRN, registered nurse (RN), and licensed practical nurse (LPN) care of patients using marijuana, recommendations for marijuana-specific curriculum content in APRN education programs, recommendations for marijuana-specific curriculum content in RN and LPN education programs, and model guidelines for assessing safeness to practice of licensees who use marijuana.
This was an ambitious endeavor. In order to create the requested guidelines and recommendations for education and care, a review of the relevant statistics, current legislation, scientific literature, and clinical research on cannabis as a therapeutic agent was required.
Valerie Smith, MS, RN, FRE, associate director, Hearing Department, Arizona State Board of Nursing, served as BOD liaison on both the Regulatory Implications of Legal Cannabis and Marijuana Regulatory Guidelines Committees. “In August 2015 at the Delegate Assembly there was a presentation by Dr. Doris Gunderson, medical director of the Colorado Physician Health Program,” recalls Smith. “Her presentation, titled ‘Marijuana: A Prescription for Trouble?’ inspired debate among the members. It was clear that they wanted more information on how to resolve discrepancies between the various states and their laws, as well as the federal laws. Members were seeking information and guidance on how to address and respond to the changes in state laws allowing for the use of medical as well as recreational marijuana. That was the beginning. The initial committee came back with a good product for the Board to get a better sense of the trends and relationships to nursing regulation. That led to the Board appointing the second committee in 2016, to write the regulatory guidelines.”
Rene Cronquist, RN, JD, Director for Practice and Policy, Minnesota Board of Nursing, served as chair of the Marijuana Regulatory Guidelines Committee, and recalls what the climate was like when Minnesota legalized marijuana for medical use. “It took a little while for the questions to start coming in,” says Cronquist. “Initially, many health care providers and organizations were cautious about caring for individuals using medical cannabis. It took a while before the program participants started showing up in various health care settings. We continue to see the challenge, particularly for the state and federal health care organizations, trying to support their patients or clients who use cannabis while at the same time needing to be compliant with the federal law.”
“Practitioners cannot provide the patient with a specific dose, route or frequency of use and dispensaries vary widely in the quality, strength and labeling of products” says Smith. “It’s really left up to the patient to titrate their dose and administer it in whatever fashion they think is best for them, often with input of dispensary staff.”
Marijuana’s classification as a Schedule I drug has stymied research into the efficacy of marijuana for medical use. Committee member Maureen Cahill, MSN, RN, APN-CNS, associate director, NCSBN, says, “It’s amazing to think about, that for an agent that’s been around for 5,000 years, and has been in use widely for so long, there is so little access to research or access to the approved agent for research.”
Cronquist adds, “Because the research is so limited, it’s challenging to find empirical evidence that will support the effectiveness of cannabis, whether it’s for different conditions, whether it’s for different populations. More research is needed on effective dosing. On the flipside, what are the downsides? What are the contraindications, and side effects that we need to know about? We don’t want to promote the use of a substance that’s not demonstrated to be effective, but by the current classifications, we’re really limiting ourselves on our ability to determine whether it is effective, and to what extent.”
Kathleen Russell, JD, MN, RN, associate director, NCSBN, adds, “Because there’s so little research, you can find a lot in the grey literature on cannabis, but you wouldn’t know from reading it what is or is not scientifically proven.”
Grey literature refers to materials and research produced by organizations outside traditional academic publishing and distribution channels. On the issue of medical marijuana, there is a lot to sort through. Kent Gowen, MAT, policy coordinator, NCSBN, tackled the scientific literature, read it, graded it, and provided the committee with a summary of findings that were then discussed. “We would not have been able to accomplish what we did without all three of the staff, but Kent did a fabulous job on that literature research,” says Smith.
Because the mindset in the medical community was divided on the issue, the committee was committed to producing evidence-based guidelines. Cronquist explains that the committee began with an open mind and a commitment to the group’s purpose. “We had opportunities to share personal opinions, but the group was very focused on producing something that would be of benefit to our various audiences,” she says. “No one had a predetermined idea of what this was going to look like.”
As board liaison, Smith brought her background in substance use disorders and mental health to the committee. “I saw the duties of my role as, one, to help focus the group on the charges, and two, to relay back to the Board how the committee was doing, to serve as a conduit of information. I remember in our first meeting, everyone was a bit overwhelmed. The staff did a fantastic job and the committee worked through the charges one at a time, putting aside personal opinions on the use of marijuana. The general thought was, ‘we can do this; we can get through it.’ And we did.”
The committee identified online courses and documents from other organizations related to aspects of medical marijuana. “We did this in part to inform ourselves, but also to have firsthand knowledge of what is available,” explains Cronquist. “While it was certainly beneficial, we concluded that important pieces were missing. What we were charged with producing was not out there.”
The committee also consulted known experts in the area of medical marijuana, its use, safety, and legislation. “We wanted this to be the best product we could produce,” explains Cronquist. “We looked at the statements of other organizations and we spoke with toxicologists, nurse educators and legal counsel.”
“Having the ability to meet and interview experts with specific areas of expertise really helped the committee focus on the charge and put aside their own personal ideas or beliefs,” says Smith. “It really began to inform the work of the committee.”
Unlike most other therapeutics, medical providers cannot prescribe marijuana, and pharmacies cannot dispense it. Certain jurisdictions allow the manufacture, distribution, and use of marijuana for medical purposes. The committee was charged with making recommendations for curriculum content for prelicensure and APRN nursing education programs, in order to provide nurses with principles of safe and knowledgeable practice when caring for patients using medical marijuana.
“In our surveys of prelicensure graduate-level education programs, we learned that there is very little content on issues related to cannabis,” says Cronquist. “To the extent that there is content, it’s sometimes focusing on substance use disorder with marijuana. There is very little on the endocannabinoid system, or dosing. Programs with content were in jurisdictions that had medical cannabis. Legal or not, people are using it, and nurses need to have the knowledge to effectively care for patients who are using it.”
“When we tried to identify what type of education is available to nurses, we discovered there is a fair amount out there being presented by people who are staunch advocates for medical and recreational marijuana,” says Smith. “The education they are providing really doesn’t help serve to inform how we care for patients using medical or recreational marijuana. Education about marijuana for medical purposes is significantly lacking in prelicensure and advanced practice programs.”
At the culmination of its two years of work -- the result of a deep dive into the relevant topics and an exhaustive literature and evidence review -- the committee has produced a set of guidelines that create a strong foundation for safe and knowledgeable nursing care of patients using medical or recreational marijuana.
The NCSBN National Nursing Guidelines for Medical Marijuana documents the results of the committee’s work, and presents this important information in two parts. Part I presents the results of these reviews and consultations. Part II presents the specific Guidelines created by the Committee, which include:
- Current Legislation, Scientific Literature Review, and Nursing Implications
- Nursing Care of the Patient Using Medical Marijuana
- Medical Marijuana Education in Pre-Licensure Nursing Programs
- Medical Marijuana Education in APRN Nursing Programs
- APRNs Certifying a Medical Marijuana Qualifying Condition
This groundbreaking body of work the committee has produced fills the gap in the literature on the nursing care of patients using medical marijuana, and provides evidence-based nursing guidelines.
“The guidelines are original,” says Russell. “How often do you get to work on something that is original and the first of its kind, in terms of its comprehensiveness? I think the guidelines really point out what a nurse needs to know, and what faculty need to teach.”
“We produced something that we felt was needed and will truly be beneficial, both as guidance to nurses and nursing education programs,” says Cronquist. “My hope is that it continues to trigger conversation, that it minimizes stigma of individuals using cannabis, and ultimately continues to highlight the need for continuing research.”
“It was rewarding to respond to the requests of the NCSBN membership and provide them with these resources, based on the best available data and evidence that we have today, to more effectively respond to the rapid expansion of these laws,” says Smith. “I believe these guidelines are just the beginning. There’s a lot more to be known, and I’m hoping that at some point the federal government will allow for scientifically rigorous studies to help further inform the use of marijuana in caring for patients. The guidelines will continue to evolve as we have the evidence and the data to evolve with them.”