Authorize. Any act of certification, attestation, or other method for a practitioner to affirm that a patient may benefit from medical cannabis. This is explicitly not a prescription. |
Cannabis. Any raw preparation of the leaves or flowers from the plant genus Cannabis. This report uses “cannabis” as a shorthand that also includes cannabinoids. |
Cannabidiol (CBD). A major cannabinoid that indirectly antagonizes cannabinoid receptors, which may attenuate the psychoactive effects of tetrahydrocannabinol. |
Cannabinoid. Any chemical compound that acts on cannabinoid receptors. These include endogenous and exogenous cannabinoids. |
Cannabinol (CBN). A cannabinoid more commonly found in aged cannabis as a metabolite of other cannabinoids. It is nonpsychoactive. |
Certify. For the purpose of this report, to “certify” is the act of confirming that a patient has a qualifying condition. Many jurisdictions use alternative phrases, such as “attest” or “authorize”; however, 13 of 29 jurisdictions use “certify” language in their statutes. |
Clinical research. For the purpose of this report, “clinical research” involves studies that experimentally assign randomized human participants to one or more drug interventions to evaluate the effects on health outcomes. Contrasted with Preclinical research or studies, which experimentally or observationally use animal models, cell cultures, and/or biochemical assays to determine possible biological effects of an intervention. These studies also include observational studies of human participants that do not control interventions. |
Designated caregiver. An individual who is selected by the Medical Marijuana Program qualifying patient and authorized by the Medical Marijuana Program to purchase and/or administer cannabis on the patient’s behalf. Also sometimes referred to as an “alternate caregiver.” |
Dronabinol. The generic name for synthetic tetrahydrocannabinol. It is the active ingredient in the Food & Drug Administration (FDA)-approved drug Marinol ( Food and Drug Administration, 2017 ). |
Endocannabinoid system. A system that consists of endocannabinoids, cannabinoid receptors, and the enzymes responsible for synthesis and degradation of endocannabinoids ( Mackie, 2008 ). |
Marijuana. A cultivated cannabis plant, whether for recreational or medicinal use. The words “marijuana” and “cannabis” are often used interchangeably in various lay and scientific literature. This report will primarily use the word “cannabis” as a shorthand that also includes cannabinoids. When referring to a medical marijuana program, this report will use the word “marijuana,” as it is often used within program references. |
Medical Marijuana Program (MMP). The official jurisdictional resource for the use of cannabis for medical purposes. Search the jurisdiction’s website or Department of Health for “medical cannabis program” or “medical marijuana program” ( National Conference of State Legislatures, 2017 ). |
Nabilone. The generic name for a synthetic cannabinoid similar to tetrahydrocannabinol. It is the active ingredient in the U.S. Food & Drug Administration’s (FDA)-approved drug Cesamet ( Food and Drug Administration, 2006 ). |
Schedule I Controlled Substances. Defined in the federal Controlled Substances Act as those substances that have a high potential for abuse; no currently accepted medical use in treatment in the United States; and a lack of accepted safety for use of the substance under medical supervision. |
Tetrahydrocannabinol (THC). One of many cannabinoids found in cannabis. THC is believed to be responsible for most of the characteristic psychoactive effects of cannabis ( U.S. Department of Transportation, National Highway Traffic Safety Administration, 2017 ). |
Federal and State Legislation Through 2018
Federal Legislation and Actions
- Mikos R.A.
- U.S. Department of Justice, Office of the Attorney General
State Legislation and Actions
- ProCon.org
- ProCon.org
Type of Provision | Jurisdictions |
---|---|
MMP | AK, AR, AZ, CA, CO, CT, DC, DE, FL, HI, IL, LA * , MA, MD, ME, MI, MN, MT, ND, NH, NJ, NM, NV, NY, OH, OR, PA, RI, VT, WA, WVLouisiana lacks the necessary infrastructure to enact its MMP and the state’s previous statutory language failed to grant necessary protections to physicians and users. Legislators have yet to decide who will be the legal cultivators for the state and how to regulate pharmacies that will distribute medical cannabis. |
Allow cannabidiol products (often for intractable seizures; often the use is restricted to clinical studies) | AL, GA, IA, IN, KY, MO, MS, NC, OK, SC, TN, TX, UT, VA, WI, WY |
Allow APRNs to certify a qualifying condition referred to in medical marijuana statute | HI, ME, MA, MN, NH, NY, VT, WA |
No cannabis statutes | ID, KS, NE, SD |
Recreational use of cannabis | AK, CA, CO, DC, MA, ME, NV, OR, VT, WA |
Although there are 57 qualifying conditions included among the different jurisdictional laws, the most common qualifying conditions across all MMPs are:
|
Literature Review
Gaps in Comprehensive Reviews
Therapeutic Effects of Cannabis (Literature last updated February 2018)
Cochrane Methods Bias. (n.d.). Assessing risk of bias in included studies. Retrieved from http://methods.cochrane.org/bias/assessing-risk-bias-included-studies
Clinical evidence supporting cannabis for medical conditions
- •Cachexia
- •Chemotherapy-induced nausea and vomiting
- •Pain (resulting from cancer or rheumatoid arthritis)
- •Chronic pain (resulting from fibromyalgia)
- •Neuropathies (resulting from HIV/AIDS, MS, or diabetes)
- •Spasticity (from MS or spinal cord injury)
- •Reduction of seizure frequency (Dravet syndrome and Lennox-Gastaut syndrome)
- •Reduction of posttraumatic stress disorder (PTSD) nightmares
- •Improvement in tics (Tourette syndrome)
Qualifying Conditions Without Clinical Evidence
Qualifying Conditions Without Cannabis Therapeutic Clinical Evidence | Shared Symptom With an Evidence-Based Qualifying Condition |
---|---|
Painful peripheral neuropathy, spinal cord injury, spinal cord diseases (arachnoiditis, Tarlov cysts, hydromyelia), neurofibromatosis, chronic inflammatory demyelinating polyneuropathy, causalgia, Arnold-Chiari malformation, syringomyelia, complex regional pain syndrome, chronic radiculopathy | Neuropathy |
Residual limb pain, Sjogren’s syndrome, interstitial cystitis, fibrous dysplasia, fibromyalgia, post laminectomy syndrome, sickle cell disease, arthritis, severe psoriasis, psoriatic arthritis | Pain |
Intractable skeletal muscular spasticity, spastic quadriplegia, Tourette’s syndrome, spinocerebellar ataxia, muscular dystrophy, dystonia, cerebral palsy, Parkinson’s disease | Spasticity |
Chronic traumatic encephalopathy, myoclonus | Seizures |
Cystic fibrosis, anorexia | Wasting |
Chronic pancreatitis | Nausea and vomiting |
Nail-patella syndrome | Intraocular pressure (similar to glaucoma, which is not supported by quality evidence) |
Huntington’s disease, post-concussion syndrome, myasthenia gravis, lupus, hydrocephalus, mitochondrial disease, autism, decompensated cirrhosis, ulcerative colitis, migraine, Alzheimer’s disease, amyotrophic lateral sclerosis | Diseases with multiple shared/similar symptoms |
- Food and Drug Administration
Effects of Cannabis That May Influence Treatment Decisions
Physiologic Effects of Cannabis
- Krishnan S.
- Cairns R.
- Howard R.
- Langford R.M.
- Mares J.
- Novotna A.
- Vachova M.
- Novakova I.
- Notcutt W.
- Ratcliffe S.
Adjunctive Use of Cannabis With Opiates, Antidepressants, and Benzodiazepines
Neurologic Symptoms
Subjective Measures vs Objective Measures for Spasticity and Pain
Adverse Effects of Cannabis
Described Adverse Effects of Major Cannabinoids
- Food and Drug Administration
Specific patient groups
- •Users with persistent cannabis dependence showed greater IQ decline than those who never used cannabis. This decline is greatest in users who began using during adolescence (Meier et al., 2012). Early-onset cannabis users show greater structural differences in critical brain regions relating to memory and show a weakened ability to learn (Schuster et al., 2016).
- •In young (approximately age 20 and older), educated chronic users, decrements in the ability to learn and remember new information and impairment of verbal recall as well as visual recognition may occur (Schoeler et al., 2016).
- •Structurally, adults who smoke cannabis regularly during adolescence have impaired neural connectivity involved in functions that require a high degree of integration (e.g., alertness and self-conscious awareness) and learning and memory (Smith et al., 2015;Yücel et al., 2008).
- Food and Drug Administration
Overdose, abuse, dependence, and withdrawal
- Lopez-Quintero C.
- de los Cobos J.P.
- Hasin D.S.
- Okuda M.
- Wang S.
- Grant B.F.
- Blanco C.
Drug-drug interactions
- National Institutes of Health
Methods of Administration
Dosing Considerations
- Food and Drug Administration
The Entourage Effect
Price Consideration
Drug Name | Price Averages |
---|---|
Sativex | A vial with 15 sprays costs $22 dollars/vial. Average dose of 5 sprays per day yields $7/day and $51/week. This price was derived from the 2005 Patented Medicine Prices Review Board of Canada (www.pmprb-cepmb.gc.ca) report on Sativex. Available in Canada. Not available in the United States (undergoing FDA Fast Track trials). |
Cesamet (nabilone) Schedule II Controlled Substance | ~$2,000 for 50/1-mg capsules. Wide variance in effective dose per day (2mg to 10mg). Average dose of 2mg/day yields $80/day. FDA approved. Not covered by Medicare. |
Marinol (dronabinol) Schedule III Controlled Substance | $140–$271.05 for 60/2.5-mg capsules, $150–$281.95 for 30/5-mg capsules, $500–$1,019.40 for 60/10-mg capsules. Average dose of 5mg–10mg/day yields $8–$16/day without insurance. FDA approved. Covered by Medicare. Insurance may cover 3%–99% of costs. |
Medical cannabis | ~$150–$200 for 28g as the low end of possible dispensary prices in the United States. ( Colorado Department of Revenue, 2015 ; Hickey, 2014 ; Is it cheaper to buy weed on the street or at a dispensary?, 2016 )Is it cheaper to buy weed on the street or at a dispensary?. https://priceonomics.com/the-most-expensive-and-cheapest-cities-to-buy/ Date: 2016, February 3 A starting dose of 5% THC per cannabis cigarette and the goal of 2.5mg absorbed THC requires 0.60g–1g of cannabis per dose. For pain, this may require four or more doses per day. This regimen could result in $600/month for management of pain using smoked cannabis. Patient cultivation regulations may reduce this cost. (This price estimate is approximate for all products sold at U.S. medical dispensaries.) |
Nursing Implications
Six Principles of Essential Knowledge
- 1.The nurse shall have a working knowledge of the current state of legalization of medical and recreational cannabis use.
- Mikos R.A.
- 2.The nurse shall have a working knowledge of the jurisdiction’s MMP.
- 3.The nurse shall have an understanding of the endocannabinoid system, cannabinoid receptors, cannabinoids, and the interactions between them.
- 4.The nurse shall have an understanding of cannabis pharmacology and the research associated with the medical use of cannabis.
- •Cachexia
- •Chemotherapy-induced nausea and vomiting
- •Pain (resulting from cancer or rheumatoid arthritis)
- •Chronic pain (resulting from fibromyalgia),
- •Neuropathies (resulting from HIV/AIDS, MS, or diabetes)
- •Spasticity (from MS or spinal cord injury)
- 5.The nurse shall be able to identify the safety considerations for patient use of cannabis.
- 6.The nurse shall approach the patient without judgment regarding the patient’s choice of treatment or preferences in managing pain and other distressing symptoms.
- •Clinical indications, such as diagnosis, history, goals for use of medical marijuana, probability of success, other options for care
- •Patient’s personal preferences based on information of benefits and risks
- •Attention to decision making by the patient’s proxy, parent, or guardian, if the patient is incapacitated in decision making or is a minor
- •Quality of life based on the patient’s subjective viewpoint
- •Situational context, such as family and other important relationships, economic factors, access to care, and potential harm to others.
Conclusion
- •Nursing Care of the Patient Using Medical Marijuana
- •Medical Marijuana Education in Pre-Licensure Nursing Programs
- •Medical Marijuana Education in APRN Nursing Programs
- •APRN Certifying a Medical Marijuana Qualifying Condition.
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