The use of cannabis as a medicinal agent is a hotly debated and contentious issue in the United States. Cannabis has been touted as a treatment for many conditions, including nausea and anorexia caused by chemotherapy, AIDS-related wasting, neuropathic pain, spasticity associated with multiple sclerosis, and glaucoma. Its use for medical purposes has enjoyed strong support among professional health care organizations and the public at large; 14 states and the District of Columbia now allow its use, although regulations and qualifications vary widely. (The advocacy group Americans for Safe Access dedicates a site to explaining those laws state by state: http://bit.ly/gs7hIw.)
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Although the U.S. Department of Justice announced in 2009 that users and distributors of medical cannabis wouldn't be pursued as long as they followed state laws, the federal government has resisted any change to the drug's illegal status at the national level.
This isn't only an issue of state laws conflicting with federal law; even within states that permit medical cannabis, the rules about its use in the institutional setting may be hazy. These ill-defined regulations can put health care professionals in a precarious position. And because many nursing homes rely on federal or state funding, there are unanswered questions as to whether health care providers can legally provide or administer any form of medical cannabis to residents.
"There are issues of loss of licenses and certifications," said Allen St. Pierre, executive director of the National Organization for the Reform of Marijuana Laws, or NORML. "The idea of a Schedule I drug being used or tolerated at a facility that's licensed by a state or federal government is anathema."
But this isn't a new issue, and for NORML it began even before the advent of "medical cannabis proper," according to St. Pierre. In 1990, he said, NORML would take calls from organizations that provided homes away from home for families and patients dealing with painful diseases. In these cases, said St. Pierre, "we would have older teenagers, who, with their physician's recommendation, wanted to use cannabis on site."
The legal counsels or managers of such organizations were caught between wanting to provide the best possible health care for people at a very difficult time in their lives and trying not to jeopardize the operation for future clients, given that this was a clear violation of the law. St. Pierre contends that the conflict—between providing good health care and breaking the law—has wrapped itself around nearly every tier of the health care industry.
FEDERAL VS. STATE RULES
Cannabis sativa is available in leaf form (known as marijuana, pot, weed, or reefer) or in various extracted forms (as hashish or oil) and can be taken in a variety of ways (smoked, ingested, or vaporized). It's best known as a recreational drug, although its medicinal properties have been documented for thousands of years. It was legally available in the United States until the beginning of the 20th century. In 1937 the first federal laws against cannabis use were passed. (For more on the history of cannabis in the United States, see "A Brief History of Medical Marijuana" in Time: http://bit.ly/3NFI7d.)
Cannabis is currently listed as a Schedule I drug, which means that the government doesn't recognize any medical value. Despite the federal laws, a growing number of states are liberalizing their laws and allowing patients varying degrees of access to cannabis. Although firm numbers remain somewhat elusive, it's believed that the percentage of older users is growing. If that's true, it would indicate that long-term care facilities will increasingly have to address the situation. (This year NORML plans to roll out the NORML Senior Alliance, which will offer information to older adults about the medical uses of cannabis.)
One of the main problems is that many state laws don't specifically address the use of cannabis in nursing homes and other institutions. For example, Alaska law doesn't require any facility monitored by its Department of Administration to accommodate cannabis users. In Montana, smoking is prohibited in all health care facilities, but cannabis may be used in other forms; individual facilities may set their own rules, including under what conditions and circumstances cannabis use would be permitted. Maine, on the other hand, permits nursing homes and inpatient hospice workers to act as registered caregivers for patients using medical cannabis.
Another pressing concern is that these facilities often receive federal funding, either directly through Medicare or indirectly through Medicaid. This places administrators in an awkward position, having to choose between complying with federal law (and maintaining funding) and permitting access to cannabis to residents who rely on it.
"We may only find out what will happen if a brave nursing home takes the risk and does the right thing for its patients," said Mary Lynn Mathre, MSN, RN, an addiction specialist and president of the nonprofit group Patients Out of Time. "Given the Obama administration's statement about not interfering with medical marijuana patients who are getting legal recommendations from their care provider, it seems very wrong to not allow nursing home patients to use it because the facility receives federal funding." She added that "it would be great to see nursing home administration organizations pass a formal resolution recognizing this potential problem and asking the federal government to allow patients the option to use this medicine as they would any other medicine."
NURSING'S STANCE ON THE ISSUE
Overall, nursing organizations, including the American Nurses Association and more than a dozen state nursing associations, support supervised access to medical cannabis. But if experts are correct, and the number of older adult cannabis users escalates in nursing homes and assisted living facilities, nurses may find themselves in a rather unusual situation. Aside from possibly violating federal drug laws, there are other issues to consider. Who dispenses the cannabis? What is the dosage? How will the facility obtain it?
California has been a pioneer in exploring the issue of medicinal cannabis use, having been the first state in the nation to pass an initiative that loosened its laws and allowed for medical usage.
"In California, we have laws that protect patients' rights," said Deborah Burger, RN, copresident of the California Nurses Association (National Nurses United), which supports the use of medical cannabis. "If patients have been prescribed the medication, they should get it. Nurses in those areas are bound by California law to advocate on behalf of the patient." And if California nurses have had problems with it, Burger hasn't heard about it. "I haven't heard that there were any issues with nursing homes refusing to allow patients to use it," she said.
Sometimes the "don't ask, don't tell" approach is the best option, according to Mathre. "I can tell you that many hospice nurses turn a blind eye to cannabis use in the home because they know it helps." She explained that during a legislative committee hearing on a medical cannabis bill in Wisconsin, a nurse who represented her hospice organization spoke in favor of the legislation and acknowledged the problem that nurses in this situation face. "They may be witnessing illegal activity, but they pretend not to see or know what's going on because, in their hearts, they know the patient benefits from the use of cannabis."—Roxanne Nelson
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