ILLINOIS NURSES ASSOCIATION
POSITION PAPER ON PROVIDING PATIENTS SAFE ACCESS TO
THERAPEUTIC MARIJUANA/CANNABIS
December 2004
Executive Summary
This position paper addresses the need to support
patients who require safe access to therapeutic cannabis.
Cannabis has been used throughout the world for medicinal
purposes for centuries and has been used safely under
appropriate prescriber supervision to treat a great
variety of conditions and symptoms. Cannabis is considered
by the scientists directly involved with cannabinoid
research to be one of the least toxic substances known
that delivers a therapeutic response. There are two
dimensions in which controversy about the therapeutic
use of cannabis is positioned: the scientific and the
cultural. In the scientific dimension, there is almost
a half-century of research that supports the safety
and efficacy of cannabis for conditions such as reducing
nausea and vomiting, stimulating appetite, controlling
spasticity, decreasing the suffering from the experience
of chronic pain, and controlling seizures. In the cultural
dimension, there is an embedded mythology about the
nature of cannabis sustained in large part to its being
designated in the early 20th century as a dangerous
narcotic and illegal substance. Cannabis came to be
associated with a counter culture underclass such as
black jazz musicians, Mexican illegal immigrants, beatniks
in the 1950s and hippies in the 1960’s and only
recognized for its recreational and illegal use (Dr.
Andrew Weil, CNN interview, November 29, 2004).
Illinois nurses have an obligation to the public regarding
matters of science and health as well as an obligation
to protect the integrity of the profession. A basic
principle of the ANA maintains that nurses participate
in the profession's efforts to protect the public from
misinformation and misrepresentation. Therefore, the
Illinois Nurses Association joins the Institute of Medicine
(1999), the American Nurses Association (2003) and twelve
Constituent Member Associations, the American Public
Health Association, and the American Academy of Family
Physicians, among other organizations in recognizing
the value of science over cultural misrepresentation
and supports patients requiring safe access to therapeutic
cannabis. The Illinois Nurses Association supports a
multi-pronged approach to supporting patients needing
cannabis through continued and increased research, education
of nurses and the public, advocating for legislation
protective of professional prescribers and bona fide
patients, and advocating for a federal and state re-scheduling
of this currently Schedule I substance.
Background
Historical
Cannabis was an essential part of the American pharmacopoeia
until the 1940s and is once again emerging as a significant
treatment for persons with serious illness (Zimmer &
Morgan, 1997). Cannabis was one of the two most widely
used medicinals in the United States until the Marijuana
Tax Stamp Act of 1937 began the prohibition of its use
under the guise of concern for lost federal tax revenue.
Cannabis was designated a Schedule I drug by the Controlled
Substances Act of 1970 effectively banning all legal
therapeutic use.
Mythologies about cannabis, as with those about gender
and race, have been dispelled over the past several
decades. In the interest of scientific accuracy and
ethical decision-making, nurses have an obligation to
educate themselves regarding the embedded inaccuracies
and untruths in society about cannabis. Even as the
federal government continued to criminalize cannabis
use and prosecute individuals, government sponsored
commissions and review boards consistently reported
findings that supported the safety and decriminalization
of cannabis (Zimmer & Morgan, 1997). Zimmer and
Morgan cite the New York LaGuardia Commission Report
of 1944 as stating “there is no direct relationship
between the commission of crimes of violence and marijuana…and
marijuana itself has no specific stimulant effect in
regard to sexual desires. The use of marijuana does
not lead to morphine or cocaine or heroin addiction”
(p. xvi). Further, in 1972, President Nixon’s
National Commission on Marijuana and Drug Abuse contended
that “the Commission is of the unanimous opinion
that marijuana use is not such a grave problem that
individuals who smoke marijuana, or possess it for that
purpose, should be subject to criminal procedures”
(p. 2). [It must be noted that since the time of the
Commission it has been found that smoking of any substance
is hazardous and many other additional routes are currently
available to administer therapeutic cannabis].
Nurses, in the interest of public health, will need
to examine the mythologies about cannabis they have
been accustomed to, such as: cannabis has been scientifically
proven harmful, has no medicinal value, is highly addictive,
is a gateway drug, kills brain cells, causes crime,
damages the fetus, and impairs memory, cognition, and
motivation (Zimmer & Morgan). These claims have
not been substantiated and in many cases found unsupported
by scientific evidence. Indeed, much of the common thinking
regarding cannabis can be traced to a foundation of
economic self-interest of some professional, business,
and institutional groups.
Current State of the Science
The past two decades have provided the opportunity
to explore and analyze, from an interdisciplinary perspective,
the controversies and conditions in historical and state-of-the-art
cannabis science (Joy, Watson, & Benson, (Eds).
Institute of Medicine, 1999). The science of cannabis
has been examined relevant to ethical, legal, public
policy and health policy perspectives. Biochemical fundamentals
have been examined and hundreds of relevant clinical
trials have been conducted (Grinspoon & Bakalar,
1993). In 2001,the University of California established
the Center for Medicinal Cannabis Studies and has at
least 14 studies in progress and several pending state
and federal approval. This is one of many academic institutions
in the United States addressing the need for cannabinoid
research. In the United Kingdom, GW Pharmaceuticals
has been conducting and completing Phase I and Phase
II clinical trials with cannabis-based medicines. GW
is currently conducting several Phase III clinical trials
involving more than 1,000 participants. One area the
British researchers have been studying is the sublingual
administration of the THC component of cannabis for
patients with intractable pain and a significant analgesic
effect has been found (Americans for Safe Access, 2004).
Cannabis has been found to have a wide margin for safety
with appropriate professional supervision and there
is no mortality rate associated with its use.
The growing body of scientific evidence supporting
cannabis use has been well documented by the Institute
of Medicine (Joy, Watson, & Benson, (Eds.), IOM,
1999) and The American Public Health Association (1995).
APHA noted that the therapeutic effects of cannabis
appear to work differently from traditional therapeutic
and medicinal approaches providing alternative therapy
and assistance to patients resistant to conventional
modalities. The most common circumstances that cannabis
is considered effective for have been in: reducing nausea
and vomiting associated with chemotherapy, stimulating
appetite for patients with wasting syndromes due to
HIV/AIDS and cancer, controlling spasticity associated
with spinal cord injury, multiple sclerosis and possibly
Parkinson’s disease, decreasing the suffering
from the experience of chronic pain, and controlling
seizures in a variety of conditions. Less effective
is its use for relieving intraocular pressure associated
with glaucoma. Current research has indicated favorable
preliminary findings of efficacy for conditions such
as migraine, arthritis, the agitation associated with
Alzheimer’s disease, and attention deficit and
hyperactivity disorders among others (The Third National
Clinical Conference on Cannabis Therapeutics, 2004).
In spite of the support from major scientific and professional
associations such as the American Academy of Family
Physicians and the American Nurses Association in addition
to IOM and APHA, there are still conflicting opinions
and controversy remains among some. The IOM has recommended
continued research in cannabinoid science. This research
is especially important to determine the number, nature,
and efficacy of the many compounds found in the cannabis
plant in addition to and aside from the most commonly
known compound THC, which is primarily responsible for
the psychoactive effects of cannabis but as researchers
are finding, not for the analgesic, anti-inflammatory,
and anti-emetic properties that are most desired in
therapeutic use. Scientists have found that other cannabinoid
components such as CBC and particularly CBD have low
psychoactive effects but greater anti-inflammatory,
analgesic, and anti-emetic efficacy.
Opponents of legitimizing cannabis as a therapeutic
often cite the drug dronabinol (Marinol), oral THC,
as an approved means of access to the benefits of cannabis.
However, perhaps due to the slower absorption rate of
orally administered Marinol and the fact that it contains
only one cannabinoid compound, THC, “a series
of U.S. state studies in the 1980s [found that] cancer
patients given a choice between using inhaled marijuana
and oral THC overwhelmingly chose cannabis” (Americans
for Safe Access, 2004 citing reports to state governments
of California, New Mexico, and Tennessee). In addition,
oral preparations are an obstacle to relief for many
patients. The majority of scientists and patients at
The
Third National Clinical Conference on Cannabis Therapeutics
in Charlottesville, VA in May 2004 concurred that
the synthetic form of THC does not deliver as good a
therapeutic effect as does natural cannabis which contains
in herb form over 60 different cannabinoids, each affecting
a different part of the brain at a variety of cannabinoid
receptors. It was the conclusion of many of the researchers
at the conference that it is a balance of cannabinoid
components that is most helpful and efficacious for
patients.
Legal Actions and Implications
Nine states (California, Washington, Oregon, Alaska,
Hawaii, Arizona, Colorado, Nevada, and Maine) and the
District of Columbia have passed therapeutic cannabis
laws (ANA, 2003). Voters have approved the use of cannabis,
however in several states there have been incidences
where administrative and legislative bodies have refused
to accept the new regulations or codify provider legislation
and where the federal government has arrested legal
users. Individuals, families, and providers have risked
breaking the law to alleviate suffering and to enhance
quality of life for many. Those in the above states
who had been at significant risk for criminal consequences
from the Drug Enforcement Agency (DEA) will be further
protected with the recent Supreme Court decision to
uphold the Ninth Circuit Court of Appeals’ ruling
that protects individuals and providers in those states
from federal prosecution. The 2004 Supreme Court decision
to uphold the Ninth Circuit Court of Appeals decision
in Conant v. Walters protecting physicians who recommend
cannabis to their patients from criminal charges in
addition to other judicial decisions such as that of
Raich v. Ashcroft has set the precedent for changing
cannabis regulation in the nation. In Raich v. Ashcroft
a federal appeals court established that it is legal
under federal law for patients to grow, possess, and
consume cannabis for therapeutic purposes (Americans
for Safe Access, 2003). The United States Supreme Court
heard arguments in late November 2004 in the case of
Ashcroft v. Raich to determine if federal law banning
marijuana possession can be enforced in states that
have legalized therapeutic cannabis use.
Nursing Actions and Challenges
It is important to note that the impetus to promote
the scientific and scholarly agenda on cannabis has
been led by two American nurses, Mary
Lynn Mathre, MSN, RN, CARN (Virginia Nurses Association)
and Melanie Dreher, PhD, RN, FAAN (Iowa Nurses Association)
and has facilitated the international dialogue currently
taking place among scientists, providers, patients,
and legal experts. They recently convened The
Third National Clinical Conference on Cannabis Therapeutics
in Charlottesville, VA in May 2004 in which over
250 nurses, physicians, patients, and attorneys participated.
In 2003, the American Nurses Association passed an action
report with recommendations regarding therapeutic cannabis
that emphasized advocating for safe patient access to
cannabis (ANA, 2003). In addition, twelve of ANA’s
CMAs have positions that address the therapeutic use
of cannabis: Alaska, Colorado, Connecticut, Hawaii,
Minnesota, Mississippi, New Mexico, New York, New Jersey,
North Carolina, Virginia, and Wisconsin. The ANA has
been progressive and consistent in its approach to this
issue going back to the 1996 Congress on Nursing Practice
which advocated support for “the education of
registered professional nurses regarding current, evidence
based therapeutic uses of marijuana/cannabis, and the
investigation in controlled trials of the therapeutic
efficacy of marijuana/cannabis” (p.5, 2003).
The therapeutic cannabis issue presents many challenges
to Illinois nurses including overcoming cultural misconceptions
about the substance, understanding the historical standpoints
of a variety of public, private, and professional stakeholders,
educating themselves on cannabinoid science and its
interface with the neurochemistry of the cannabinoid
receptor system, listening to and acknowledging the
stories of patients, keeping abreast of the components
of cannabis-based medicines, their modes of delivery,
and efficacy rates, and educating the public. Moreover,
nurses need to be aware that as states make provisions
for prescriptive marijuana use, the new laws are tending
to identify only physician prescriptive authority. Nurses
need to act immediately to ensure quality health care
access to the public concerning the use of cannabis.
This access is clearly incomplete and jeopardized if
advanced practice nurses are not included as providers.
In addition, there is the obvious economic impact on
many nurses if their prescriptive authority regarding
cannabis is impeded. At the present, there is a concerted
effort to reschedule cannabis from Schedule I to Schedule
II or, as many clinicians and scientists suggest, schedule
III. It will be up to the nursing associations to protect
the interests of nurses’ prescriptive authority
and thus, the public’s welfare.
The ANA (2003) action report
concluded, “ there is significant research that
demonstrates a connection between therapeutic use of
marijuana/cannabis and symptom relief. The American
Nurses Association needs to actively support patients’
right to legally and safely access marijuana/cannabis
for symptom management and to promote quality of life
for patients needing such an alternative to conventional
therapy” (P.5). The Illinois Nurses Association
supports the position of the ANA and will be counted
among the organizations that support the right of patients
to access legally and safely therapeutic cannabis, and
the right of providers to prescribe, without recrimination,
therapeutic cannabis for their patients.
POSITION STATEMENT
It is the position of the Illinois Nurses Association
to:
1. Support continued research in controlled investigational
trials on the therapeutic efficacy of cannabis, including
methods of administration.
2. Support the right of patients to have safe access
to therapeutic cannabis under appropriate prescriber
supervision.
3. Support and encourage the education of registered
nurses regarding current, evidence based use of therapeutic
cannabis.
4. Support the ability of health care providers to discuss
and/or recommend the therapeutic use of cannabis without
the threat of intimidation or penalization.
5. Support legislation to remove criminal penalties
including arrest and imprisonment for bona fide patients
and prescribers of therapeutic cannabis.
6. Support federal and state legislation to include
cannabis classification as a Schedule III drug.
(Adapted from ANA, 2003)
REFERENCES
American Public Health Association. (1995). Access to
therapeutic marijuana/cannabis. Washington DC.
Americans for Safe Access. (2004). Medical marijuana
and cancer, Medical marijuana and chronic pain, Medical
marijuana and HIV/AIDS, Medical marijuana and multiple
sclerosis. Berkeley, CA. (pamphlets).
American Nurses Association (2003) Providing patients
safe access to therapeutic marijuana/cannabis. House
of Delegates Action Report with Recommendations.
Grinspoon, L. & Bakalar, JB. (1993). Marijuana,
the forbidden medicine. New Haven: Yale University Press.
Joy, JE, Watson, SJ, & Benson, JA. (Ed.s).(1999).
Marijuana and medicine: Assessing the science base.
Washington, DC.: Institute of Medicine. National Academy
Press.
The Third National Clinical Conference on Cannabis
Therapeutics. (May 20-22, 2004) University of Virginia,
Charlottesville, VA. Conference proceedings.
Zimmer, L. & Morgan, JP. (1997). Marijuana myths,
marijuana facts. New York: The Lindesmith Center.
Submitted by the Assembly on Health Policy of the Illinois
Nurses Association
November 23, 2004
