Medical Marijuana
Abstract
This study examines the role of nurse practitioners in prescribing marijuana to qualifying patients. Physician shortages have prompted practitioners to take up a more active role in primary health care. However, dissenting views have argued that nurse practitioners lack adequate knowledge and skills to diagnose illnesses or to prescribe medications, including controlled substances such as medical marijuana. Therefore, NPs have advanced training and they qualify to dispense primary care and make referrals when additional examination by a specialist is required. This position is presented in the role of NPs, indicating that they can prescribe medical marijuana to manage pain and alleviate patient suffering. However, the study notes that NPs require additional training that would enable them to accomplish this mandate more effectively.
The Role of Nurse Practitioners in Prescribing Medical Marijuana
The shortage of medical doctors is a challenge in many states, especially regarding the provision of primary care. Therefore, nurse practitioners (NPs) have been recognized as professionals that can adequately fill this gap and enhance patients’ access to quality healthcare. Through this practice, NPs fulfill a critical medical need that would not be addressed in their absence. Nevertheless, debates have been evident regarding the competency of NPs in fulfilling the primary care role. For instance, the role of NPs in prescribing medical marijuana has been contentious. Those who advocate for the role of NPs’ in prescribing marijuana and other controlled substances argue that the practitioners have adequate knowledge, skills, and experience to undertake this mandate effectively. Although the issue continues to attract debates in the medical field, adequate evidence is available to suggest that NPs possess the right judgment to recognize illnesses that would be treated or managed by medical marijuana.
As of 2018, more than 31 states in the U.S., including Guam, Puerto Rico and Washington D. C. had officially legalized medical marijuana for medical use. Previously, marijuana was a schedule one controlled substance and still is under federal law (Bridgeman & Abazia, 2017). By allowing nurse practitioners to prescribe marijuana, patients would have more choices when selecting a healthcare provider who is accessible, affordable, and aligned to their specific needs. However, it is necessary to distinguish nurse practitioners (NPs) from registered nurses. For instance, Balneaves, Alraja, Ziemianski, McCuaig, and Ware (2018) described NPs as registered nurses with advanced degrees and extensive experience in nursing practice, who are trained to diagnose diseases, prescribe medications, and request tests. Some NPs are specialized in specific fields, such as mental health, primary care, and cancer management.
As the number of doctors continues to decline, NPs are increasingly undertaking a more significant role in the dispensation of healthcare particularly in areas with few medical doctors. Consequently, society has gradually become accustomed to receiving care from qualified nursing practitioners. However, major opposition has been raised, especially from medical doctors who want to protect their profession (Kraus & Dubois, 2016). Some doctors have actively participated in court cases aimed at denying NPs the opportunity to provide nursing care, and by extension, prescribe marijuana to patients who stand to benefit from the intervention. Their actions imply that the position of the NPs regarding pain management with marijuana is still not well established.
However, the recent legislation that legalizes the use of marijuana as a medical treatment suggests that nursing practitioners require additional training to avoid knowledge gaps in the area (Bridgeman & Abazia, 2017). The knowledge and skill limitations have been blamed for the low confidence among the nurses in prescribing cannabis to the patients (NCSBN, 2018). To support NPs in delivering quality care to clients, it is necessary to initiate investigations to assess their current knowledge base on providing primary care, including recommending the use of marijuana for treatment. It is also suggested that such analysis should examine their attitudes towards this therapeutic intervention, as well as the issues and challenges they experience in their practice when using the therapy.
Nurse practitioners usually prescribe medical marijuana as a form of palliative care. According to Phillipsen, Butler, Simon-Waterman, and Artis (2014), the approach entails providing compassionate care to offer comfort and alleviate symptoms and treat side effects for patients. Some of the symptoms that have been reported to improve after the use of medical marijuana include insomnia, nausea, fatigue, and chronic pain (Isaac, Saini, & Chaar, 2016). Nurses should be empowered to offer a remedy that would counter the suffering caused by these symptoms.
Regulations
In the U.S., NPs are authorized to prescribe medications, including some controlled substances. However, the extent to which they can recommend some drugs varies across the states, with some jurisdictions applying restricted authority while others have minimized or complete mandate (Kraus & Dubois, 2016). States in which the prescribing authority is restricted require NPs to maintain a professional relationship with a physician to provide oversight. Considering the regulatory discrepancies, states such as Alabama and Florida have a limit on a nurse practitioner’s role in dispensing medical care. A state like Washington allows NPs to prescribe medical marijuana but might place restrictions on other controlled substances. The discrepancies in the laws present a challenge to NPs in pain management using marijuana.
The ongoing decriminalization of medical marijuana has generated complex issues for NPs and other medics. These regulatory challenges are mainly associated with the inconsistent evidence on the efficacy of the remedy, the risks to patients’ needs, as well as current trends and practices (Phillipsen et al., 2014). To overcome some of these impediments, the National Council of State Boards of Nursing insisted that practitioners should be aware of the contexts or circumstances where medical marijuana is still illegal and which situations are within the laws regulating medical marijuana prescription (NCSBN, 2018). Such awareness will ensure that the nurses are not practicing contrary to regulations in any given jurisdiction since the use of cannabis beyond prescription is still illegal in some areas.
The Medical Marijuana Program (MMP) guides the use and dispensation of cannabis for medical purposes in the United States. The program also details the qualifications of individuals who can prescribe the drug as well as for what purposes the remedy is recommended. While prescribing authority endowed upon NPs is particularly vague in the MMP, the program states that in some cases, a nurse can prescribe medication to patients (NCSBS, 2018). The prescribing nurse is also required to have an “understanding of the endocannabinoid system, cannabinoid receptors, cannabinoids, and the interactions between them” (NCSBS, 2018, p. 524). They should also be knowledgeable of the medical components of marijuana as well as their therapeutic applications. The MMP could clarify its guidelines to make them easily understandable to practitioners.
Under the Federal government law, it is illegal to consume cannabis. However, position papers from the Department of Justice previously discouraged the prosecution of individuals using or prescribing the substance as a form of medication. Nevertheless, the NCSBN (2018) reported that these provisions had been rescinded as of 2018, and prosecutors are now required to rely on current standards and practices in determining cases that should be legally pursued. Within state jurisdictions, medical marijuana is legislated under the Departments of Health as well as the Medical Marijuana Program (Bridgeman & Abazia, 2017). Patients who have a condition that requires medical marijuana therapy should produce a report from a certified health worker. In addition, they should register with the MMP and visit an authorized clinic that can dispense medical marijuana.
The MMP has identified specific conditions that qualify for marijuana prescription. Hence, NPs must be updated on those requirements to avoid contravening the law or prescribing for conditions that do not benefit significantly from the intervention. NCSBN (2018) identified the specific conditions for which NPs can prescribe medical marijuana, such as Alzheimer cancer, Crohn’s disease, and other gastrointestinal conditions that cause an irritable bowel, nausea, arthritis, Glaucoma, Hepatitis C, cachexia, HIV/AIDS, post-traumatic stress disorder, epilepsy, and seizures. Nurse Practitioners may also prescribe the drug for ALS, neuropathies, muscle spasms (persistent), Parkinson’s disease, sickle cell disease, and multiple sclerosis in addition to all terminal illnesses to ease patient anxiety and discomfort (Bridgeman & Abazia, 2017). The recognized illnesses make it easier for practitioners to determine patients who are qualified for the intervention.
Some conditions have been found to benefit from medical marijuana significantly. Through randomized trials, nausea caused by chemotherapy, cachexia, fibromyalgia-related chronic pain, neuropathies caused by diabetes, MS, or HIV/AIDS, and spinal cord related injuries benefited from the intervention (NCSBN, 2018). The reduction on the number of seizures per day, minimization of nightmares caused by PTSD, and the mitigation of Tourette’s syndrome tics are among the conditions that moderately benefited from this therapy (NCSBN, 2018). However, nurse practitioners are cautioned that use of marijuana can conceal the symptoms of the disease, thereby generating a subjective sense of well-being.
Arguments Against NPs Role in Prescribing Medical Marijuana
Opposition against NPs role in prescribing medical marijuana appears to unfold within two distinct dimensions. The first aspect relates to the perception that nurses are not qualified to prescribe marijuana or other controlled substances (Kraus & Dubois, 2016). The second dimension posits that the drug poses more risks and negative effects than the associated benefits (Dills, Goffard & Miron, 2016). Hence, no one, doctor or otherwise, should be prescribing the drug in the first place. Therefore, both schools of thoughts have generated debates regarding the role of NPs in prescribing medical cannabis to patients.
The opposition against the use of medical marijuana has declined due to evidence, regarding the benefits of cannabis to patients as well as legalization initiatives of the drug to alleviate medical-related discomfort. After all, as Borgelt and Franson (2017) insist, optimization of care to enhance patient outcomes should be the highest priority in medical practice. With these developments, the current debate about medical marijuana revolves around those authorized to prescribe it and the qualifications they should have.
The American Medical Association (AMA) has been denouncing the role of NPs in prescribing medical marijuana. The Association has argued that allowing the practitioners to diagnose and prescribe medication is akin to endangering the lives of patients (Kraus & Dubois, 2016). The Association insists that the shortage of doctors cannot be used as an excuse to put patients at risk. The position is that the current situation should not be a reason for overhauling the standards of medical practice to accommodate the shortage.
The Association also posits that efforts should focus on increasing the enrollment of more students into medical practice and generating interest in the medical profession among learners. In addition, the AMA argues that medical care should be approached more like a team effort and that nurses should be under the supervision of doctors at all times (NCSBN, 2018). The implication is that nurses would be denied the ability to operate independently and to intervene in alleviating patients suffering as much as they possess the knowledge to make such decisions.
The use of medical marijuana is still a contentious issue in medical practice. While the medical fraternity has been mostly united in espousing the medical benefits of marijuana, some scholars, such a McKivigan (2016), claim that the effectiveness of marijuana for pain management has been grossly exaggerated. Dills, Goffard, and Miron (2016) also state that medics’ support for cannabis is not backed by research, but rather by cultural and social perspectives of the practice. The authors also report that while the adverse effects of marijuana in users are well known across the research fraternity, its benefits are still understudied and assumptions should not be made by anecdotal social perspectives (McKivigan, 2016). Cannabis is known to have psychoactive, impairing, and intoxicating effects on users. Other negative impacts include high chances of addiction, long-term cognitive and psychological issues, among others (Bridgeman & Abazia, 2017). Importantly, there is a scarcity of rigorous randomized studies investigating both the pros and cons of the drug.
Patients also have concerns about the efficacy of cannabis as a treatment therapy. Nurse practitioners have reported distress when patients decline to use medical marijuana even with the promise of a better quality of life (McKivigan, 2016). McKivigan (2016) further stated that some nurses have also expressed fears about their inability to control the use once it is prescribed, which would place them at an awkward position with the law and risk prosecution. Indeed, Balneaves et al. (2018) found that nurses had inadequate knowledge about the proper dosage and could not develop effective plans for intervention in patients requiring medical marijuana. Considering that marijuana is highly addictive, nurses might fail to control its use, and hence cases of dependent on the controlled substance may arise. Clear directives and guidelines should be developed to minimize cases of addiction.
Another key factor often highlighted by those who oppose is the impact of smoking on respiratory health. Without establishing the effectiveness of marijuana on a patient’s illness relative to the known side effects, Ziemianski, Capler, Tekanoff, Lacasse, and Luconi (2015) discouraged nurses and other medics from prescribing the drug. Based on inadequate doctors’ confidence and competence in recommending marijuana to patients and how to use it to manage a medical issue, McKivigan (2016) advises that nurses should be careful when considering this option. These factors represent some of the most cited arguments by opponents of medical cannabis.
Support of the Role of NPs in Prescribing Medical Marijuana
As early as 1996, the American Nurses Association (ANA) recommended that nurses should be educated on the therapeutic benefits of marijuana. Since then, the organization has insisted that nurses have the ethical obligation to advocate for patients’ access to care, including the use of marijuana to alleviate pain and discomfort (NCSBN, 2018). Supporters of this claim argue that nurse practitioners are trained and skilled on diagnostics and interventions at the primary care level. These skills also enable them to recognize when a patient should be referred to a medical doctor for additional evaluation.
Nurse practitioners undergo four years of training for an undergraduate degree and three years of residency before becoming licensed professionals. Besides, others have advanced degrees, including doctorates, with extensive practical experience from their years of practice. It is this group of nurses that are regarded as adequately qualified to provide quality health care and determine when a patient requires further assessment by a specialist (Phillipsen et al., 2014). Doctors on their part go through four years of undergraduate training, four years of medical training, and three years of residency. The intensity of training for both NPs and doctors reveals adequate skills and knowledge suggesting that NPs should be allowed to practice independently.
Comparing the NPs and doctors’ knowledge and skills is critical. In a study that compared nursing practitioners and doctors skills and practice, the findings established that both groups had almost the same characteristics in terms of the number of referrals, the overall health of patients and their outcomes for specific illnesses (Mudinger, Kane, Lenz, & Totten, 2000). Mudinger, et al. (2000) assigned patients to either a doctor or NPs randomly and examined their outcomes after six years. The study found that NPs are more effective listeners compared to doctors and understood when a patient should be referred to a medical doctor for further assessment. In support of NPs having an expanded role, especially in prescribing controlled substances, anecdotal evidence suggests that patients are sometimes left in great pain when a doctor is not available to prescribe powerful painkillers. Mudinger et al. (2000) reveal that nurses spend more time with patients, which make them accessible to make critical decisions about the required therapy. Therefore, their availability places them in a better position to understand patients’ needs and make more informed choices towards their treatment regimen.
Pain management is regarded as a core competency in nursing practice, and relief from pain is viewed as a patient’s right. As Phillipsen, Butler, Simon-Waterman, and Artis (2014) argue, these factors place NPs at the forefront of effective pain management. Fulfilling this responsibility requires them to have some level of independence to prescribe the most effective medication. Therefore, denying nurses the right to prescribe a remedy that has been proven to provide considerable relief from pain is a direct contradiction of nursing ethos. Nurses should prescribe any medication, including controlled substances if such interventions significantly improve patients’ lives.
Canada allows its NPs to prescribe medical marijuana to eligible patients. Previously, only certified physicians were authorized to do so. Murphy (2019) aver that medical marijuana is being covered by many employees in Canada though health benefit and health spending initiatves. The extension of this privilege to NPs requires adequate knowledge of dispensing this responsibility. In response, a Canadian study by Balneaves et al. (2018) investigated nurses’ knowledge gaps, regarding the use of medical marijuana for qualifying patients and concluded that significant knowledge gaps could be filled by developing educational content that addresses this topic during nurse training and career development. Although additional and more specific knowledge and skills for NPs to execute their healthcare mandate more effectively are necessary, nurse practitioners possess sufficient knowledge that should allow them to prescribe marijuana for medical purposes.
Conclusion and Implication
As it is evident from the discussion, NPs should understand the merits and demerits of medical marijuana to fulfill their beneficence mandate to patients. This knowledge should then inform their decision-making on whether to prescribe the drug based on the benefits it represents to the patient compared to the side effects. Furthermore, some of the arguments presented by opponents of marijuana are legitimate and should be considered when prescribing marijuana. For instance, the research has revealed that medics often lack the confidence and competence to prescribe marijuana in ways that would benefit the client. In this case, nurses should make it a priority to expand their knowledge of the treatment and situations where the use of marijuana is preferable over other options. Being aware of the law and regulations that govern medical marijuana is also critical considering that different jurisdictions have varied requirements on the use of marijuana. Practitioners should be cognizant of the differences to ensure that they do not break the law as well as their patients.
In addition, it is evident that nurses have a significant role in prescribing medical marijuana to patients. Therefore, the nurse practitioners should be accorded adequate recognition, regarding their role in prescribing the drug because they are close to their patients, spend more time with their clients, and qualified doctors may not be enough to meet the needs of the patients. The un-uniform laws and regulations governing the prescription make it particularly difficult for NPs to execute their mandate effectively. While some jurisdictions allow the practitioners to prescribe medical cannabis, others have put restrictions or limited the type of conditions that qualify for the medication. Besides, it is still illegal to consume or distribute marijuana, as much as many states have recently enacted legislation that makes it legal for medical reasons.
Such regulatory contradictions and the absence of standardized guidelines for practitioners to observe in recommending marijuana therapy create substantial confusion in the field. Hence, NPs feel less confident in recommending this therapy, and sensing their hesitation, patients may be reluctant to use marijuana to ease their symptoms. Nevertheless, these challenges can be overcome by harmonizing the legal requirements for both state and federal law as well as the guidelines for ANA and AMA. Such an approach will ensure that NPs receive the support they need to fulfill their role as they optimize patients’ outcomes.
Most importantly, adequate education and training have emerged as being among the top priorities for enabling the competent prescription of marijuana by NPs. The discussion has revealed that through AMA, doctors have voiced concerns about the qualifications of nurses in identifying patients who would most benefit from the therapy. These concerns have failed to consider that NPs undergo extensive training, which prepares them to make diagnoses, prescribe appropriate therapeutic interventions, and recognize cases that require the oversight or expertise of doctors. Nonetheless, the NPs will benefit from additional training that focuses on medical marijuana in nursing practice. Considering that the evidence on the efficacy of marijuana for specific conditions is still scarce, additional training will enable NPs to make informed choices that will maximize the health outcomes of their patients.
