Medical Marijuana

According to the Centers for Disease Control and Prevention (CDC), at the federal level in the United States (U.S.), cannabis is still considered a Schedule I substance under the Controlled Substances Act. Schedule I substances are those that are thought to have a very high dependency potential with no medical use, which makes the distribution of cannabis a federal offense(CDC, 2024).

According to the CDC, for medical use of cannabis, as of February 2024, 47 states, the District of Columbia, and three territories (Guam, Puerto Rico, and the U.S. Virgin Islands) allow for the use of cannabis for medical purposes through comprehensive programs. Moreover, it is worth mentioning that 14 states and two territories have a comprehensive medical-only program. However, nine states in the U.S. have medical programs that only allow the use of cannabidiol (CBD) or low-tetrahydrocannabinol (THC)-containing products for qualifying medical conditions as defined by the state. In this context, comprehensive medical programs refer to those programs that allow the use of cannabis products beyond CBD or low THC-containing products for medical purposes as defined by the state or territory (CDC, 2024).

It is important to know that the Northern Marianas territory allows legal cannabis use; however, they do not have any specific medical program. Therefore, they are not included in medical-use programs.

As stated by the CDC, as of February 2024, in the U.S., 24 states, the District of Columbia, and two territories (Guam and North Mariana Islands) allow for the use of cannabis for non-medical adult purposes. Most of those states and their other details, such as cannabis legalization statutes, possession limits, home cultivation allowances, and key legislative actions, are mentioned in the table below (Table 1).

Medical cannabis refers to medical preparations made from cannabis plants to exert therapeutic response. The active chemical compound of cannabis is cannabinoids. In health delivery services, cannabis is used to manage various conditions and symptoms such as chronic pain, side effects of chemotherapy, epilepsy, and anxiety.

Cannabis has various routes of administration, which makes it useful as it offers flexibility to suit the needs of multiple patients and their preferences. It comes in multiple forms of preparation, including oils, capsules, tinctures, edibles, topical creams, and inhalation. Hence, it has different rates and durations of absorption because each preparation has a different pharmacokinetic profile. This property also enables healthcare providers to meet individual patient requirements (University of San Diego, n.d.).

Cannabis is the scientific name of the plant species that includes three main subspecies: Cannabis sativa, Cannabis indica, and Cannabis ruderalis. However, it represents the entire plant and is often used to refer to everything related to the plant, such as recreational, medical, or industrial purposes.

Cannabinoids are the chemical compounds that the cannabis plant contains. There are over 100 such chemical compounds, and the most commonly talked about are THC and CBD, which are known to have effects on the human body.

Cannabis is an umbrella term that contains all the products that are derived from the same plant, including hemp, which contains low-THC cannabis, and marijuana, which contains high-THC cannabis.

Marijuana specifically refers to the parts of the cannabis plant that are usually flowers, leaves, and stems, which contain high levels of THC. It is a psychoactive compound that causes the "high" sensation when consumed. Moreover, the term marijuana is more commonly used to refer to the medical or recreational use of cannabis because of its psychoactive effects. However, the term marijuana is often used in legal and cultural contexts, especially when referring to cannabis used for recreational or medicinal purposes.

The main differences between cannabis and marijuana are highlighted in Table 2.

In summary, marijuana is a type of cannabis, but cannabis refers to the whole plant, including all its varieties (U.S. Department of Health and Human Services, 2019).

When talking about cannabis, it is essential to know about cannabinoids. They are naturally occurring compounds that are found in the cannabis plant. Moreover, they interact with the body's endocannabinoid system (ECS), which plays a pivotal role in regulating normal bodily processes such as mood, appetite, pain, and immune response. Nowadays, cannabinoids are being produced synthetically rather than extracting them directly from the cannabis plant. However, they are naturally found in other plants, such as liverwort, echinacea, and some fungi. There are more than 100 cannabinoids included in medical cannabis, but the most common ones are THC and CBD. They are being studied the most in medical sciences to discover how they can benefit human beings (University of San Diego, n.d.).

THC is a psychoactive compound that is responsible for the effects that give that "high" often associated with recreational cannabis use. However, in the healthcare system, THC is mainly known for its anti-nausea and pain-relieving properties. On the other hand, CBD is non-psychoactive and is widely known and studied for its anti-inflammatory, anti-seizure, and anti-anxiety effects. Moreover, there are also other less-known cannabinoids, which include cannabinol (CBN), that show sedative properties and have the potential to help treat sleep disorders. Furthermore, cannabigerol (CBG) possesses antibacterial properties and is under research because of its neuroprotective properties (University of San Diego, n.d.).

Over time, marijuana use has become common as more and more states are legalizing its medical use. Here in Table 3 is the information about conditions in which marijuana is often given; there is also a column that tells if it is officially approved for that condition and another that provides other details.

Reasons for Marijuana Use and Common Forms:

Here are the most common reasons for marijuana use, along with the common forms of their use. They can be described as:

• Anxiety:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 36% of users.
• Insomnia:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 33% of users.
• Chronic Pain:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 34% of users.
• Depression:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 35% of users.
• Mood Disorders:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 35% of users.
• Arthritis:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 39% of users.
• Migraines:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 40% of users.
• PTSD:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 21% of users.
• Cancer Symptoms:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 34% of users.
• Libido:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use: 33% of users.
• Glaucoma:
  • Commonly used forms: Smoking, Edibles, Vaping, Concentrates, Topicals.
  • Over 1 form of use (Azcarate et al., 2020).

Medical Reasons for Marijuana Use by Gender

Here, in Table 4, it is elaborated on how marijuana use is common among genders.

From the table, it is visible that:

• Anxiety and sleep disturbances or insomnia show significant gender differences, with females using marijuana more for these reasons.
• Higher usage in males has been witnessed because of mood stabilization.
• Chronic pain, arthritis, cancer-related symptoms, and seizures/epilepsy have similar usage rates across both genders, with no significant difference (p-value > 0.05).
• PTSD and other reasons show a statistically significant difference, with females using marijuana more for PTSD (Azcarate et al., 2020).

The use of marijuana in people belonging to different races for medical purposes is elaborated in Table 5 below; it classifies races as White and non-White.

This table indicates that:

• There are similarities for most conditions because the difference between white and non-white individuals using marijuana is not very significant (as indicated by the high p-values, typically greater than 0.05). Moreover, conditions like sleep disturbances and migraines show almost the same percentage of use in both groups (Azcarate et al., 2020).
• This table indicated that there is a significant difference in the use of marijuana in treating HIV/AIDS, with a higher percentage of white individuals (1.37%) using it for this condition compared to non-white individuals (0.13%), which is statistically significant (p = 0.013).
• In chronic pain users, there is a trend where a higher percentage of white individuals (46.3%) use marijuana for chronic pain compared to non-white individuals (35.8%), but the difference is not statistically significant (p = 0.06).
• In other conditions, such as anxiety and depression, the differences between the two groups are relatively small and not statistically significant (Azcarate et al., 2020).

The following routes are used to administer marijuana to patients. However, healthcare providers should ensure that the dose is started with the lowest possible dose and increased slowly, especially when being given in edible form. Moreover, it is pertinent to know about the patient's preferences and choose the method based on the patient's needs and choices; for example, it is essential to differentiate if the patient requires quick relief or sustained effects. Also, monitor the patients for side effects and adjust dosage accordingly, particularly with THC, which has psychoactive effects and can negatively affect the patient's quality of life (Vinette et al., 2022).

• Inhalation
  • Cannabis is smoked or vaporized.
  • Effects start quickly (1-5 minutes).
  • Lasts 2-4 hours.
  • Ideal for immediate relief (pain, nausea).
  • Vaporization is safer than smoking due to reduced respiratory risks (Vinette et al., 2022).
• Oral
  • Taken through food, capsules, or tinctures.
  • Delayed onset (30 minutes to two hours).
  • Lasts 8+ hours.
  • Suitable for long-term relief (pain, insomnia).
  • Dosing can be difficult, and effects may vary.
• Sublingual
  • Liquid cannabis is placed under the tongue (tinctures or sprays).
  • Onset is 15-30 minutes.
  • Effects last 4-6 hours.
  • Ideal for faster relief without smoking or vaporizing.
  • Easier to dose than edibles (Vinette et al., 2022).
• Topical
  • Cannabis-infused creams, balms, or patches applied to the skin.
  • Localized relief within 15-60 minutes.
  • Lasts several hours.
  • Does not produce psychoactive effects.
  • Treats localized pain, inflammation, and skin issues.
• Suppositories
  • Cannabis-infused suppositories are inserted into the rectum or vagina.
  • Fast absorption (10-20 minutes).
  • Effects last 4-8 hours.
  • Used for localized issues or non-psychoactive relief.
  • Ideal for patients who cannot tolerate oral or inhaled treatments.
• Transdermal Patches
  • Patches are applied to the skin for slow, controlled release.
  • Slow onset (1-2 hours).
  • Lasts up to 12+ hours.
  • Ideal for sustained relief (chronic pain, inflammation).
  • Provides consistent dosing (Vinette et al., 2022).

Tolerating marijuana can be challenging sometimes for patients. Therefore, it is imperative to monitor for side effects, help patients cope with side effects, and weigh the risks versus benefits of the therapy.

The side effects of marijuana can be described as:

Cognitive Impairment:

• THC may impair memory.
• Affects attention and decision-making.
• The effect is stronger at higher doses (National Institute of Health, 2024).

Drowsiness and Fatigue:

• Cannabis, especially THC and CBN, causes sedation.
• May lead to drowsiness.
• Fatigue can occur as well.

Dizziness and Lightheadedness:

• Some people feel dizzy.
• Others may feel lightheaded.
• Low blood pressure may cause a higher risk of falls (National Institute of Health, 2024).

Dry Mouth (Xerostomia):

• Cannabis can reduce saliva production.
• This leads to a dry mouth sensation.

Increased Heart Rate:

• Cannabis can cause tachycardia (fast heartbeat). This is a risk for people with heart problems.

Psychiatric Effects:

• High doses of THC may cause anxiety.
• Paranoia or hallucinations may occur. This is rare when used under medical supervision. People with mental health disorders are more likely to experience this(National Institute of Health, 2024).

Impaired Motor Skills:

• Cannabis affects coordination.
• Reaction time may be slower.
• This can impair tasks like driving or using machinery.

Gastrointestinal Issues:

• Some people may feel nauseous.
• Vomiting or changes in appetite can happen.

Addiction or Dependency:

• Long-term use of THC can cause dependency.
• This may lead to cannabis use disorder (CUD) (National Institute of Health, 2024).

Medical cannabis use is being legalized in most of the states of the U.S. However, its use remains illegal on the federal level. Therefore, to treat patients with responsibility and the utmost care, healthcare providers must be aware of the state-specific laws regarding the legal aspects of medical cannabis, especially in the state where they work, because laws regarding medical marijuana use differ widely across jurisdictions. Also, for all states, the qualifying conditions are not the same, so healthcare providers should know when they are allowed to prescribe marijuana and when it is prohibited, particularly according to the place where they work. If a healthcare provider is a travel nurse, remembering laws and regulations according to different states can be confusing; therefore, remaining alert and vigilant is crucial (Boehnke et al., 2019).

Moreover, there is a variation in reporting requirements from state to state, hence making it difficult for the regulator to determine the exact number of patients or doctors who are currently utilizing marijuana as a part of their treatment regimen and whether lawmakers need to develop a new regulation to accommodate new use cases (Boehnke et al., 2019).

To be as compliant as possible, healthcare providers must remain updated on evolving laws and regulations about marijuana from the Food and Drug Administration (FDA), Drug Enforcement Administration (DEA), and other official bodies involved. A thorough documentation of patient assessments and treatment plans is useful for healthcare providers to know about proper dosing and outcomes of marijuana therapy; it can also aid in legal investigations if required. Furthermore, medical cannabis specialists and legal experts can help healthcare providers and facilities function with the complexities of prescribing marijuana and avoid any regulatory scrutiny (Boehnke et al., 2019).

Medical marijuana administration can be challenging for healthcare providers as they need to be completely aware of laws and regulations and how medical marijuana use is going to affect the patient, either positively or negatively. Here are some of the most important nursing implications that providers should follow while administrating marijuana to patients (Ryan et al., 2021).

Patients receiving medical cannabis should undergo regular assessment checks and a thorough health history, including a complete review of past treatments, previous cannabis intake experience, comorbidities, disease and drug history, food and medication allergies, medical and supplement reconciliation, physical assessment, and the risk for psychiatric disorders and substance use disorders (Ryan et al., 2021).

Also, it is important to work collaboratively with other healthcare providers and the patient to determine their goals and encourage them to focus on that particular condition first, which can help decrease variables and improve adherence. The care plan should ensure that the patient's goals are included and facilitated while decreasing potential adverse effects and maximizing outcomes. It is essential to teach patients how to read and understand product labels as it will help them better understand dosages and enable them to independently self-titrate their medication (Ryan et al., 2021).

Having a lot of information in the patient's record can help improve therapy outcomes. Therefore, make sure to know about the route, dosage, administration time, effect, and length of action of medical cannabis therapy (Ryan et al., 2021).

Keep in mind that a typical cannabinoid serving size ranges from 5-10 milligrams (mg), and the 10 mg serving size can be too high for a patient who has never taken cannabis before. Therefore, follow the protocol of "start low and go slow." However, no established national dosage protocol exists or is being followed for medical cannabis when given for specific conditions. This is because the federal cannabis laws do not recommend specific dosages to patients (Ryan et al., 2021).

Cannabis dosage is challenging because every patient is different, and hence, the responses to cannabinoids also differ from person to person. Suppose you have more information about the patient, such as the route of administration, dosage, length of action, time of administration, and effect of the drug. In that case, you can help the patient improve the outcome and educate them better about their therapy. Moreover, cannabis has biphasic properties, which means it produces one effect at a low dose and the opposite effect at a higher dose. However, cannabis causes adverse effects because of large doses, which can exacerbate symptoms such as pain, insomnia, and anxiety. Therefore, having the know-how of dosage is important as you would not want to exacerbate the same symptoms that are being treated (Ryan et al., 2021).

There are various contraindications for marijuana use, and it should not be administered if the patient has any of those conditions, or healthcare providers should exercise extra caution when administrating cannabis-based medication to those patients. Moreover, they can also decline to prescribe marijuana in favor of alternative treatments if they consider that the risk is more than the benefit.

Healthcare providers should know that marijuana use is contraindicated in the following conditions.

Pregnancy and Breastfeeding

A pregnant or lactating mother should not be given marijuana because of its potential risk to the fetus and infant development. Therefore, if the patient requires it for some symptoms, alternatives should be taken into consideration (MacCallum et al., 2021).

Previous Substance Abuse

Patients with a history of drug or alcohol abuse are at higher risk of developing cannabis dependence; therefore, if a patient has been addicted to previous substances, make sure to give them alternative treatments rather than marijuana, which can again lead to substance abuse (MacCallum et al., 2021).

Mental Health Conditions

Marijuana, if given to patients with severe mental health conditions such as bipolar disorder, severe anxiety, or schizophrenia, can exacerbate the pre-existing symptoms. Therefore, its use may need to be avoided in patients with these conditions (MacCallum et al., 2021).

Cardiovascular Diseases

Cannabis can cause increased heart rate or blood pressure fluctuations, so its use should be avoided in patients with heart diseases such as arrhythmia, hypertension, or heart failure (MacCallum et al., 2021).

Liver or Kidney Disease

Cannabis is metabolized by the liver and kidneys; therefore, its use should avoided in patients with a history of liver or kidney impairment or should be closely monitored during the therapy (MacCallum et al., 2021).

Pediatric Population

Cannabis use should be greatly discouraged in children; however, there is an exception with certain medical conditions such as epilepsy. It should be given under strict medical supervision to prevent substance dependency in children (MacCallum et al., 2021).

Compromised Immune System

Patients with weakened immune systems, such as those undergoing chemotherapy, should not be given medical marijuana as they are at increased risk of infections, and cannabis products, if not regulated properly, contain contaminants that can lead to infection (MacCallum et al., 2021).

Drug interactions can sometimes lead to fatal consequences by either potentiating or lowering the effects of drugs. Therefore, nurses and other healthcare providers must be well aware of drug interactions, especially for marijuana, as it is a Schedule I drug with high abuse potential (Antoniou et al., 2020).

In Table 6 below, there is a summary and examples of the drugs affected by medical cannabis use.

It is important to monitor the patient throughout cannabis therapy to ensure the safe use of other medications. Regular check-ups for adverse effects like sedation, dizziness, or motor coordination issues are necessary. Drug interactions should be assessed carefully. Monitor for sedation and adjust dosages if necessary. Healthcare providers should be cautious with drugs metabolized by the same enzymes (CYP2C9, CYP2C19, CYP3A4). Avoid combining cannabis with CNS depressants.

Janice, a 42-year-old female who lives in Colorado, has progressively declining mobility and pain due to multiple sclerosis. Her healthcare provider, Dr. Thompson, had tried multiple conventional treatments, but Janice's symptoms only progressed over time. After thoroughly reviewing Janice's medical history, including previous substance abuse issues, he mentioned the possibility of using medical marijuana as an adjunct treatment option.

Janice, who has tried many therapeutic options, was willing to try medical marijuana to alleviate her symptoms. Dr. Thompson had previously tried opioids for Janice, and her pain was not successfully managed; also, he knew that research was showing that medical marijuana has a lower risk of dependency and overdose in comparison to opioids. Dr. Thompson recommended a balanced ratio of THC and CBD in the form of a tincture, with 2.5 mg THC + 2.5 mg CBD twice daily. The care plan included follow-up phone calls the day after Janice started this new therapy, an in-person follow-up a week later, and regular monthly visits to ensure efficacy and monitor for side effects. 

After three months of therapy, Janice reports a decrease in pain reduction and an increase in mobility.

With the increasing legalization of marijuana, healthcare providers must be well informed of the updates and the laws and regulations regarding it. Moreover, be vigilant with ongoing cannabis therapy and ask patients if they have any adverse effects. Marijuana should be prescribed and administered only when the benefit outweighs the risk.

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