Departments -SUBSTANCE ABUSE - Coordinated by Mary Gorman, MS, CS, CARN

MEDICINAL USE OF MARIJUANA

[Q]Our medical unit treats a number of patients with cancer and AIDS who
use marijuana at home to relieve symptoms. They often want to continue the
practice while hospitalized. I don't want to contribute to their
discomfort by stopping them, but since marijuana is illegal I'm not sure
what to do. I also wonder, how can I tell the difference between someone
who uses marijuana as a medicine and someone who uses it to get high?

[A]You're in a difficult position. Marijuana is illegal, and laws against
its use or possession are harsh. Users risk arrest, fines or even jail
time, forfeiture of property and loss of custody of children, not to
mention stress and legal costs. Nurses who help patients acquire or use
marijuana risk loss of license and job as well as criminal penalties.
Hospitals that allow the use of an illegal substance on their premises can
also face legal consequences.

You might respond to patients who wish to use marijuana in the hospital,
"I'm sorry. I can't help you obtain marijuana, and hospital policy does
not allow you to use it here. I believe you when you tell me marijuana is
helpful to you. I will do everything I can to communicate your needs to
your medical team. Additionally, you can discuss with the team a trial use
of dronabinol (Marinol), a synthetic version of
delta-9-tetrahydrocannabinol (THC), the primary psychoactive constituent of
marijuana. The drug has been approved by the FDA for relieving
chemotherapy-induced nausea and vomiting in cancer patients who don't
respond to conventional antiemetics and for stimulating appetite in
patients with AIDS. If the trial succeeds, the social worker can explore
the manufacturer's assistance program for the patient before he is
discharged, should his insurance not cover the drug.

Use of the cannabis plant (marijuana) for symptom control has gained
increasing attention among both clinicians and the public. As nurses, we
realize that sometimes we use medicines that can be quite toxic -
chemotherapeutic agents, for example. Cannabis, by contrast, has a wide
margin of safety, and throughout its 5,000 years of use a lethal overdose
has never been documented.

In the late 1970s and mid-1980s six states conducted research on
marijuana's effectiveness for chemotherapy-induced nausea and vomiting and
all concluded that marijuana is an effective antiemetic. Cancer patients
using marijuana report immediate relief from chemotherapy-induced nausea
and vomiting. AIDS patients with wasting syndrome demonstrate increased
appetite. Both groups of patients have indicated a greater ability to cope
emotionally with disabling or life-threatening illness. While dronabinol
represents a legal alternative to marijuana and one paid for by insurers),
patients don't experience the same degree of relief from the pharmaceutical
product. The cannabis plant contains numerous chemicals called cannabinoids
and it's believed that it's the combination of these - or specific
cannabinoids such as cannabidiol - that has therapeutic value, not the
psychoactive cannabinoid, THC.

You can support your patient who confides in you about his use of marijuana
by giving him clear and accurate information, thus minimizing potential
physical risks associated with the use of the drug. For example,
contamination by mold -- especially Aspergillus -- can cause fatal lung
infections in the immunocompromised patient. You can advise the patient,
"You need to be careful about possible contamination. Baking marijuana at
300BC for about 15 minutes may slightly decrease the potency but will
destroy any mold, which could otherwise cause a serious infection,
especially with your compromised immune status." You'll also want to reduce
any potential risks from smoking. You can discuss alternatives, such as
steeping tea with the marijuana or baking it in brownies. However, the
oral route may not be an option for patients who have severe nausea or who
are vomiting. Inhaling marijuana is efficient and allows for titration to
the dose they need for comfort. (This has been cited as an advantage of
marijuana over dronabinol.) Refer patients to related research (see
Selected References) for additional information.

Some patients may be using marijuana to get "high" rather than for symptom
control. The best way to know if a patient is using a drug for therapeutic
reasons is to ask. "Tell me about your use of marijuana. When and how is
it most helpful? How do its psychoactive properties affect you? Are you
ever uncomfortable using it?"

In addictions nursing the definition of addiction includes three
components: a compulsion to use; loss of control of use; and continued use
despite negative consequences. A thorough assessment of your patient's use
of marijuana will reveal whether these conditions exist.

In recent years, several state nurses associations and other professional
societies have issued resolutions or position papers in support of access
to marijuana for medical purposes. -- Mary Lynn Mathre, RN

SELECTED REFERENCES

* Mathre, M. L., ed. Cannabis in Medical Practice: A Legal, Historical,
and Pharmacological Overview of the Therapeutic Use of Marijuana.
Jefferson, NC, McFarland, 1997.

* Randall, R. C., ed. Marijuana, Medicine and the Law. Washington, DC,
Galen Press, 1988-1989, vols. I-II.