November 1997

Volume 97, Number 11
ISSN:0002-936X

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 300º 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

• 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.