By Jeanie Davis

If a patient asks about medical marijuana, how will you respond? Are you familiar with the legalities and science to advise your patient?

The legalities are complex, but the bottom line is this: medical marijuana is gaining support nationwide.

“Case managers are getting questions about medical marijuana,” says Patricia Carothers, BSN, RN, MS, CCM, president of Colorado-based My NetRN, Inc. “No matter what your view is, there’s no hiding from this. You’ve got to be prepared to answer patients’ questions.” Case managers must understand the logistical, medical, and ethical implications of medical cannabis if they are to guide clients.

Marijuana was as common as aspirin in the 19th century, used to treat multiple health problems. In the 1930s, the United States government started restricting access. Today, marijuana is illegal on the federal level, classified like heroin as a Schedule I drug.

But times are changing. Recreational marijuana has been legalized in 11 states. Medical marijuana is legal in 33 states and Washington, D.C. Guam, Puerto Rico and the U.S. Virgin Islands have approved medical marijuana for “qualifying conditions,” and more states are taking steps toward legalization.

In fact, marijuana remains the most popular drug that is illegal under federal law, reports the Harvard Health Letter. A 2014 survey suggests that about 10% of marijuana consumers — more than 2 million — may use it exclusively for medical reasons.

However, medical marijuana is only FDA-approved for treatment of two rare, severe forms of epilepsy: Dravet syndrome and Lennox-Gastaut syndrome. Many more people use medical marijuana to alleviate chronic pain, anxiety, epileptic seizures, decreased appetite, and many other conditions.

Case Managers Field Questions

Healthcare providers are trying to sort out the issue, says Carothers. Even in “legal” states like Colorado, some physicians refuse to recommend medical marijuana to patients, so they cannot obtain it from a dispensary.

The doctor’s decision compromises patient autonomy and, perhaps, safety. “Healthcare professionals should honor and respect freedom of choice for their patients,” Carothers says.

In non-legal states, some people are self-medicating with recreational marijuana. “What is our response going to be?” Carothers notes that most adverse effects occur in cannabis-naïve patients who ingest high amounts of THC. This is much more likely to happen when they take the recreational route.

“All of your clients should be made aware of these potential risks,” Carothers adds.

She advises: “People often have a complicated relationship with medical marijuana. They’re interested, heard about it from a friend who used it, but don’t know where to start. We need to be their source of information.”

Medical marijuana is the marijuana plant used to treat medical conditions. It is basically the same plant as recreational marijuana. However, cannabis plants bred for medical purposes will vary, depending on the strain, in levels of chemicals that create a “high.” Yet all strains are rich in chemicals that affect pain and other bodily functions.

How Does It Work?

Cannabis contains hundreds of chemicals, called cannabinoids, each affecting the body differently.

Marijuana mimics our own natural endocannabinoids, Carothers explains. The endocannabinoid system is involved in a wide variety of functions, including pain, mood, appetite, memory, stress, sleep, metabolism, and immunity.

Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the primary chemicals with medical applications. THC produces the “high” people feel when they smoke marijuana or eat foods containing it. CBD1 binds with receptors in the brain and central nervous system. CBD2 receptors are in the immune system.

“The receptors in our body are ready to bind with the compounds in cannabis for activating responses,” she explains.

Cannabis used for fiber contains usually less than 1% of THC, but medical marijuana contains varying amounts of THC, Carothers says. “Patients with medical marijuana access can sometimes obtain higher levels of a THC product vs. a recreational product,” she says. “It certainly depends upon their condition and need.”

How Is It Administered?

Medical marijuana can be smoked, inhaled through a vaporizer, ingested (gummies, lollipops, brownie), or applied topically in a lotion, spray, oil, or cream. In liquid form, a few drops can be placed under the tongue. Reports of detrimental issues with vaping involved people using non-cannabis substances, Carothers says.

The body processes the substance differently based on how it is administered, she explains. With oral ingestion, the substance must pass through the stomach and liver, so there is delayed onset and longer duration. “Oral doses are difficult to titrate for that reason.”

This variability of absorption and potency can be difficult to judge regardless of how it is administered, says Carothers. Inhalation is the easiest to titrate, and is the most common route. Although considered safe, inhalation can lead to respiratory irritation, she adds.

She strongly recommends microdosing — using between 2 and 2.5 milligrams of either THC or CBD. She recommends the “start low and go slow approach” for everyone, but especially seniors and those using marijuana for the first time.

What Does It Treat?

Most people take medical marijuana to reduce chronic pain, nausea, and vomiting due to chemotherapy, and muscle spasticity related to multiple sclerosis or epilepsy seizures. While research of medical marijuana is limited due to federal laws, most existing evidence supports using medical marijuana for the above conditions, says Carothers.

Medical marijuana also can be taken for Alzheimer’s disease, anorexia, appetite loss, Crohn’s disease, epilepsy, glaucoma, schizophrenia, post-traumatic stress disorder, muscle spasms, and Wasting Syndrome.

Research in a Tel Aviv laboratory is addressing many questions, including whether cannabis kills cancer cells; and, if it does, which types of cancer; and which cannabis strains are effective. The “which strains” question is crucial.

One study involved children with autism given a low THC/high CBD compound; that study had a 78% success rate on various endpoints including anxiety, violence, sleep, and communications.

However, the effect may be strain-specific, as a similar study involved a low THC/high CBD strain, but provided by a different grower. The children experienced no effect at all, Carothers reports.

As medical marijuana is not scientifically standardized, she knows case managers struggle to advise patients. “Start low, go slow,” she suggests.

How Can Patients Obtain a Prescription?

The patient must have a medical condition that qualifies for medical marijuana use. If they live in a legal state, they must check the list of qualifying conditions. The state also may require a medical marijuana ID card to buy it at a dispensary.

To obtain the ID card, a physician with an active Drug Enforcement Administration certification must recommend it for the patient. If the doctor will not make a recommendation, the next step is to visit a medical cannabis specialist. Medical marijuana dispensaries typically will offer this type of specialist.

Patients who live in a non-legal state cannot obtain medical marijuana from a legal state without risking serious criminal charges for illegal possession, trafficking, or both.

Patients who live in a legal state can obtain medical marijuana from another legal state if they are visiting. Some states accept out-of-state authorizations. It is important to note the acceptance of an out-of-state medical card is entirely up to the dispensary owner’s discretion.

A medical cannabis dispensary should employ an experienced provider. A medical background is a plus, but not always a given, says Carothers. Ideally, the person dispensing has taken a certification course. The dispensary should provide a separate room for discussing the patient’s complete medical history as well as the current medications, activities, and desired outcomes.

Each patient should receive a customized product unique to his or her condition, she explains. Through a medical marijuana dispensary, patients receive more education, pay less, get higher CBD potency, and receive a higher-quality product than if they purchased cannabis through a recreational dispensary, she adds.

“Nurse case managers are on the front lines, in the trenches on every health topic,” says Carothers. “People feel comfortable talking to nurses; they come to us for information. It’s important for case managers to have ready resources that are peer-reviewed, clear, and true.”

The Case Manager’s Role

Hopefully, case managers and physicians will honor and respect their patients’ freedom of choice, says Carothers. “Is it ethical to refuse a request for medical marijuana based on personal views?” she asks. “Surely, compassion is a crucial component of our ethical behavior.”

Case managers should be able to explain the science of medical marijuana, she says, including the risks and benefits of cannabinoids. “We should be able to provide our patients with resources to inform and educate them.”

Also, case managers must be realistic, as patients may self-medicate if they cannot obtain a doctor’s permission. “What is our response going to be? Typically, the adverse effects occur in cannabis-naïve patients who ingest high amounts of THC when taking recreational marijuana. All patients should be made aware of this risk,” she says.

If the patient is pregnant, that risk is higher, Carothers adds. The American Medical Association does not support using cannabis during pregnancy. The patient’s physician should be brought into the conversation.

Examine Biases

It is important to not be judgmental, which is not always easy, says Vivian Campagna, MSN, RN-BC, CCM, chief industry relations officer for The Commission for Case Manager Certification.

“Think about your personal biases, because that is an important aspect of your response to patients,” she says. “Can you be objective and helpful in discussing it with a patient? If you do have a bias, that will inherently override your objectivity and may skew your response toward inaccuracies.”

You must respond to patients’ questions, she advises, with this caveat: “If you feel you can’t objectively answer questions, advise that a co-worker or other knowledgeable person discuss it with the patient.”

Also, learn how the provider feels before entering any conversation with the patient. If the provider is not on board, you risk harming the client-physician relationship, says Campagna. “You have to tread very carefully, as people do have strong feelings about medical marijuana.”

She advises discussing it hypothetically with the physician, without mentioning the patient’s name. “This will help preserve your patient’s relationship with the physician, as well as your own relationship with that physician,” she explains. “We need to have teamwork with providers to be effective, and don’t want to risk alienating the provider or creating an adversarial relationship. It’s a very fine line we have to walk.”

If medical marijuana is illegal in your state, and a patient asks, you have to discuss the laws. “Keep in mind, medical marijuana is still not legal on the federal level. If the patient buys it in a neighboring state, they could face legal action,” says Campagna. “Even if they’re taking a road trip and carrying their legally purchased medical marijuana, there can be legal ramifications. The same holds true with CBD products as well, since they are not allowed in all states.”