Cannabis Use in Long-Term Care: An

Emerging Issue for Nurses

Conflicting laws at the state and federal levels put nurses in the middle.

T
he use of cannabis as a medici-
nal agent is a hotly debated and
contentious issue in the United
States. Cannabis has been touted
as a treatment for many condi-
tions, including nausea and anorexia caused
by chemotherapy, AIDS-related wasting,
neuropathic pain, spasticity associated with
multiple sclerosis, and glaucoma. Its use
for medical purposes has enjoyed strong
support among professional health care or-
ganizations and the public at large; 14 states
and the District of Columbia now allow its
use, although regulations and qualifications
vary widely. (The advocacy group Americans
for Safe Access dedicates a site to explain
ingthose laws state by state: http://bit.ly/
gs7hIw.)
Although the U.S. Department of Justice
announced in 2009 that users and distribu-
tors of medical cannabis wouldnt be pur-
sued as long as they followed state laws, the A budtender at Harborside Health Center, a nonprofit medical marijuana dispensary in
Oakland, California, picks out a tray from the display of different cannabis strains. The case
federal government has resisted any change also contains other products for medicinal marijuana patients including baked goods and
to the drugs illegal status at the national hashish. Photo by Robyn Twomey / Redux.
level.
This isnt only an issue of state laws conflicting But this isnt a new issue, and for NORML it
with federal law; even within states that permit began even before the advent of medical cannabis
medical cannabis, the rules about its use in the in- proper, according to St. Pierre. In 1990, he said,
stitutional setting may be hazy. These ill-defined NORML would take calls from organizations that
regulations can put health care professionals in a provided homes away from home for families and
precarious position. And because many nursing patients dealing with painful diseases. In these
homes rely on federal or state funding, there are cases, said St. Pierre, we would have older teen-
unanswered questions as to whether health care agers, who, with their physicians recommenda-
providers can legally provide or administer any tion, wanted to use cannabis on site.
form of medical cannabis to residents. The legal counsels or managers of such organi-
There are issues of loss of licenses and certifi zations were caught between wanting to provide
cations, said Allen St. Pierre, executive director the best possible health care for people at a very
ofthe National Organization for the Reform of difficult time in their lives and trying not to jeop-
Marijuana Laws, or NORML. The idea of a ardize the operation for future clients, given that
Schedule I drug being used or tolerated at a facility this was a clear violation of the law. St. Pierre con-
thats licensed by a state or federal government is tends that the conflictbetween providing good
anathema. health care and breaking the lawhas wrapped

ajn@wolterskluwer.com AJN April 2011 Vol. 111, No. 4 19
 itself around nearly every tier of the health care
industry.
FEDERAL VS. STATE RULES
Cannabis sativa is available in leaf form (known as
marijuana, pot, weed, or reefer) or in various ex-
tracted forms (as hashish or oil) and can be taken in
a variety of ways (smoked, ingested, or vaporized).
Its best known as a recreational drug, although its
medicinal properties have been documented for thou
sands of years. It was legally available in the United
States until the beginning of the 20th century. In 1937
the first federal laws against cannabis use were
passed. (For more on the history of cannabis in the
United States, see A Brief History of Medical
Marijuana in Time: http://bit.ly/3NFI7d.)
Cannabis is currently listed as a Schedule I drug,
which means that the government doesnt recog-
nize any medical value. Despite the federal laws, a
growing number of states are liberalizing their laws
and allowing patients varying degrees of access to
cannabis. Although firm numbers remain some-
what elusive, its believed that the percentage of
older users is growing. If thats true, it would indi-
cate that long-term care facilities will increasingly
have to address the situation. (This year NORML
plans to roll out the NORML Senior Alliance, which
will offer information to older adults about the
medical uses of cannabis.)
One of the main problems is that many state
laws dont specifically address the use of cannabis
in nursing homes and other institutions. For ex
ample, Alaska law doesnt require any facility mon
itored by its Department of Administration to
accommodate cannabis users. In Montana, smok-
ing is prohibited in all health care facilities, but
cannabis may be used in other forms; individual
facilities may set their own rules, including under
what conditions and circumstances cannabis use
would be permitted. Maine, on the other hand,
permits nursing homes and inpatient hospice work
ers to act as registered caregivers for patients using
medical cannabis.
Another pressing concern is that these facilities
often receive federal funding, either directly through
Medicare or indirectly through Medicaid. This
places administrators in an awkward position,
having to choose between complying with federal
law (and maintaining funding) and permitting ac-
cess to cannabis to residents who rely on it.
We may only find out what will happen if a
brave nursing home takes the risk and does the right
thing for its patients, said Mary Lynn Mathre,
MSN, RN, an addiction specialist and president of
the nonprofit group Patients Out of Time. Given
20 AJN April 2011 Vol. 111, No. 4 ajnonline.com
the Obama administrations statement about not
interfering with medical marijuana patients who
are getting legal recommendations from their care
provider, it seems very wrong to not allow nurs-
ing home patients to use it because the facility re-
ceives federal funding. She added that it would
be great to see nursing home administration orga-
nizations pass a formal resolution recognizing this
potential problem and asking the federal govern-
ment to allow patients the option to use this medi-
cine as they would any other medicine.
NURSINGS STANCE ON THE ISSUE
Overall, nursing organizations, including the Amer
ican Nurses Association and more than a dozen
state nursing associations, support supervised ac-
cess to medical cannabis. But if experts are correct,
and the number of older adult cannabis users esca-
lates in nursing homes and assisted living facilities,
nurses may find themselves in a rather unusual sit-
uation. Aside from possibly violating federal drug
laws, there are other issues to consider. Who dis-
penses the cannabis? What is the dosage? How
will the facility obtain it?
California has been a pioneer in exploring
theissue of medicinal cannabis use, having been
the first state in the nation to pass an initiative
that loosened its laws and allowed for medical
usage.
In California, we have laws that protect pa-
tients rights, said Deborah Burger, RN, copresi-
dent of the California Nurses Association (National
Nurses United), which supports the use of medical
cannabis. If patients have been prescribed the med
ication, they should get it. Nurses in those areas
are bound by California law to advocate on behalf
of the patient. And if California nurses have had
problems with it, Burger hasnt heard about it. I
havent heard that there were any issues with nurs-
ing homes refusing to allow patients to use it, she
said.
Sometimes the dont ask, dont tell approach
is the best option, according to Mathre. I can tell
you that many hospice nurses turn a blind eye to can
nabis use in the home because they know it helps.
She explained that during a legislative committee
hearing on a medical cannabis bill in Wisconsin,
anurse who represented her hospice organization
spoke in favor of the legislation and acknowl-
edged the problem that nurses in this situation
face.They may be witnessing illegal activity, but
they pretend not to see or know whats going on
because, in their hearts, they know the patient
benefits from the use of cannabis.Roxanne
Nelson t