Medicinal cannabis is legal in some form in 47 states, 3 United States territories, and the District of Columbia. An estimated three million Americans use cannabis for relief of a variety of illnesses, and this figure is expected to grow based on policy changes. However, cannabis remains illegal at the federal level as a Schedule I drug under the 1970 Controlled Substances Act. Schedule I classification of cannabis has impeded the advancement of research, leaving providers with little evidence-based information to educate their patients. Furthermore, the disparities in individual state laws create significant social and health inequities in gaining access to medicinal cannabis. Conflicting state and federal policies regarding medicinal cannabis create logistical and ethical dilemmas, and all U.S. stakeholders—patients, providers, and health delivery systems—may be impacted by conflicting federal and state policies. This brief addresses the impact of conflicting cannabis policies.
Keywords: medicinal cannabis, policy, controlled substances, patients, research, Schedule I drugAs of December 2020, medicinal cannabis in some form is legal in 47 states, the District of Columbia, Guam, United States Virgin Islands, and Puerto Rico (National Conference of State Legislatures, 2020). An estimated three million Americans use cannabis for relief of a variety of illnesses (Americans for Safe Access [ASA], 2019a), although this number may not accurately reflect the many Americans using medicinal cannabis without formal authorization from their state. Individual state policies that permit the possession, use, and distribution of cannabis directly conflict with federal cannabis policies that maintain a strict prohibition on most forms of cannabis. Indeed, most cannabis forms remain classified as a Schedule I drug in the United States based on the 1970 Controlled Substances Act (CSA). The exceptions include three types of cannabis: (a) synthetic cannabinoids, such as Nabilone ® and Dronabinol ® , which are Schedule II, (b) a cannabidiol (CBD) oral solution, Epidiolex ® , descheduled in April of 2020 and no longer subject to the CSA, and (c) industrial “hemp” which are strains of Cannabis sativa that contain less than 0.3% delta-9 tetrahydrocannabinol (THC) and are produced in a manner consistent with the laws set forth in the 2018 Farm Bill, which removed “hemp” from the definition of “marijuana” in the CSA.
Medicinal cannabis comes in many forms including dried flower, tinctures, edibles, vaporizations, patches, and rubs. The cannabis plant contains dozens of phytocannabinoids that interact in various ways with the body’s endocannabinoid system. The most commonly studied phytocannabinoids are THC and CBD. THC has been manufactured in a synthetic form as Nabilone ® and Dronabinol ® . CBD has been reported to have a number of therapeutic properties, but no psychoactive effects. Strains of cannabis with high concentrations of CBD and less than 0.3% THC are termed “hemp” and are no longer included in the CSA’s definition of “marijuana.” For more information about these medications, please refer to the national nursing guidelines published in 2018 (Russell et al., 2018).
Schedule I classification of cannabis has impeded the advancement of research (National Academies of Sciences, Engineering, and Medicine [NASEM], 2017). The current regulatory barriers inhibit researchers from examining key public health questions regarding the therapeutic and adverse effects of cannabis. The lack of randomized control trials and other high-quality scientific evidence in the United States leaves health care providers with little information with which to educate their patients. Lack of research has resulted in limited evidence regarding the safety and efficacy of medicinal cannabis. This policy brief examines the impact of conflicting cannabis policies on patients, providers, and hospital delivery systems.
The C. Sativa plant has been used as a therapeutic agent for more than five millennia, being introduced as folk medicine in China during the Neolithic period, around 4000 BC (Ben Amar, 2006). The first documentation of C. Sativa’s therapeutic properties was in 2737 BC by the Chinese Emperor Shen-Nung. The plant then migrated from China to India, and to Egypt, Persia, Syria, and Greece (Bostwick, 2012). The drug was introduced to Western medicine in 1839 by the British physician William O’Shaughnessy after which physicians throughout Europe and the United States began prescribing the drug, noting its anticonvulsive, analgesic, anxiolytic, and antiemetic properties (Bostwick, 2012).
The cannabis plant was listed in the U.S. Dispensatory in 1854 (Ben Amar, 2006). It was compounded into tinctures, extracts, cigarettes, and plasters and commonly used across Western countries for ailments including asthma, anorexia, insomnia, whooping cough, and sexual dysfunction (Bostwick, 2012). Cannabis continued to be prescribed in the United States for decades until the 1930s when hysteria in the popular press, amplified by movies such as Reefer Madness, led many Americans to believe the drug could “induce user insanity and incite societal mayhem, pg 181” (Bostwick, 2012). Many contend that this hysteria predominately arose from the western and southwestern states who associated its use with Mexican migrant workers (Musto, 1972) and “Negro” jazz musicians (Mason et al., 2012). This frenzy led Congress to pass the Marihuana Tax Act of 1937 that taxed cannabis for prescription and nonprescription use (Ben Amar, 2006). This congressional act was passed despite strong opposition from the American Medical Association (Aggarwal et al., 2009). In 1942, cannabis lost its legitimacy as a therapeutic drug when it was officially removed from the U.S. dispensary (Ben Amar, 2006; Bostwick, 2012). In 1971, cannabis was placed in Schedule I and possession was criminalized by the CSA.
In June 1971, President Nixon declared a “war on drugs,” increasing the size and presence of federal drug control agencies. The U.S. war on drugs escalated over the following decades with sanctioning of multiple policing strategies including mandatory sentencing, stop-and-frisk, and no-knock warrants. These policies have disproportionately affected racial/ethnic minority communities. For example, Black Americans are nearly 4 times more likely to be arrested for cannabis possession then their White counterparts (Edwards et al., 2013). Furthermore, Black and Latinx households are disproportionately targeted by SWAT teams (American Civil Liberties Union, 2014), often resulting in violence. Social movements, such as Black Lives Matter, have formed to challenge aggressive police tactics, particularly those targeting Black communities (Cooper, 2015; Joseph, 2020). However, movements to end police brutality are often overwhelmed by the structural power and cultural hysteria of the war on drugs (Joseph, 2020).
Recent research into the human endocannabinoid system has renewed interest in the potential therapeutic benefits of cannabis. The cannabinoids, which are a diverse group of chemical compounds found in the human body and the cannabis plant, have been shown to have antioxidant and neuroprotective properties (Hampson et al., 2003). A NASEM (2017) report concluded that there is sufficient evidence demonstrating that cannabis has modest therapeutic effects for chemotherapy-induced nausea and vomiting, chronic pain, and multiple sclerosis-related spasticity (NASEM, 2017), and more recent evidence exists for pediatric epilepsy (Devinsky et al., 2017). However, research in the United States and most European countries remains limited by several important factors.
The classification of cannabis as a Schedule I drug has significant implications for researchers examining the potential therapeutic and adverse effects of cannabis. To perform a randomized control trial, a researcher must obtain multiple approvals from the National Institute of Drug Abuse (NIDA), U.S Food and Drug Administration (FDA), Drug Enforcement Administration (DEA), and the Department of Health and Human Services, in addition to a Schedule I license for this research. The researcher must then request cannabis from the only DEA-licensed cannabis farm in the United States, housed at the University of Mississippi. Moreover, academic researchers are prohibited by federal law from using any commercially available cannabis products in their research. As illustrated by the NASEM (2017) report, there were between 498,170 to 721,599 units of medicinal and recreational edibles sold in Colorado per month in 2015. However, federal law prohibits scientists from testing these products for contaminants, assessing their effects in animal models, or investigating their safety and efficacy in patient populations (NASEM, 2017). To further complicate matters, the cannabis grown at the University of Mississippi has been criticized for its low percentage of THC (8%), which is far lower than most available strains in the retail markets (16%–23% THC) (Hellerman, 2017). In addition, there have been reports that the University of Mississippi’s cannabis has high levels of yeast and mold (Hellerman, 2017), raising concern for its safety in human subjects and suggest the need for federal testing standards.
In an effort to meet the growing demands for NIDA-approved cannabis for research, in 2016, the DEA now evaluates new applications for entities to cultivate cannabis for research (Drug Enforcement Administration [DEA], 2016a). However, as of 2019, no application had been reviewed, prompting one applicant (Scottsdale Research Institute) to file a lawsuit against the DEA (Miller, 2020). In response, the DEA said it would evaluate the pending applications, but only after proposing rules for administering the growing program, which were released in March of 2020 (Miller, 2020). In part, this delay is due to the DEA’s obligations under the Single Convention on Narcotic Drugs. Further inhibiting cannabis research is the relative lack of funding. In the United States, cannabis research is largely funded by NIDA, whose mission is to “advance science on the causes and consequences of drug use and addiction” rather than support research into the potential therapeutic benefits of drugs (NASEM, 2017). As a result and consistent with NIDA’s mission, less than one fifth of cannabis research funded by NIDA concerns the therapeutic properties of cannabinoids (NASEM, 2017).
The lack of scientific evidence regarding the efficacy and safety of cannabis has left many health care providers reluctant to recommend or guide patients on the use of medicinal cannabis. At least one study found that nearly all patients wanted more information about medicinal cannabis from their health care providers; however, the majority of patients received information from sources outside the health care system (Pergam et al., 2017). Without the guidance of sound research, patients often use friends/family, social media, cannabis dispensaries, and cannabis advocacy groups to learn about dosage and administration of medicinal cannabis (Pergam et al., 2017). While information sharing is important for naïve medicinal cannabis users, it also presents the possibility of misinformation and false information.
Conflicting cannabis policies create significant logistical and ethical dilemmas in the health care system. All stakeholders in the U.S. health care system may be impacted by conflicting federal and state policies. This brief addresses each stakeholder group individually.
Currently, medicinal cannabis use in the United States is restricted by geographical location and socioeconomic status. Only individuals living in states where medicinal cannabis is legal, and who have sufficient means to purchase medicinal cannabis, have access. This current regulatory system creates significant social and health inequities in gaining access to medicinal cannabis.
By way of example, posttraumatic stress disorder is a qualifying condition for medicinal cannabis in many states; however, Veterans Affairs’ (VA) nurse practitioners and physicians are prohibited from completing forms or registering veterans for participation in state-approved marijuana programs. Therefore, veterans without private insurance must pay costly out-of-pocket fees to see non-VA providers to obtain a medicinal cannabis recommendation. This cost may prohibit some individuals from obtaining cannabis for conditions that may benefit from cannabis use. Furthermore, if a veteran is admitted to a VA hospital, she/he will not be able to continue their medicinal cannabis use because “possession of cannabis, even for authorized medicinal reasons, while on VA property is in violation of federal law 38 CFR 1.218(a)(7) and places the veteran at risk for prosecution under the Controlled Substances Act, 21 U.S.C 801 et. al.” (Department of Veterans Affairs, 2017, p. 3).
Other aspects of conflicting cannabis policies contribute to social inequity. State-level cannabis policies often are idiosyncratic and contradictory. Conditions that would qualify a patient for medicinal cannabis in one state may not qualify them in other. For example, only four states allow the use of cannabis to treat medication-resistant opioid addiction, and only eight states allow nurse practitioners to certify a patient for medicinal cannabis (Gowen et al., 2018). These restrictions may limit access in rural and low socioeconomic communities who often rely on nurse practitioners as their primary providers. Only six states have included antidiscrimination legislation into their cannabis acts. California, Washington, Illinois, Arizona, Delaware, and New Hampshire have expanded their medicinal cannabis bills to include antidiscriminatory sections, designed to protect medicinal cannabis patients. In all other states, a patient’s medicinal cannabis use may be used to preclude them from employment and housing and can prohibit them from potential medical therapies and procedures, including organ transplantation (Ryan et al., 2019). These are all examples of health inequality between patients in various geographical locations.
Conflicting cannabis policies place patients and their families at risk of prosecution. At the federal level, patients and their families are at risk of prosecution for use or distribution of a Schedule I drug. For example, parents who provide cannabis to their child are subject to 10 years of imprisonment and $500,000 fine for administering a Schedule I drug to a minor. There is at least one report of parents being arrested in Georgia for allowing their adolescent son to use cannabis for relief of seizures (Victor, 2018). The rights of patients using medicinal cannabis remains unclear, and many patients suffer discrimination in employment, child custody, housing, public accommodation, education, and medical care (ASA, 2019b). Previously, the Department of Justice (DOJ), through the Ogden and Cole memos, provided instructions for all State Attorneys General not to focus their efforts on prosecuting individuals possessing, cultivating, or distributing cannabis in accordance with their state’s laws. However, these instructions were rescinded by the Attorney General at the time, Jefferson Sessions (Sessions, 2018). And to further confusion, the Rohrabacher–Farr amendment, part of the omnibus spending bill passed annually by Congress, denies funding for the prosecution of those acting within their state’s laws; however, the interpretation of this amendment has been challenged. In short, conflicting policies have created a gray zone where it is unclear the extent to which the DOJ will prosecute individuals using medicinal cannabis.
Individuals using medicinal cannabis may face prosecution in their individual states. Although medicinal cannabis is fully legal in 34 states, it remains prohibited in 16 states, and in most legal states, only those with medicinal cannabis licenses/registrations are given the protections under state laws. Parents who provide medicinal cannabis to their children are at the greatest risk of prosecution, as this behavior may be considered child abuse. This form of prosecution is particularly important for pediatric health care providers who are mandated to report child abuse. Parents may choose not to disclose the use of cannabis for their child to health care providers, due to fears that disclosure would lead to reporting, prosecution, and loss of custody. This creates distrust between the patient and provider, hinders the patient–provider relationship, and results in an incomplete medical history.
Besides fear of prosecution, patients may not disclose their medicinal cannabis use to health care providers because of stigmatization. Adult medicinal cannabis users have reported significant stigma related to their cannabis use (Ryan & Sharts-Hopko, 2017). Illicit drug use is associated with a high degree of stigma from health care providers in a variety of settings (Room, 2005). Patients may choose not to disclose their medicinal cannabis use to a health care provider due to concerns they will be stigmatized or labeled a “drug addict”. This can fracture the patient–provider relationship, lead to an incomplete medical history, and cause unnecessary harm to the patient.
The variability in state policies can also cause inadvertent harm to patients through a lack of product and consumer safety protocols. Each year, ASA analyzes and grades all state medicinal cannabis policies and found that many states lack sufficient safety protocols such as potency/compound identification and required laboratory testing for contaminants (ASA, 2019a). Contaminant testing is particularly important for patients who are immunocompromised. The ASA (2019a) found significant variability in state consumer safety protocols with some states such as Washington, Ohio, Oregon, and Maryland having near-perfect scores and many other states having no score due to complete lack of consumer safety protocols. Nurses and patients should be aware of their states’ policies and protocols for safely cultivating and dispensing medicinal cannabis.
Health care providers are often undereducated about the endocannabinoid system and the role it may play in health care. This leaves registered nurses (RNs) and advance practice registered nurses (APRNs) unable to advise patients who ask about cannabis as a form of treatment. Some states provide training for health care professionals seeking to learn more about medicinal cannabis (Carlini et al., 2017), but these courses are often optional and have significant costs. To address this dearth in education, the National Council of the State Boards of Nursing (NCSBN) published guidelines in 2018. They provide recommendations for practicing RNs/APRNs and schools of nursing regarding curriculum development to promote safe and knowledgeable care of patients using medicinal cannabis. Several important recommendations are summarized in the following (Russell et al., 2018). Despite these detailed recommendations, it is unknown if nursing schools are adopting these recommendations and incorporating cannabis education into curriculum.
All nursing students and all practicing RNs and APRNS should have a working knowledge of their individual state’s medicinal and recreational cannabis laws and policies. Significant variability exists between the intricacies of state policies, and all nurses should be familiar with those details. Furthermore, all nurses should understand the federal cannabis laws and how these laws have prohibited research.
All nurses and nursing students should be familiar with general medicinal cannabis policies. In most states, a process has been established for patients to develop a relationship with a provider who can verify that the patient meets criteria for medicinal cannabis, as defined by that state, and can then recommend cannabis. The patient may then have to register with the state to obtain a license. Procurement and administration are the responsibility of the patient and/or the patient’s designated caregiver. Some medicinal cannabis laws allow employees of hospices, nursing or medicinal facilities, or a visiting nurse, personal care attendant, or home health aide to act as a designated caregiver.
All nurses should have a general understanding of the endocannabinoid system, cannabinoid receptors, cannabinoids, and the interactions between them.
All nurses should have a general understanding of cannabis pharmacology and research associated with medicinal cannabis. This is challenging given the restrictions on research. Nurses should have knowledge of the moderate to high-quality research showing therapeutic benefit for qualifying conditions. They should have knowledge of adverse effects and drug interactions. APRN students and practicing APRNs should understand the principles of dosage titration. All nurses should understand risks to certain patient populations such as children and adolescents, pregnant women, and those with mental illness or substance use disorders. Nurses should be familiar with different cannabis products and routes of administration.
Nurses should be able to identify safety considerations for patients using cannabis, including storage considerations and appropriate disposal.
Nurses should not administer cannabis to a patient unless specifically authorized by their state’s law. Nurses should be familiar with the instances in which they may administer cannabis or synthetic THC to a patient.
Nurses have an ethical responsibility to approach patients without judgment regarding this choice of treatment or preferences for managing distressing symptoms. Nurses should be aware of their own beliefs and attitudes.
APRNs have further responsibilities when caring for medicinal cannabis patients including, but not limited to, a review of a patient’s mental health and alcohol and substance history; knowledge and recognition of the signs and symptoms of cannabis use disorder; completing a thorough medication reconciliation; and determine ongoing monitoring and evaluation of the patient. All APRNs should be familiar with their state’s medicinal cannabis laws as to whether they can recommend medicinal cannabis and whether a specific course or training is required.
Hospital systems are often unsure how to handle conflicting state and federal policies when it comes to allowing cannabis inside the acute care setting. Some states’ legislations permit hospitals to dispense cannabis while others do not. In states where hospitals allow cannabis use associations, such as the Minnesota Hospital Association, multidisciplinary committees have been formed to create policies, with templates available online (Durkin, 2017). It is important that development of these policies come from a multidisciplinary team including physicians, pharmacists, nurses, legal counsel, and representatives from external agencies (such as drug diversion and professional boards). An official cannabis policy which clearly states the roles and responsibilities of health care providers in the institution can help to ease concerns of licensed professionals working in the institution.
Even in states where medicinal cannabis is legal, many hospitals prohibit the use of cannabis due to concerns of losing Centers for Medicare and Medicaid Services certification and reimbursement. This is problematic for patients with chronic illnesses who routinely use medicinal cannabis and are frequently hospitalized. In the hospital, the patient may have to substitute cannabis for other pharmaceutical products to manage distressing symptoms.
Hospitals are also unsure how to develop or modify policies regarding employee drug use. In most health care systems, employees are routinely tested for all illicit drugs prior to employment. Impairment of a nursing professional while providing care can result in serious injury to patients and presents a potential for public harm. Impairment from cannabis use is subjective, and current laboratory testing cannot provide an accurate objective threshold that establishes impairment based on specific levels of THC or THC metabolites (Compton, 2017). This creates a challenge for many populations, but particularly for nurses and other health care providers whose licensing is monitored by state boards. To address this issue, the NCSBN provided guidelines for state boards of nursing; however, those guidelines are not publicly available. The NCSBN did release a presentation in which parts of those guidelines were reported. The NCSBN recognizes that current laboratory testing cannot detect impairment and that a case-by-case approach is often warranted considering factors such as state legality, aggravating and mitigating circumstances, and allegations of impairment.
A significant part of the medicinal cannabis debate centers around the classification of cannabis as a Schedule I drug. The debate should focus on rescheduling. There have been several petitions for rescheduling, which have all been denied by the DEA. The most recent DEA (2016b) rescheduling denial cites a lack of scientific evidence as the primary reason for maintaining Schedule I status. As stated prior, scheduling classification has greatly prohibited research. This, therefore, creates a paradoxical situation wherein research is inhibited by scheduling, and accurate scheduling is inhibited by a lack of research.
Several professional health care organizations, including the American Nurses Association (2016) and the American Academy of Pediatrics (2015), have recommended reclassifying cannabis to Schedule II. The American College of Physicians, American Medical Association, and NASEM have recommended a review of cannabis’s Schedule I status. The American Cannabis Nurses Association has recommended establishing a new cannabis-only schedule (Schedule VI) to accommodate all cannabis products. Most professional health organizations agree that more well-designed clinical trials are needed, and thus, barriers to federally funded “gold standard” research design should be addressed.
There are two ways to reschedule cannabis in the United States; one is through the executive branch (DOJ and DEA), and the other is through the legislative branch (U.S. Congress). DEA petitions for rescheduling have all been denied for lack of scientific research, and this conclusion is unlikely to change. Furthermore, even with more available research, DEA scheduling evaluations take many years. The most recent DEA denial for rescheduling was completed and published in 2016, 7 years after the petition was filed in 2009.
The United States Congress could pass a law amending the CSA to transfer cannabis to another schedule. Dozens of bills have been introduced to the House of Representatives (HR) and the Senate (S) which address cannabis regulation, but only few address rescheduling and research. As of May 2020, several bills, including HR 747, HR 712, HR 601, HR 127, and S 179, would expand access to cannabis for research and decrease liabilities for institutions performing research, mostly through the VA system. Only one bill, HR 171, would reschedule cannabis, and bills HR 420, S 420, and S 2227 would remove it altogether from the CSA. It is important to note that although dozens of cannabis regulation bills have been filed, most do not make it past committee approval and are never introduced to the House or Senate floor. However, with increasing national support for cannabis, and demands from a growing industry, politicians may face increasing pressure to change federal policy.
In accordance with the endorsements of the American Nurses Association, we recommend reclassification of cannabis to Schedule II to allow for research into the therapeutic and adverse effects of cannabis. Furthermore, we support the expansion of NIDA and other funding for research examining the therapeutic potential of the cannabinoids with a wider range of cannabis products. We concur with the NCSBN’s guidelines for nurses and recommend that all schools of nursing incorporate medicinal cannabis education into their curriculum. We support continuing education classes for all RNs and APRNs which address the topics presented in the NCSBN guidelines. Finally, we recommend that current and future cannabis policies reflect a need for inclusion and diversity so that racial/ethnic minorities, those in lower socioeconomic statuses, and other marginalized populations are provided equal access.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The development of this article was supported by research grants NR016914, R01AA025684, R01CA212517, R01DA036541, and R01DA043696 from the National Institute of Nursing Research, National Institute on Alcohol Abuse and Alcoholism, National Cancer Institute, and National Institute on Drug Abuse. The funders had no role in the preparation, review, or approval of the article. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research, National Institute on Alcohol Abuse and Alcoholism, National Cancer Institute, National Institute on Drug Abuse, or the National Institutes of Health, or the U.S. Government. The Center for Health Policy and Media Engagement at the George Washington University School of Nursing provided support for this Issue Briefs.
Jennie E. Ryan, PhD, CPNP-AC, is an Assistant Professor at Thomas Jefferson University. She earned her PhD at Villanova University and completed a post-doctoral research fellowship at the University of Michigan. Her research interests include medical cannabis, cannabis policy, harm reduction, health disparities, and child and adolescent health.
Sean Esteban McCabe, PhD, MDW, is the Director of the Center for the Study of Drugs, Alcohol, Smoking and Health (DASH) in the School of Nursing at the University of Michigan. His clinical background is in treating adolescents, young adults and adults with substance use disorders. His interests in research include the epidemiology of substance use disorders, prescription medication use and misuse, sexual orientation, and survey methodology.
Carol J. Boyd, PhD, MSN, FIAAN, FAAN, is the Co-Director of the Center for the Study of Drugs, Alcohol, Smoking and Health (DASH). In addition to her position as the Deborah J Oakley Collegiate Professor Emerita in the School of Nursing, Dr. Boyd also holds U-M appointments as Professor Emerita, Women’s Studies, LSA; Research Professor Emerita, Addiction Center, Department of Psychiatry; and Research Professor Emerita, Institute for Research on Women & Gender. Her current program of research focuses on examining the relationship among gender, health and drug, alcohol and nicotine use.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.