Lynette W. Jack, PhD RN CARN
Editor's note: This column offers members an opportunity to discuss an issue and present an opinion that is designed to stimulate thinking on the part of our readers. Neither the National Nurses Society on Addictions nor the editors of Perspectives on Addictions Nursing necessarily endorse positions taken by guest column writers but do support the opportunity for varying positions to be heard.
Mary Lynn Mathre, MSN RN CARN
Some addictions nurses have thought of marijuana only as a drug associated with abuse and/or addiction. However, the drug has been documented as having medicinal value. This article examines the medicinal value of marijuana and the history of efforts to prohibit marijuana's use.
The therapeutic value of marijuana
The therapeutic properties of marijuana come from the numerous chemicals found in the leaves, buds, and resin of the cannabis plant. The cannabis plant, commonly called hemp, is also well known for the value of its fiber and pulp from the stalk as well as the highly nutritional seed oil.
The history of marijuana's medicinal use was traced by Mikuriya (1973). The earliest records of medicinal marijuana use have been traced back to China in 2737 BC, and evidence of its therapeutic use can be found throughout world cultures. It was used in colonial America and listed in the U.S. Pharmacopoeia, as tincture of cannabis, until 1941. In the 19th century, William B. O'Shaughnessy, MD, studied marijuana and concluded that it was safe and effective in the treatment of various maladies. The first extensive U.S. study, conducted by the Ohio State Medical Society in 1860, had similar conclusions.
More recently, in 1980, the Institute of Medicine (IOM) of the National Academy of Sciences, at the request of the U.S. Secretary of Health and Human Services and the director of the National Institutes of Health, agreed to conduct a review and analysis of health-related effects of marijuana. IOM's findings recognized marijuana's therapeutic potential in decreasing the intraocular pressure for glaucoma patients, controlling the severe nausea and vomiting associated with chemotherapy, acting as an anticonvulsant, relaxing muscles and thus counteracting spasticity problems, and other uses. The IOM investigators highly recommended further research to determine the full therapeutic potential of this drug. This study also noted that marijuana seems to work differently than other conventional medicines (Institute of Medicine, 1982). The government's response was to print only 300 copies of this study -- not even enough for each member of Congress.
Safety: Numerous studies have been conducted to determine marijuana's toxic level: they have concluded that it would take 20,000 to 40,000 times the normal dose to induce death (Institute of Medicine, 1982: Randall, 1988). Another way of stating this would be that a person would have to ingest (or inhale) 1,500 pounds in 15 minutes. After studying all the evidence, the judge in DPF v. DEA #92-1179 and ACT v. DEA #92-1168 found marijuana to be "one of the safest therapeutically active substances known to man" (Randall, 1989, p. 440). He continued. "One must reasonably conclude that there is accepted safety for use of marijuana under medical supervision. To conclude otherwise, on the record, would be unreasonable, arbitrary and capricious" (Randall, 1989, p. 444).
Addictive potential: In regard to physical dependence from chronic use, marijuana has relatively minor, if any, withdrawal symptoms. Tolerance to natural marijuana develops slowly, if at all. The effects of marijuana are generally more subtle than those of other substances of abuse, such as crack cocaine: often it is considered not strong enough by many addicts and rarely is their drug of choice.
A knowledge of addiction provides the nurse with the understanding that it is not the drug that makes the addict, but rather the negative relationship a person has with a particular drug or drugs. People can become addicted to marijuana just as they can to any other psychoactive drug. Treatment for their addiction should be available to these people. However, the fact remains that marijuana, like many other psychoactive drugs, does have medical value: the fact that some people may have an addiction problem should not prevent others from benefiting from its therapeutic potential. Studies have found opioids to be effective pain management agents, with an addiction rate of less that 1% in hospitalized patients treated for their pain, (McCaffery & Vourakis, 1992).
The prohibition efforts
Under the Controlled Substances Act of 1970, marijuana is a Schedule I controlled drug. This status prohibits its use by anyone and prohibits physicians from prescribing it for patients. Until February 1992, there was a little-known loophole that allowed a handful of patients legal access to this medicine: the Investigational New Drug (IND) Program administered by the Food and Drug Administration. Unfortunately, in February 1992, U.S. Secretary of Health & Human Services Louis Sullivan, MD, closed this access to all new applicants, as well as to more than 30 patients who had been approved for having access to this medicine but had not yet received their supply. Only 10 patients who had been approved and already were receiving their medicine have been allowed continued legal access to this drug.
Various theories attempt to rationalize the government's prohibition of this drug/plant: As an efficient fuel, it presented competition to the oil industry. As a durable natural fiber, it presented competition to the synthetic fiber industry; in fact, Levi's jeans originally were made of hemp. "Reefer madness" hysteria was created in the 1930s by Harry Anslinger of the Bureau of Narcotics and Dangerous Drugs, which eventually evolved into the Drug Enforcement Agency (DEA). Use of the Mexican name of the cannabis plant, marijuana, was popularized by the Hearst newspaper chain to scare the public into believing that there was a new and dangerous drug being introduced to American youth by black musicians and Mexicans. The act of bigotry insinuated that the use of this drug would lead to insanity or acts of violence such as rape or murder. The result of this media blitz was the passage of the Marijuana Tax Act of 1937, which marked the beginning of marijuana's prohibition (Herer, 1991).
The Controlled Substances Act of 1970 completed the prohibition efforts. This act provided five levels of control for psychoactive drugs, with Schedule I drugs under the most restrictions and Schedule V drugs under the fewest restrictions. To be placed in Schedule I, a drug had to meet three criteria: (a) it had to have no therapeutic value, (b) it had to be deemed unsafe for use under a physician's care, and (c) it had to be highly addictive. The DEA was given authority to place drugs in the "appropriate" schedules. the DEA placed marijuana in the Schedule I category, which resulted in the complete prohibition of the growth and use of this plant -- an act that could be seen as politically and medically generated. Marijuana does not appear to meet the criteria for Schedule I.
Responding to prohibition: The National Organization for the Reform of Marijuana Laws (NORML) was founded in 1970 in response to the harsh penalties, including lifetime prison sentences, instituted by a variety of state and federal laws for the possession of marijuana. While NORML's primary focus was to change the legal status of marijuana for all users, the organization also began legal action to allow patients access to its medical use. This legal action has continued for more than 20 years with the assistance of the Alliance for Cannabis Therapeutics (ACT) and the Drug Policy Foundation (DPF). Finally, the lawsuit was brought before the DEA's own chief administrative law judge, Francis Young, with the motion to remove marijuana from the Schedule I category and make it available by prescription. Only two criteria needed to be challenged: (a) that marijuana had medicinal value and (b) that marijuana was safe for therapeutic use. In 1988, after reviewing more than 5,000 pages of evidence, Young ruled that marijuana did meet both criteria, and therefore it must be removed from Schedule I (Randall, 1988, 1989). However, in 1989, DEA Director John Lawn refused to abide by Young's decision and marijuana was kept in Schedule I. More recently, the Physicians' Association for AIDS Care and National Lymphoma Foundation have joined this lawsuit to continue the fight (DPF v. DEA #92-1179 and ACT v. DEA #92-1168).
A political and legal issue or a health issue?
Since the passage of the Controlled Substances Act, 35 states have fought the prohibition of marijuana and have passed legislation recognizing marijuana's therapeutic value (Randall & O'Leary, 1993). In 1991, the city of San Francisco, ravaged by the AIDS epidemic, passed a resolution recognizing marijuana's medicinal value; by 1992, the California Medical Association recognized marijuana's medicinal value and made plans to take its resolution to the American Medical Association to press for a similar national policy. These state and local acts, although will intended, are useless, as the federal prohibition overrides them.
Despite the prohibition of the natural marijuana plant, pharmaceutical companies were allowed to develop a marijuana pill that is composed of delta-9-tetrahydrocannabinol (THC), the main psychoactive chemical in the plant. There are other cannabinoids in this plant that have their own therapeutic action and/or influence the action of others. A plant that can be easily grown and consumed as medicine is Schedule I, while a pill of the main psychoactive chemical contained in that plant can be developed by a pharmaceutical company and sold for profit as a Schedule I drug. Also important to note is that it appears the pharmaceutical industry pressured the government to prohibit university research of marijuana.
The role of addictions nurses
in the medicinal use of marijuana
Addictions nurses understand that no drug is completely safe and that any drug can be abused. Prior to using any medication or drug, the patient should have an understanding of its expected benefits and associated risks so that he or she can make a responsible decision regarding its use.
Nurses are patient advocates. Addictions nurses advocate treatment for addicted people. Addictions nurses also advocate medicinal treatment of life- and sense-threatening illnesses if the medicine improves the quality of life for a patient. Nurses, as healthcare professionals, must honestly and rationally examine this issue, rather than respond to scare tactics and moral judgments about "illegal drug users."
As addictions nurses, we are expected to base our knowledge of drugs of abuse and the disease of addiction on scientific evidence and clinical experience. Advocating legal access to marijuana for patients whose quality of life can be improved through the use of this drug is a moral and ethical obligation we owe the general public, if we are truly serving as patient advocates.
Address correspondence to Mary Lynn Mathre, MSN RN CARN, c/o NNSA, 4101 Lake Boone Trail, Suite 201, Raleigh, NC 27607.
Herer, J. (1991). Hemp and the marijuana conspiracy: The emperor wears no clothes. Van Nuys, CA: Hemp Publishing. Institute of Medicine. (1982). Marijuana and health. Washington, DC: National Academy Press. McCaffery, M., & Vourakis, C. (1992). Assessment and pain relief in chemically dependent patients. Orthopedic Nursing, 11(12), 12-27. Mikuriya, T.H. (Ed.). (1973). Marijuana: Medical Papers 1839-1972. Oakland, CA: Medi-Comp Press. Randall, R.C. (1988). Marijuana, medicine, and the law. Washington, DC: Galen Press. Randall, R.C. (1989). Marijuana as medicine: Initial steps. Washington, DC: Galen Press.
Editor's note: Responses or rebuttals to this column are invited in the form of a letter to the editor. Perspectives on Addictions Nursing reserves the right to select letters for publication and to edit the selected letters to meet clarity, style, and space requirements. Letters should be directed to Christine Vourakis, DNSc RN CARN, Editor, Perspectives on Addictions Nursing, 5700 Old Orchard Road, First Floor, Skokie, IL 60077-1057.
Perspectives on Addictions Nursing / Vol. 4, No. 2 / June 1993