Oncology Nurses Help Patients Navigate Medicinal Marijuana Complexities

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Oncology nurses must navigate an increasingly complex web of state medical marijuana laws, with varying provisions and roles for healthcare providers, according to speakers at the Oncology Nursing Society (ONS) 42nd Annual Congress, held May 4–7 in Denver.

“It’s complicated,” said Lisa Kennedy Sheldon, PhD, APRN-BC, AOCNP, of the Dana-Farber Cancer Institute in Boston and chief clinical officer at ONS.

“There are a lot of regulations,” she said. “How do you know what’s standardized? How much do you give people? Side effects and symptoms? And all of this conflicts with federal law.”

The federal government still classifies cannabis as a Schedule I narcotic, meaning that it has no recognized medicinal value and has a high risk of abuse.

This was not always the case, Sheldon said. In the 1800s, physicians routinely dispensed cannabis to help their patients with pain, menstrual cramps, cough, and dozens of other illnesses and conditions.

Following resurgent use in the 1960s in the counterculture and among Vietnam war protestors, President Nixon signed the 1970 Controlled Substances Act, which declared marijuana a Schedule I drug, alongside heroin, as part of the new “war on drugs.”

The US Drug Enforcement Agency has been petitioned five times since 1972 to reschedule marijuana but each request has been denied. California was the first state to legalize medicinal marijuana, in 1996. Today, 25 states have such programs, but their details vary from state to state. Despite such state programs, marijuana remains illegal under federal law, complicating medical research efforts.

Restrictions on clinicians’ roles and inpatient rules for medicinal marijuana vary from state to state and facility to facility, Sheldon cautioned.

Cannabis and cannabinoids are beginning to play a larger role in cancer palliation, and it is important for oncology nurses to better understand associated psychopharmacologic, clinical, and safety issues, said Carey S. Clark, PhD, RN, AHN-BC, associate professor of the University of Maine in Augusta and president-elect of the American Cannabis Nurses Association.

Cannabinoid receptors are found not only in the brain but throughout the body, with roles in bone physiology, inflammation, fat storage, blood pressure regulation, and hormone levels, Clark said.

“Cannabinoids can help with appetite,” Clark said. “Early palliation is really key for treating our cancer patients. Cannabis can help with pain, nausea, sleeping and depression issues, and anxiety.”

Different cannabis strains and products have different levels of the cannabinoids tetrahydrocannabinol (THC) and cannabigerol, and can therefore have different effects, Clark cautioned.

Cannabinoid receptors and the body’s own endocannabinoids are found in pain circuits throughout patients’ bodies, modulating both pain sensitivity (nociception) and inflammation-associated pain.

There is evidence that cannabis can help prevent opioid dose escalation, Clark said.

“Cannabis can be used safely with opiates,” she asserted. “There are very few cannabinoid receptors in the brainstem.”

Oncology nurses should be prepared to inform patients on state laws and how and where patients can safely and legally obtain medicinal marijuana.

“Even in states with medical marijuana, some doctors are still reluctant to recommend cannabis, but hopefully that will change as we get past the fear and stigma associated with it,” she said. “We need to be part of ending the stigma associated with cannabis use-particularly medicinal use.”

Nurses also need to be ready to communicate with patients about the different delivery devices and to caution them about dosing, Clark said.

“I recommend that patients start low and go slow,” she said. “And to be mindful and conscious of the effects they’re having.”

Patients should be advised to keep a diary to log when they consumed cannabis, how much, its effects and any side effects, as well as possible medical interactions, Clark said. It is often up to nurses to learn how best to support and inform their patients.

Common side effects include psychomotor and cognitive impairment, fatigue, dizziness, dry mouth, tachycardia, and dry eyes. Vomiting, sometimes attributed to cannabis hyperemesis syndrome, might actually be caused by contaminants rather than cannabis per se. “You want testing for pesticides, heavy metals, and fungi,” she said.

In part because of the scant clinical research base for marijuana, there are unanswered questions about its safety for patients with cancer, Clark acknowledged. There are suspected THC safety issues for patients with hormone-positive tumors.

Cannabis also can be associated with increased bleeding time and changes in blood glucose and blood pressure, Clark noted. Importantly, it might also affect cytochrome P450 enzyme activity in the liver, and hence drug pharmacokinetics-a potential drug-interaction concern.

And it is important that marijuana be kept away from children and pets.