Effects of Medical Marijuana on the School Nurse

Introduction

Literature Review

 The topic of medical marijuana is as complex as it is interesting to many people, including physical therapists, caregivers, patients, physicians and other health care providers. This literature review was done using the search terms “Medical Marijuana “, “school nurse”, and “laws” to collect scholarly research articles from no further back than 2012 through 2018, except for the use of Medical Marijuana by Elaine Minamide published in 2007.

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Today, many medicines currently, can trace their pharmacological roots to folk medicine and herbal therapies.  Medicine such as aspirin comes from willow bark, digitalis from foxglove, quinine from cinchona and morphine from opium poppy.  All plant-based medications whose herbal formulae have been around for centuries. Such as marijuana otherwise know as Cannabis sativa, is a naturally occurring substance, a weed growing wild in many parts of the world.  In American history, references to marijuana prescriptions show up as early as 1764 (Minamide, E. 2007, p7).

 Legislators from all over the United States have passed state explicit laws and regulations that influence medical practice and the use of marijuana as a beneficial modality. The Controlled Substances Act (CSA) places all substances which were in some manner regulated under existing federal law into one of five schedules.  This placement is based upon the substance’s medical use, potential for abuse, and safety or dependence liability.  More information can be found in Title 21 United States Code (USC) Controlled Substances Act. As recently as November of 2015, New Jersey became the first state to explicitly allow the supervision of medical marijuana for students and people with developmental disabilities.  The purpose of this literature review is to provide a frame of reference for school nurses and to inspire mindfulness of the implications for student health and pertinent nursing intercessions in the school setting (DeWitt-Parker 2016).

 Not surprising, in 1996, the state of California became the first to legalize the medicinal use of marijuana. According to the National Conference of State Legislatures (2015), 22 other states, including the District of Columbia, have passed legislature to allow marijuana as a therapeutic modality. A review of those state agreements specifies customized orders with a range of pertinent explicit medical conditions permissible for use as well as mechanisms of accessibility of product and other essential conditions.  Therefore, it is imperative that physicians, nurses and all health care personnel be familiar with their state mandates (DeWitt-Parker 2016).

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In 1970, the United States (US) Congress passed what is called Title 21 of the United States Code (USC), the Controlled Substance Act (CSA), as substances in this schedule have no recognized medicinal use but does have a high potential for abuse.  (The Drug Enforcement Administration (DEA) updates this list annually. The CSA makes things complicated for health care professionals, as many are afraid to comply with patient and family requests for physician prescribed marijuana despite state legalized programs.  In addition to this, for school nurses, the National Association of School Nurses (NASN) 2014 position statement on the subject recommends that ‘the marijuana plant remain under the US DEA Schedule I category of the CSA, and that “To date there is not sufficient scientific evidence for U.S. Food and Drug Administration (FDA) to approve the smoked marijuana plant for medical use” (NASN, 2014). It is important for all school nurses, prepared with the information of the CSA, to know their own state medical marijuana laws (if applicable), the pharmacology of medical marijuana, clinical indications for its use, and possible side effects possibly demonstrated by a student who may be eligible to receive physician prescribed marijuana prior to attending school and/or prior to school-sponsored events (DeWitt-Parker 2016).

What classifies as Medical Marijuana- Marijuana refers to the entire marijuana plant, including the leaves, flowers, stems, and seeds from the hemp plant, referred to as Cannabis sativa (National Institutes of Health [NIH], National Institute on Drug Abuse, 2014). The biologically active components of marijuana are tetrahydrocannabinol (THC) and cannabidiol (CBD) (Mayo Clinic, 2013a). The amount of THC, CBD, and other cannabinoid compounds in a given plant strain may be altered by an experienced grower depending on soil, climate, and techniques of cultivation (Rose, 2014). What is believed to happen when you smoke (inhale) or ingest cannabinoid compounds. They are believed to affect cannabinoid receptors (CB1 and CB2) found in the brain to create various pharmacologic responses based on formulation and patient characteristics (Borgelt, Franson, Nussbaum, & Wang, 2013). The endogenous cannabinoid system (ECS) regulates neuronal excitability and inflammation in pain circuits and helps to regulate other physiological processes. Absorption and duration of action differ between the two routes of administration. Indications from various quantifiable studies reveal a patient preference for inhalation based on quick onset of action and relief of symptoms. Smoking cannabis offers an onset of effect within seconds to minutes. In children and in adults for whom smoking is not an option, vaporization may be preferred. Plant cannabis may be mixed into food such as brownies and cookies for example. Due to insufficient water solubility of THC, tea is a less pursued option.

How this affects School Nursing – The arrival of legalized medical marijuana for children is a call for action on the part of school nurses, regardless of which state the nurse is practicing. The initial role for the school nurse around medical marijuana is that of health educator. The school nurse is the expected health expert in the school setting, and as a result students, parents, and administrators, may turn to the nurse to understand these laws. As a health care provider and health educator, the school nurse has the opportunity to safeguard the school community and make sure they are  aware of and recognize the difference between recreational marijuana, which is illegal, and medicinal marijuana, which may also be illegal depending on the state you reside in and is only used for patients for whom standard therapies have been tried and failed. Employing the nursing process to evaluate the student’s classroom and school social atmosphere is key to developing an Individualized Health Plan (IHP) that includes instruments to provide emotional support. Including the student, student’s parents, and registered caregiver in the development of the IHP may encourage ideal application of the plan. A critical role of the school nurse is teamwork with individuals in positions of school management to create the health policies and protocols that will promote the safety of the student registered in the Medical Marijuana Program (MMP). Interdisciplinary association is a major architect for applying policies. The school nurse can impact the policy program from the position as the school staff responsible for writing the student’s IHP. The school nurse’s knowledge about the student’s medical condition and observed response to the therapeutic regimen throughout the student’s school history is influential to creating a policy to best address the requirements in the law. School nurses coordinate and manage the care of students with chronic medical conditions and disorders in the school setting. Medication administration is one of the most common responsibilities of school nurses (NASN, 2012). In contrast to accepted standards and protocols for the administration of medications in the school setting, the medical marijuana administration by the school nurse is neither authorized nor required. Nonetheless, as school nurses maintain the student’s health records, it is appropriate to document the date, time, and location of administration by the caregiver as well as to monitor the student’s response. Tracking the usage and effect demonstrated by the student’s response will be useful data to share with the student’s physician if requested. One of the challenges intrinsic in the use of medical marijuana by a student is the fact that there is no standard dose or percentage of active ingredients. Due to the changing cultivation methods used by the various dispensaries and the uncertainty of the registered caregiver’s preparation method, the school nurse cannot be assured of the actual dose a student receives. Assessment and monitoring for possible side effects will be helpful to determine the student’s capacity to return to the classroom. THC is recognized as the primary psychoactive ingredient. The individual’s response depends on the strain, dose and frequency of use. Most marijuana users do report mild euphoria, sedation, relaxation, and hunger (Borgelt et al., 2013). In addition, users may experience diminished attention, balance, cognition, judgment, memory, and sense of time. Therefore, it is essential for the school nurse to communicate with the parent/caregiver to establish the appropriate IHP actions to enhance the student’s safe return to class and a possible alternative plan if the student exhibits side effects that prevent the return to class. The parent/caregiver will remain onsite with the student and communicate with the school nurse as the effects of the marijuana ensue. An IHP, which recognizes the school nurse’s challenging accountabilities’ effect on the accessibility of the school nurse to withstand prolonged monitoring of the student, may consider including monitoring provided by the parent/caregiver. Teachers may not be aware of the student’s use of medical marijuana if the student requests confidentiality and lacks parental permission to share medical information with school staff. This will require discretion and diplomacy on the part of the school nurse when collaborating with the student’s teacher(s) to preserve privacy

References

• Borgelt, L. M., Franson, K. L., Nussbaum, A. M., & Wang, G. S. (2013). The pharmacological and clinical effects of medical cannabis. Pharmacotherapy, 33(2), 195-209. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23386598
• DEA – United States Drug Enforcement Administration. The Controlled substances act. Retrieved from: https://www.dea.gov/controlled-substances-act
• DeWitt-Parker, C. (2016). Medicinal Use of Marijuana: What School Nurses need to know.  NASN School Nurse. Nurse (Print), 31(3), 170-176. Retrieved from https://ezproxy.eastern.edu:2790/10.1177/1942602X16638815