Pay attention to contradictory and evolving state and federal regulations to protect patients and your practice.

A physician authorizes medical cannabis for an 18-year-old student with a long-standing illness that hasn’t responded to conventional treatment. The student lives in a college dorm in a state where cannabis is legal for recreational use by anyone over 21 and also by minors with guardian approval. However, campus policy prohibits the use and storage of cannabis.

The student visits the college health center to ask for guidance. Health center staff tell him that his parents will need to store the cannabis for him, drive several hours across the state to pick him up each time he needs it, and then take him off campus to use it. The student’s family struggles to respond as their child ponders the risk of engaging in activities deemed legal in one context but illegal in another.

This case, which a parent reported to me in 2017, reflects the challenges many nurse practitioners confront while navigating the field of cannabis healthcare.

Marijuana reclassification

In April 2024, the federal government announced plans to reclassify marijuana from Schedule I to Schedule III under the Controlled Substances Act (CSA). In a notice of proposed rulemaking, the Drug Enforcement Administration (DEA) and the Department of Justice described this change as “consistent with the view of the Department of Health and Human Services (HHS) that marijuana has a currently accepted medical use as well as HHS’s views about marijuana’s abuse potential and level of physical or psychological dependence.”

After a now-closed, 2-month review for public comment, the DEA will determine the need for further hearings to address matters of fact or law. Any change to federal law will take place after several federal agencies, including the Food and Drug Administration and other regulatory agencies, harmonize codes and standards. A shift from Schedule I to Schedule III maintains marijuana as a controlled substance subject to federal rules and regulations but will significantly change the current landscape of marijuana policy and practice, with the expectation that it will expand the opportunity for long-awaited and much-needed clinical research.

In 2023, the American Nurses Association announced the recognition of cannabis nursing as a specialty. Soon, a plethora of educational programs emerged, ranging from hour-long clinical courses to master’s degrees in medical cannabis science and business. The interest in this area remains clear with more than 20 million results returned for a Google search using the keywords “continuing education,” “medical mar­i­juana”, and “nursing.”

The association recently released policy guidelines in Cannabis Nursing: Scope and Standards of Practice and the National Council of State Boards of Nursing (NCSBN) has issued standards of practice for nursing. No formal certifications currently exist for marijuana-related nursing practice, and diverse educational offerings may proliferate online without clear, consistent safeguards on quality and content.

High levels of variability in language and concepts have plagued the study and practice of marijuana-related healthcare, as has the extraordinarily uneven legal and regulatory landscape. Nurses must understand not only the clinical expertise required to enter this emerging area but also the history of research, policy, and politics.

As the account of the college student demonstrates, nurses must recognize that marijuana isn’t simply an opportunity for new forms of clinical credentialing and educational marketing. It’s a complex subject of evolving and sometimes contradictory ideological, research, political, and regulatory action.

U.S. marijuana history

The history of marijuana, which hasn’t always been illegal in the United States, includes complicated political agendas and overtones. Law policy analyst Tess Chaffee notes that as early as 1937, the federal “Marihuana Tax Act” imposed steep taxes and administrative restrictions on commerce involving marijuana, but it wasn’t actually illegal until 1970, when Congress passed The Federal Comprehensive Drug Abuse Prevention and Control Act, also known as the Controlled Substances Act (CSA). Subjecting marijuana sales to rules governing interstate commerce, the CSA imposed a novel legal structure, which categorized drugs within the now-familiar “schedule” format and established penalties for specific violations.

Alongside heroin and LSD, marijuana was placed in Schedule I because of what many described at that time as a high potential for abuse, lack of known medical applicability in therapy or treatment, and a dearth of clinical safety data. However, disagreements and conflicts quickly emerged.

In March 1972, the Shafer Commission, a federal-level scientific committee tasked with evaluating the safety of marijuana, advised that it presented no more danger than alcohol. Members of the commission endorsed a public health approach rather than prohibition. The attorney general at that time opted to maintain marijuana’s Schedule I designation despite commission recommendations.

In 2016, an investigation published in Scientific American detailed the potential that political rather than clinical considerations influenced this stance. A historian discovered documents suggesting that federal officials at the time aimed to link marijuana use with the antiwar movement so that law enforcement could use criminalization as a strategy for pursuing and damaging political activists.

The legal code: State and federal disconnect

For decades, profound legal contradictions have plagued marijuana jurisdiction policies. The current proposed policy change aims to address these issues. Because the Sixth Amendment of the U.S. Constitution establishes that federal laws supersede state laws, the Schedule I classification of marijuana applies to everyone. At the same time, however, the Tenth Amendment strictly limits which state laws the federal government can preempt. This amendment prevents using state agents to enforce a federal-level law.

This paradox has enabled citizens in some states to use medicinal cannabis even though it’s federally illegal. It also means that federal law isn’t violated if state workers only administer licenses to private companies and don’t directly participate in the cultivation or sale of marijuana.

State variations

In 1996, California became the first state to pass a proposition legalizing cannabis for medicinal purposes. In February 2024, the Centers for Disease Control and Prevention noted that 47 states, the District of Columbia, and three U.S. territories (Guam, Puerto Rico, and the U.S. Virgin Islands) now allow cannabis use for medicinal purposes. However, policies in each of these jurisdictions vary in their scope with regard to the range of allowable qualifying medical conditions and the substance concentrations permitted. In some cases, state laws have resulted from legislative or executive actions and in others from direct popular ballot vote.

Decriminalization

Thirty states have laws allowing marijuana use for recreational purposes. Adding to the confusion, some states have “decriminalized” possession of marijuana, but without formal legalization. Until the federal government formally writes, enacts, and promulgates a policy approach, and as regional and state rules and enabling legal language evolve, nurses in every state must stay informed about ongoing developments in their own communities.

Prescribing

In states that permit medical cannabis, patients must obtain a professional recommendation for use, and a provider authorized to prescribe controlled substances must certify that the patient has a state-qualifying condition. Physicians and advanced practice RNs (APRNs) with full prescriptive authority still can’t prescribe cannabis and are permitted only to certify the patient’s qualifying condition. However, the ability of APRNs to certify a patient also depends on individual state regulation, with some granting this authority only to physicians.

State registries monitor all patients and providers, but registry content varies across states because no federal rules apply. Permissible forms of advertising and product labeling also differ across states.

Location and payment

Perhaps most confusing of all, the contradiction between state and federal policy has created a patchwork of forbidden locations for marijuana use, even in states where marijuana is legal. In federally owned or subsidized public housing units for low-income residents, for example, cannabis is forbidden if they’re operated by or for the federal government.

Real estate law experts have argued that such policy contradictions create a two-tier system in which low-income Americans face marijuana-related rules and consequences different from those encountered by more affluent Americans. In addition, even in cannabis-friendly states, sales remain a cash-only business because checks and credit cards involve interstate transactions banned by federal law.

Colleges and universities

Most universities (private and public) receive money through various federal government grant programs or loans supporting research, training, or student tuition assistance. Receipt of this funding subjects them to federal restrictions, including the 1986 Drug-Free Schools and Communities Act, which regulates illicit drug and alcohol use in educational settings.

The 1989 amended law requires educational institutions receiving federal funds to implement measures preventing possession, use, or distribution of illicit drugs and alcohol. Allowing medicinal cannabis on campus could potentially lead to loss of important funding sources.

Terminology and research contradictions

Research also contains a patchwork of contradictions, and terminology impacts the results of online searches for published evidence. For example, a PubMed search in early 2024 yielded more than 14,000 results for medical marijuana, but the evidence for whether marijuana heals or harms varied depending on the keywords. For instance, different results occur when using “medical” or “medicinal” and “marijuana” or “cannabis.” How many states allow marijuana depends on what’s meant by “allow,” and the population enabled to access marijuana varies depending on what’s meant by “access.”

Substance name

The name of the substance varies within the literature. Technically, cannabis refers to the plant, Cannabis sativa, and all products derived from it; marijuana refers to parts from that same plant containing large amounts of tetra­hy­dro­cannabinol (THC), marijuana’s psychoactive ingredient. Many use “cannabis” and “marijuana” interchangeably, including among branches of different state governments and federal agencies.

Widespread reliance on popular lay language further complicates clinical communication about marijuana; research shows differences in level of psychoactive effect based on parts of the plant and how they’re processed. For example, cannabidiol (CBD) oils don’t contain the same range of psychoactive materials found in smokeable forms of marijuana, even though they’re also derived from the cannabis plant. Research also suggests that a great deal of complexity exists among the many kinds of materials derived from different parts of the plant.

Evidence

Several healthcare organizations—including the American Nurses Association, the American Academy of Family Physicians, and the National Academy of Medicine—have issued policy statements cautiously supporting the use of medicinal cannabis for various conditions. These groups acknowledge a dearth of evidence regarding tolerability, efficacy, and safety of various medicinal cannabis formulations.

Because of marijuana’s long-standing designation as a Schedule I substance, research to assess therapeutic merit has proved difficult to perform; the National Institute on Drug Abuse strictly controls distribution of marijuana for research. Even the American Medical Association, which hasn’t explicitly advocated for the use of medicinal marijuana, strongly criticized the long-standing federal prohibitions that discourage clinical trials and other forms of serious medical research.

Several medical researchers have suggested the existence of a funding bias that directs most government backing toward studies exploring harms rather than potential therapeutic effects of marijuana. However, data suggest that nearly 3 million patients enrolled in medical marijuana programs in 2020, an increase of more than 300% from 2016.

In a 2019 study of personal use practices, Boehnke and colleagues found that for over 80% of patient-reported qualifying conditions, patients achieved some level of therapeutic effectiveness. The patients most frequently reported chronic pain as the qualifying condition; however, the authors also found that a substantial number of patients reported qualifying conditions for which little or no scientifically documented medicinal effectiveness exists. They observed that many ailments listed as “qualifying conditions” under some state laws include disorders (such as anxiety, cancer, irritable bowel disease, and posttraumatic stress disorder) for which insufficient or no evidence of therapeutic value exists.

In 2019, legal scholars Tilburg, Hodge, and Gourdet called attention to significant variability among states in the qualifying conditions of eligibility for medicinal marijuana use, the types of cannabis-based or cannabis-infused products that may be sold or accessed, the approved dosing parameters, and the range of formulations for products permitted to contain THC. This presents a serious concern; clinicians find it difficult to have meaningful discussions with patients in the absence of an adequate and well-developed body of systematic research data. For this reason, a policy shift enabling further research presents benefits for nursing policy and practice.

The real work lies ahead

The legal, regulatory, and policy landscape of marijuana remains extraordinarily complex and rapidly evolving. Federal policy change could help resolve much of the confusion. However, clinical research remains seriously underdeveloped, reflecting a legacy of restrictions that have discouraged the advancement of marijuana science. This means that, for now and the near future, both patients and providers may have to rely on medically untrained marijuana dispensary staff to explain the available product options and guide patient healthcare choices. It also means that families must struggle to make complex ethical decisions.

As cannabis educational programs increase, we need to avoid putting the cart before the horse. Educational programs focused on the intricacies of the endocannabinoid system offer value, but in light of the current state of science and the patchwork nature of existing policy, these programs may not prove sufficient as a basis for informed discussions with patients. Nurses and nurse practitioners can and should play a significant role in what will soon become a major expansion in marijuana science and policy. The real work lies ahead; it will require much more than signing up for a training.

This article does not serve as legal advice. Please consult an attorney regarding state and federal laws applicable to your practice.

Frances Maynard is an associate professor at Rutgers University in Newark, New Jersey.

References

American Academy of Family Physicians. Marijuana and cannabinoids: Health, research and regulatory considerations. July 2019. aafp.org/about/policies/all/marijuana-position-paper.html#:~:text=Research%20Considerations,expands%20beyond%20institutional%20review%20boards

American Nurses Association. ANA officially recognizes cannabis nursing as a specialty nursing practice September 27,2023. nursingworld.org/news/news-releases/2023/ana-officially-recognizes-cannabis-nursing-as-a-specialty-nursing-practice

ANA Ethics Advisory Board. ANA position statement: Therapeutic use of marijuana and related cannabinoids. Online J Issues Nurs. 2022;27(1). ojin.nursingworld.org/table-of-contents/volume-27-2022/number-1-january-2022/therapeutic-use-of-marijuana

Boehnke KF, Dean O, Haffajee R, Hosanager A. U.S. trends in registration for medical cannabis and reasons for use from 2016 to 2020. An observational study. Ann Intern Med. 2022;175:945-51. doi:10.7326/M22-0217

Boehnke KF, Gangopadhyay S, Clauw DJ, Haffajee. Qualifying conditions of medical cannabis license holders in the United States. Health Aff. 2019;38(2):295-302. doi:10.1377/hlthaff.2018.05266

Centers for Disease Control. State medical cannabis laws. February 16, 2024. bit.ly/40Wo7Wb

Chaffee TA. We[ed] the people: How a broader interpretation of the Rohrabacher-Farr amendment effectuates the changing social policy surrounding medical marijuana. U Cin Law Rev. 2023;91(3):856-88.

Department of Justice. Drug Enforcement Administration. Schedules of controlled substances: Rescheduling of marijuana. May 21, 2024. federalregister.gov/documents/2024/05/21/2024-11137/schedules-of-controlled-substances-rescheduling-of-marijuana

Downs D. The science behind the DEA’s long war on marijuana. Scientific American. April 9 2016. scientificamerican.com/article/the-science-behind-the-dea-s-long-war-on-marijuana

National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017.

Steel AHJ, Greiner L. No roof for your reefer! Medical cannabis tenants need patient protections in federally assisted housing. TortSource. 2022. americanbar.org/groups/tort_trial_insurance_practice/publications/tortsource/2022/spring/no-roof-your-reefer-medical-cannabis-tenants

Tilburg WC, Hodge JG, Jr, Gourdet C. Emerging public health law and policy issues concerning state medical cannabis programs. J Law Med Ethics. 2019;47(2suppl):108-11. doi: 10.1177/1073110519857331

Key words: medicinal cannabis, medical marijuana, nursing specialties