I am a Registered Nurse with 22 years of experience, and I have had an anti-prohibition stance in regards to marijuana (cannabis) for 30 years. I was fortunate that when I moved from California to Maine 6 years ago, I was introduced to Maine’s amazing medical cannabis program. I have also been able to study and learn more about the medicinal benefits of this sacred herb through my involvement with the American Cannabis Nurses Association (I now sit on ACNA’s board of directors) and by going to cannabis clinician conferences, such as Patients Out of Time.

Cannabis is on the ballot in 9 states this November, for either legalization for adult use or medicinal consideration. As nurses, we are often concerned with safety, so the following are my thoughts on safety issues and the end of prohibition of cannabis. If you are unfamiliar with how cannabis works in the body and why it such a safe herbal medicine, I suggest you first visit my blog posting on what nurses need to know about cannabis: https://nursemanifest.com/2015/07/14/the-endocannabinoid-system-what-nurses-need-to-know-an-introduction/.

Let’s consider the following issues:

Access: The idea of increased access for adults over age 21 is compelling on many levels. As many have stated before me, all cannabis use is medicinal due to the way the herb interacts with the body’s own endocannabinoid system. (http://thejointblog.com/all-marijuana-use-is-medicinal/;  https://halcyonorganics.com/all-cannabis-use-is-medical/). Patients who cannot access cannabis legally to support their healing because they did not have a documented qualifying condition may now have access to this safe effective herbal medicine. Sites like http://www.drugguardians.com are being created with impunity and are helping the population become informed by third parties, decentralizing the source of knowledge about drugs. As legal access increases, black market issues will likely dissipate which creates a safer environment for all citizens. Meanwhile, we know that in legalized states, teen cannabis use drops significantly, effectively decreasing access for younger folks, which is often a concern for those who are considering legalization or medicinal programs (http://www.usnews.com/news/articles/2014/08/07/pot-use-among-colorado-teens-appears-to-drop-after-legalization).

Quality: In Maine, our ballot calls for testing and proper labeling of cannabis products sold at both recreational stores and recreational cafes. This is a major step forward to ensuring safe use of quality cannabis products for both patients and recreational users. Many patients now are being encouraged to start low and go slow with their dosing of their medication, and proper labeling will help to ensure that people can use cannabis with comfort knowing the relative psychoactive effects increase as THC levels of the cannabis products increase. Additionally, products will be tested for pesticides and contaminants, further ensuring the medicine and products people are accessing is safe.

Smoking: I often hear that medical providers are very concerned with the idea that smoking cannabis may be harmful to the person. While there may be some minimal changes to lung structures, there is no strong correlation with COPD and lung cancer in cannabis smokers (http://www.ncbi.nlm.nih.gov/pubmed/23802821; http://www.ncbi.nlm.nih.gov/pubmed/21859273). However, there are many ways to ingest cannabis, and vaporizing cannabis is a way to inhale the medicine without having contact with some of the combustive byproducts that are related to any perceived risk of smoking cannabis. For more therapeutic effects, regular users of cannabis and those seeking its healing properties are generally encouraged to use edibles and tinctures, as they target whole body homeostasis more effectively.

OUI/ DUI: Driving under the influence of any psychoactive medication is obviously an issue. However, levels of THC in the body do not directly equate to impaired driving in the same way that alcohol does, secondary to the way THC is metabolized in the body and how it remains in the body due to it being a fat soluble substance (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456923/). “Stoned drivers” do not pose the same risk to the public’s well-being as “drunken drivers” do; indeed “stoned” drivers tend to drive more slowly. Researchers from UCLA have called for more efforts to be made around lowering acceptable blood alcohol levels to truly curb issues around impaired driving (http://www.nytimes.com/2014/02/18/health/driving-under-the-influence-of-marijuana.html?_r=0), as being at .08 BAL leads to an eleven fold increase in the risk for being in a car accident, while driving under the influence of cannabis leads to a two-fold increase of being in an accident (texting while driving has a two fold increase and talking on the phone while driving has a 3 fold increase in risk for car accidents) (http://www.huffingtonpost.com/sam-tracy/putting-marijuana-dui-in-_b_6023136.html). Driving or operating machinery while under the influence of cannabis is unacceptable and indicates a risk, however in Colorado since legalization of recreational use of cannabis was initiated, DUI fatalities have decreased (https://www.washingtonpost.com/news/the-watch/wp/2014/08/05/since-marijuana-legalization-highway-fatalities-in-colorado-are-at-near-historic-lows/?utm_term=.64fa02a0cc5e). It should be noted that Colorado made a concerted effort to promote safer driving conditions and decreasing driving while intoxicated once they ended cannabis prohibition. all states should be making efforts to combat intoxicated and unsafe driving practices.

Children: When cannabis was made recreationally available in Colorado, it appeared that more children were being accidentally exposed to cannabis (http://www.usatoday.com/story/news/nation/2014/04/02/marijuana-pot-edibles-colorado/7154651/). I would posit however that once the plant became legal, more parents were willing to seek medical attention if their child had accidentally ingested cannabis infused edibles or other cannabis products. Additionally, the relative number of cannabis ingestion issues versus other toxic substances truly remains quite low in Colorado at 6.4% of all “poisoning” cases treated within the pediatric population (http://www.cnn.com/2016/07/27/health/colorado-marijuana-children/index.html). There has not been a single reported death from a child (or any person) ingesting cannabis (unlike other ingested toxins, such as laundry pods: http://www.cnn.com/2014/11/10/health/laundry-pod-poisonings/index.html). So while we will need to educate consumers about the risks of pediatric access and ingestion of cannabis, the risks remain relatively low. In most cases, children recover quickly from cannabis intoxication, with hospitalization for supportive care only, which generally lasts 1-2 days and generally leads to no lasting side effects (http://health.usnews.com/health-news/news/articles/2013/05/27/kids-poisoned-by-medical-marijuana-study-finds
). Both the states and the individual companies who will be selling cannabis should be responsible for educating the public around ensuring pediatric safety should a state chose to legalize. Ideally some of the tax dollars generated from cannabis sales would be geared toward education of the public on safe cannabis consumption and storage.

Teen Use: Teen cannabis use has actually declined as more states legalize or become medicinal cannabis states (https://www.washingtonpost.com/news/wonk/wp/2014/12/16/teen-marijuana-use-falls-as-more-states-legalize/). This in part may be due to tougher regulations making it harder for teens to access cannabis, and a decrease in black market availability of cannabis.

Pregnancy: Dr. Melanie Dreher, the Former Dean of Rush University school of nursing, is a nurse who researched the Ganga culture in Jamaica for over ten years, and determined that there were no adverse outcomes to the fetuses who were exposed to cannabis (https://www.youtube.com/watch?v=K9WorIM0RhA; https://www.youtube.com/watch?v=RDV5HhmP4UI). A recent study also reported that cannabis use is safe during pregnancy (though caution may still be advised)(http://www.scienceworldreport.com/articles/47194/20160910/marijuana-safe-during-pregnancy-experts-encourage.htm) and breast feeding while using cannabis also appears to have minimal risks (http://cannabisclinicians.org/breastfeeding-and-cannabis/).

Harm Reduction: Cannabis has been studied as a harm reduction tool, particularly when it comes to addiction and treating folks for pain related issues. Physicians have called for neuropathic pain to be treated with cannabis instead of opioids (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3295721/). We also know that cannabis can decrease the need for escalating doses of opioids, and assist people who are opioid dependent in either decreasing thier doses of opiates or completely overcoming their addiction (http://nationalaccesscannabis.com/press-release/opiate-study-press-release/).
For an overview of the body’s endocannabinoid system and the issue of biological harm reduction, please see here: http://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-2-17

Overdoses with opioids have fallen in states where medicinal and legal cannabis are available (http://www.nytimes.com/roomfordebate/2016/04/26/is-marijuana-a-gateway-drug/overdoses-fell-with-medical-marijuana-legalization; and https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose). With high rates of opioid addiction plaguing our country, it makes sense to legalize cannabis now to help address this issue.

Self-Medicating: People self-medicate with substances on a daily basis; from alcohol to caffeine to tobacco. People self-medicate with herbs as well from turmeric to Echinacea, to vitamins and natural thyroid supplements. With legalization and regulation, people have a better chance of using safe, monitored, quality herbal cannabis medicine. For most of our recorded human history, cannabis was used as a healing herb. This came to a halt when cannabis prohibition became a global stance. Additionally, legalization opens the door for more open discussions between healthcare providers and patients. Healthcare providers such as nurses and doctors must become educated around the body’s endocannabinoid system and the therapeutic use of cannabis to create homeostasis and support healing.

Pathways for New Healing Products: Currently, many new cannabis products that are available in legal states are not available to medicinal patients in states where only medicinal cannabis is legal. For instance, various teas, salves, edibles and patches that are available in Colorado, Washington, or Oregon are not yet always available for medicinal patients in other states. Once states have a legalized cannabis regulation processes in place, it may be that people can access items such as a topical sub-dermal patches to deliver cannabis medicine or specific cannabinoids. A person may be able to use a CBD (a non-psychoactive cannabinoid) only patch during the day to help with issues like, pain, anxiety, nausea, and depression, and a CBN patch (another non-psychoactive cannabinoid) at night to help with sleep. In this example, the person would have minimal if any exposure to the psychoactive effects of THC in cannabis, and yet they may experience a greater quality of life. From a justice perspective, people deserve to make choice around the medicines they would like to utilize for their own healing, particularly when the medicines are safe.

Social Justice Issues and Policing: Recently, the chiefs of police in Maine came out against the yes on 1 ballot initiative to legalize marijuana in Maine. It is interesting to me that this organization stated they are “unprepared to address legalization issues,” when certainly looking at the legalization issues in Colorado and Washington should provide plenty of data and solutions to common issues. I would posit that there would be fewer marijuana trafficking issues and convictions, and the police could turn greater attention to bigger and more harmful issues in Maine, such as the opioid crisis and OUI related to alcohol ingestion. Additionally, cannabis legalization is a step toward social justice given the illogical, irrational, and unsuccessful war on drugs (http://www.sfgate.com/opinion/article/Marijuana-legalization-a-step-toward-social-5848468.php, http://theweek.com/articles/542678/why-pot-legalization-also-fight-social-justice). Legalizing cannabis should free up our law enforcement agencies to fight crimes that cause greater damage, even as it lowers the need for them to be addressing black market cannabis issues.

I would like to close with my final thought:

All cannabis is medicinal. Our bodies have our own endocannabinoid systems; we make our own endogenous cannabinoids. However when we become deficient in these cannabinoids, we may become ill and need to seek exogenous sources of cannabinoids, or support our own bodies in creating more endocannabinoids. Cannabis is a safe effective medicine with a low rate of addiction and minimal if any withdrawal symptoms, similar to caffeine. Ingestion of cannabis itself has never lead to a death (unlike many prescription and OTC drugs, alcohol, and nicotine products), and it is time we begin to move beyond the government’s ineffective “prohibition of marijuana” stance and take steps toward effective access for all adults.

In the states where cannabis is a ballot initiative, I urge us as nurses and other healthcare providers to explore the data around cannabis as a medicine and consider our roles as  advocates for patient access to the healing support this medicine can provide.