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Perhaps no topic is more controversial than the use of marijuana in clinical practice. Within the United States, there are an estimated 55 million recent active users, defined as one to two uses within the previous year, and 35 million regular users, defined as one to two uses per month. The subject of cannabis use and regulation in the United States is evolving rapidly.

The current regulatory environment surrounding cannabis is both contradictory and continually changing in response to broad-based popular pressure to end decades of marijuana prohibition. These pressures are bolstered by emerging scientific data that are refining and altering both the popular and scientific consensus regarding the potential risks and benefits of cannabis use. There is every reason to believe that the current high level of interest and use in the U.

Physicians should ensure that they are sufficiently informed to responsibly evaluate and discuss cannabis use in the context of patient care. In modern medical practice, physicians commonly address cannabis use in detail as part of routine medical care. A medical history might include inquiries about marijuana use in drug abuse screenings, as part of a comprehensive social history or mental health visits.

More extensive discussions typically have not played a large role in the daily practice of allopathic medicine. However, cannabis has gained much more mainstream attention in recent years. A number of states have passed laws permitting cannabis use, either for specific populations or for general recreational use by adults. With these shifts in legal status, and parallel shifts in the broader cultural presence of cannabis use, physicians should seek to increase their knowledge about cannabis and cannabinoids to counsel and manage patients appropriately.

The criminalization of marijuana and the associated rejection of its potential medicinal benefits by medical, legal, and mainstream culture is a relatively recent development that emerged over the course of the last century. This negative modern characterization of cannabis has been challenged by some scientists and other supporters of cannabis legalization in recent decades.

The evolution of cannabis prohibition in the United States is complex. Some argue that it was driven as much by political and economic issues as by any concern for public health. California passed Proposition in , beginning a trend toward relaxing legal prohibitions against cannabis production and use. Over the course of several years, other states have passed legislation allowing marijuana purchase, possession, and usage to some degree. Despite these changes in state policy and a more normalized presence in mainstream culture, federal policies have been slower to shift.

The Centers for Disease Control and Prevention CDC website currently refers to marijuana as an illegal drug and cites numerous resources promoting potentially negative or harmful effects. Schedule I drugs are considered primarily harmful and to lack legitimate beneficial application to outweigh the potential harm they may cause.

Other Schedule I drugs include heroin and lysergic acid diethylamide. Other substances, like oxycodone and methamphetamine, are classified as Schedule II drugs. These agents have specifically approved medical indications, but are regulated stringently because of concerns about their potential to cause harm. Despite repeated attempts by advocates requesting reclassification of marijuana as a Schedule II drug, the DEA recently denied two petitions to reschedule cannabis.

The FDA currently acknowledges the interest in cannabinoids for potential medical benefits, but urges a cautious and reasoned approach to study and legislation rather than reacting to the tide of popular sentiment. The CDC also has loosened its stance on testing for cannabis use in opioid users. The most recent guidelines of Prescribing Opioids for Chronic Pain now recommend against the testing for substances such as cannabis for which there may be uncertainty about the effects that a positive test may have on patient management. Although this shift may presage further changes in federal policy toward cannabinoids in the years to come, the current dichotomy between legalization efforts at the state level and the more conservative approach of federal agencies toward easing the regulatory underpinnings of marijuana prohibition creates a difficult environment for physicians who answer to both state and federal authorities that regulate their practice of medicine.

Formal reclassification as a Schedule II drug at the federal level would resolve this difficulty by ceding a clear legal authority for physicians to determine whether cannabis use would be safe and effective for their patients. The legalization of cannabis at the various state levels does not necessarily reserve any legal authority for physicians to regulate and monitor cannabis and cannabinoid use. Some states have passed laws allowing for more broad adult use of cannabis that mirrors alcohol and tobacco regulation.

By regulating cannabis and cannabinoid use as an exploited vice rather than medicinal therapy, state legislation may sidestep acknowledging, creating, or perpetuating a distinction between medicinal and recreational use of cannabinoids. The disparity between state and federal laws already is affecting the rights of state-registered medicinal cannabis users, who may be barred from lawful ownership of firearms, for example.

The lack of clarity and consistency in the regulation of cannabinoids at the state and federal levels makes it especially imperative for physicians to educate themselves about the potential benefits and risks of cannabis use. In states in which medicinal use is permitted, physicians often must rely on sparse and inconsistent data regarding the safety and efficacy of cannabinoids for treating various health conditions.

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In states in which recreational use of cannabis is permitted, physicians may encounter patients who already have incorporated cannabinoids into their lifestyles. Whether they are doing so for specific medicinal purposes, patients may be using cannabis without any physician consultation regarding the potential beneficial or adverse effects of cannabinoids on their health. To elicit and encourage constructive dialogue with patients about the potential health implications of cannabinoids and cannabis use, it is incumbent on physicians practicing in these environments to present an educated and informed perspective to patients who are considering or currently engaged in cannabis use.

This article will review the pharmacology of cannabis and address the ethical determinants physicians must consider when counseling known or potential users. This knowledge will allow physicians to effectively engage their patients regarding how cannabinoids may affect their overall health. Roman historian Pliny the Younger, in his pioneering encyclopedia on the natural world, mentions the use of cannabis as an intoxicant.

In , Dr. Cannabis is an annual flowering plant that grows in tropical and temperate climates. A variety of C.

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Cannabis sativa. Cannabis indic a. Cannabis ruderalis. The flowers or buds of unfertilized female plants may contain high concentrations of cannabinoids. See Figure 2. Soil composition, temperature, carbon dioxide levels, and lighting, among other factors, can influence the cannabinoid profile of any plant. Cultivators can manipulate conditions to produce small plants that quickly yield small amounts up to a single ounce, or much larger plants yielding up to 25 ounces of usable cannabis. Flowering female cannabis plant.

Producing these high concentrations of cannabinoids requires careful and meticulous cultivation. In the wild, cannabis fertilization of female flowers by male plants results in the flower or bud-producing seeds rather than cannabinoids. Early generations of seeds produced during cultivation are more likely to have genetic weaknesses, such as being hermaphroditic. Harvesting a consistent and high-quality crop requires a great deal of time and care. More than cannabinoids have been isolated from the cannabis plant.

These have been grouped into 11 distinct classes. In the native form, cannabinoids usually are found as carboxylic acid derivatives i. Although both acid and neutral forms of cannabinoids may be bioactive, inducing psychoactive and inebriating effects requires decarboxylation into neutral, active forms, usually accomplished by smoking, vaping, baking, or otherwise processing the carboxylic acid forms of cannabinoids with heat e.

The same biologic precursor of cannabinoids, geranyl pyrophosphate, is used by the cannabis plant to synthesize terpenoids. Terpenoids are aromatic essential oils, also found in many other plants, such as lemon limonene , pine alpha-pinene , lavender linalool , and orange nerolidol , that contribute to the characteristic aroma of cannabis.

Cannabinoids are produced in secretory glands called trichomes, which are highly concentrated along the flowering surface of the female plant. When mature, these trichomes and their contents contribute to the unique crystalline color, smell, and sticky texture of cannabis. From a functional standpoint, cannabinoids are classified as secondary metabolites. The effects of cannabis depend on a number of factors, including dose, cannabinoid profile, and individual response.

As with other pharmacologic agents, the effects of cannabis are subject to inter-individual variations. For example, hormone levels and pharmacogenetic variations of drug-metabolizing enzymes and receptors may play a role in altering individual responses. See Table 1.

Neurotransmission, psychotropic effects, analgesia, 18 vascular tone. Allosteric modulator influences activity of other ligands without activating receptor Inflammation, analgesia, osteoclast formation and function Antiemetic, antinausea, 18 increased cerebral blood flow neuroprotection for ischemia , 43 anxiolysis Multiple: vasorelaxation of aorta and superior mesenteric arteries similar to rosiglitazone ; inhibition of vasorelaxation in resistance mesenteric arteries; antitumor proliferation; adipogenesis; gastro-inflammatory disorders Anti-inflammatory, neuropathic pain, dopamine release from ventral tegmental area Immunosuppression, 46 anti-inflammatory, antiarrythmic The psychotropic effects of cannabis primarily are a result of cannabinoids interacting with the cannabinoid 1 receptor CB1.

This is one of two endogenous receptors identified that make up the endocannabinoid system. Both CB1 and cannabinoid receptor 2 CB2 are G-protein-coupled receptors that initiate a cascade of downstream secondary messengers when activated.

Ethics: Ethical Issues with Medical Errors: Shaping a Culture of Safety in Healthcare

An abbreviated description of the mechanism is as follows: During periods of neuroexcitation, 2-AG is released and binds to cannabinoid receptors on presynaptic nerve terminals in the CNS. Through secondary messenger cascade, calcium influx is inhibited and neurotransmitter release is decreased. Importantly, it should be noted that other receptors also may play a role in the psychotropic effects of cannabis. Another endogenous ligand, anandamide, also has been discovered that acts as a partial agonist for the CB1 receptors. Authors speculate its physiologic role may be in other systems, outside the endocannabinoid system.

In contrast to CB1 receptors, CB2 receptors occupy the periphery, more specifically the immune cells e. Here, the endocannabinoid system is thought to play a role in inflammation and immune response. The specific effect on receptors varies between cannabinoids. On the other hand, CBD is an antagonist for these receptors and, as such, it lacks psychoactive or high-inducing effects. CBD at doses 15 to 60 mg attenuated effects of 30 mg THC including tachycardia, disturbed time tasks, and strong psychological reactions. CBD changed THC symptoms in such a way that the subjects receiving the mixtures showed less anxiety and panic but reported more pleasurable effects.

CBD attenuated THC effects including tachycardia, impairment on stance stability on a wobble board, and ability to track on a pursuit meter. High CBD cannabis was associated with significantly lower degrees of positive psychotic symptoms, but not negative symptoms or depression. The cannabinoid concentration that ultimately reaches systemic exposure depends on a number of factors, including product purity, dose, preparation, and route of administration. Cannabis can be delivered by nearly all routes of administration, including inhaled, oral, topical, rectal, and vaginal. Topical formulations generally are not psychoactive.

Oil extracts of the plant also can be smoked, vaporized, or ingested. Inhaled cannabis has an almost immediate onset of action and can produce psychoactive effects within minutes. Peak effects are achieved at about 15 minutes, and the duration of action is about four hours. See Table 3.

Begins within minutes, maximum effect achieved in 15 minutes, after which there is a moderate to rapid decline in effects over the next 4 hours. Maximum effect within 2 to 3 hours, remaining elevated until 4 hours post-dose, followed by a gradual decline of effects over the next 2 hours. This is becoming an increasingly common form of cannabis delivery.

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The systemic availability of oral cannabis is poor, achieving only about one-third of the systemic exposure as smoking. Edible cannabis can be made with almost any food. Formulations that are sprayed or dissolve in the mouth via the oral mucosa also are available, and these may provide improved bioavailability and enhanced effects as a result of avoiding first-pass metabolism. The potential for drug-to-drug interactions should be considered in patients using cannabis.

Pharmacodynamic interactions to consider include additive effects with medications that cause CNS depression, cognitive dysfunction, and adverse cardiovascular events. In terms of pharmacokinetic interactions, cannabinoids undergo drug metabolism and transport and, thus, have potential for interaction. In addition to its use for euphoria, relaxation, and changes in perception, cannabis has a wide range of clinical applications. See Table 4. I knew that if Mrs. May died, there was a good chance that I would not ever be allowed to practice nursing again.

You are always so careful. My heart sank. Today, I still remember the kindness that was bestowed on me that day. When I told the oncologist about my terrible error, he stated that he had ordered a lower dose of the medication for Mrs.

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The oncologist said that she would be very, very sick for about a month but would not die from the overdose. He would treat her aggressively with agents to increase her cell counts so that she would have enough reserve to keep her counts from going down to zero. The next morning Mrs. May came to the clinic. I arrived early to tell her how very sorry I was.

She said that her oncologist had told her if I had not come forth and told him of the mistake, she might not have lived.

She trusted the doctor that she would not die from the error. I am happy to say that Mrs. May is still alive today. She certainly was a very sick lady for the next 2 weeks. I have never felt this bad in my life, but I will make it. May made it. Her tumor decreased to one half its original size in about a month.

Almost 2 years after this incident, Mr. May were able to enjoy an international vacation together. I talk with Mrs. May whenever she comes to the clinic and she always gives me a hug and reassurance that she is okay. Was I unbelievably fortunate? Can a medication error happen to even the most careful and conscientious nurse?

Am I even more conscious of my ethical obligations to provide safe care? This incident has changed my life. The classroom was totally silent. Many of us were fighting back tears. Medical errors are not typically caused by a negligent or incompetent healthcare professional. Instead they are often the result of a breakdown in processes that guide delivery of patient care Bonney, Sarah was a competent, careful, and caring nurse, but variances in the usual process of care set up a situation for error.

The medication was new to Sarah and was ordered in a format that led to confusion of dose versus dilution. Medication orders should be written in clear and consistent formats so that the person administering the drug can readily understand the appropriate dose. Also, the chart was removed from the clinic setting before Sarah had a chance to record the medication administration. Access to the order on the medical record while administering the medication provides an important safety check to ensure the correct dose is both administered and recorded.

Many potential and actual medical errors fall within the sphere of nursing practice Lachman, Thus nurses have an ethical obligation to help prevent and manage medical errors. The remainder of this column will discuss ethical principles related to medical errors for nurses to consider, along with recommendations that can help to shape a culture of safety for the prevention of medical errors. Ethical issues related to medical errors can be categorized around four ethical principles: autonomy and right to self-determination; beneficence and nonmaleficence; disclosure and right to knowledge; and veracity Bonney, Each of these principles will be discussed below.

Healthcare providers have an ethical obligation to inform patients about their ongoing plan of care, including if a medical error has occurred. If Sarah had not informed others of her error, Mrs. May would not have been able to make appropriate decisions about the treatment that she needed as a result of the error.

Healthcare providers are also obligated to assist patients in making decisions, as the physician did in his care of Mrs. May about the medication error and potential adverse effects helped her to maintain trust in those caring for her and follow their instructions for treatment so that she could minimize harm from the error. The principles of beneficence and nonmaleficence direct healthcare providers to do what is best for patients and avoid harm. This may create moral conflicts for healthcare providers in terms of balancing projected benefits with possible risk for the patient.

Healthcare providers should take necessary steps to minimize the harm caused by an error. Sarah may have thought that informing Mrs. May of the error would cause unnecessary worry and suffering but had she not informed others of her error, Mrs. May would not have received important treatments to offset potential harm.

Healthcare providers have an ethical obligation to disclose information that patients need for informed decision making. May make decisions about her care, thus respecting her autonomy and decreasing the potential for harm. Every institution needs clear and detailed policies for disclosure of information about medical errors. Moving forward, invited guests will continue to collaborate in research, advocacy, and practice to enhance systems of care for children with medical complexity. Knowledge and perspectives gained through this symposium will be disseminated through scholarly publications.

This monthly conference series at Johns Hopkins Hospital attracts attendees to each session from the entire hospital community — physicians, nurses, medical students, social workers, chaplains, etc. Noon p. In addition to her work in genetics, she has longstanding interests in the areas of medical socialization, provider-patient communication under conditions of uncertainty, and cultural differences in attitudes toward health and disease.

These themes are reflected in Dr. Geller also has longstanding interests in ethics education. In addition, she co-directs or serves as faculty in four medical school courses. She also co-directs the required Integrative Medicine course. Two other courses are elective. Geller taught young Chinese geneticists about the social, psychological, cultural and ethical components of their research. She is a Fellow of the Hastings Center. Carrese has been a visiting professor at several academic medical institutions and he has been invited to speak at many national and international meetings.

In Dr. Carrese received a National Award for Scholarship in Medical Education at the Society of General Internal Medicine annual meeting in April for his body of work in the area of clinical ethics education.