In 1998, Oregon was the second state in the US to legalize access to medical cannabis, when it launched our Oregon Medical Marijuana Program (OMMP).  Despite our progressive beginnings, Oregon’s current protocols are failing to meet cannabis patient’s needs, and many consumers opt to access cannabis through Oregon’s adult use/recreational access and pay the higher fees.    Considering we are a destination for many “cannabis refugees”, and a trailblazer in cannabis legalization nationally, we should have effective programs and supports for medical cannabis, and instead our current regulations impede optimal medical cannabis patient care.

Further supporting our need to make improvements is the Americans for Safe Access 2021 State of the States report, which graded Oregon’s medical cannabis program at only 54.43% overall, by awarding 374 of 700 points possible.  Most notably, Oregon scores only 50/100 in the category of patient rights and civil protections, and 45/100 for affordability (1).   Considering our 24-year tenure as a legal medical cannabis state, we should be achieving stellar marks.   Instead, our low score reflects that we have many issues to address in our endeavor to honor Oregon’s cannabis trailblazer beginnings, and our noble intent to serve patients in need.

Unfortunately, Oregon’s opportunity to provide a duplicatable program, or be a shining example to newer cannabis-legal states is quickly dissipating, and instead our mishandling of OMMP patients’ needs provides others a clear example of what not to do.   The following overview includes detailed insights on the many root contributors to our current disarray in Oregon, with the intent of improving the legislative process and ensuring cannabis patient’s needs are met appropriately and ethically.  

I’m a cannabis patient who happens to be a nurse, and I became an OMMP patient in 2014, so I have a unique perspective on this issue.   The following insights are based on my personal experiences as a participating OMMP patient, and a cannabis-specialty nurse endeavoring to educate patients, provide solutions to their barriers, and follow their profound outstanding needs.  

In order to become a legal medical cannabis patient in Oregon, one must meet specific health criteria, and have current (<90 day old) documentation providing a qualifying OMMP condition from their primary physician (2).  The medical cannabis certification process often requires a separate doctor appointment that’s not covered by insurance ($250 average) with one of many clinics signing OMMP authorizations as an exclusive offering.  I experienced this exact process myself a few times, before eventually finding a Primary Care Physician that would provide my OMMP certification.   Using a PCP for certification enables insurance coverage, and reduced the cost of my OMMP certification to my insurance copay.    Unfortunately most PCP’s are unwilling to facilitate this process, which may present affordability issues and restrict their OMMP participation.

While we have a few amazing Oregon physicians providing education to patients along with their certification for OMMP, more often this interface between OMMP doctor and patient spans 5 minutes, and the patient walks away with only a signature.  This was consistently my experience, regardless of the physician or type of clinic used to obtain my OMMP certification, where a signature was my only takeaway.  

As a nurse I understand that a signature does not constitute a prescription as is required for pharmaceuticals, which always requires a specific product, and detailed recommendations for dosing, timing, and method of administration.   Patients prescribed pharmaceuticals also have the option to request education from their pharmacist, who can advise about possible side effects and interactions with other medications.   

Our current medical cannabis approach in Oregon can be likened to a doctor giving a patient a blank prescription note with a signature only, and leaving them to visit the pharmacy, guess which product might be appropriate from thousands of choices, and figure out how to use it without any medical guidance.  This is not conducive to optimal cannabis therapy outcomes, nor does it provide for appropriate education regarding patient considerations and possible risk factors (4).

Comparatively, if we were treating medical cannabis patients using our standard medical ethics, they would receive evidence-based education, product guidance, and a full screening for individual considerations including pharmaceutical interactions (3).   Competent medical care of the cannabis patient is linked with optimal therapeutic outcomes, and reduced risk factors (4).  While I know some amazing budtenders, even the best of them aren’t qualified to deliver medical guidance such as screening for pharma interactions, yet in Oregon this role defaults to them as the primary resource, thanks to the deliberate absence of reputable medical supports.   

The current methods in Oregon completely disregard cannabis patients’ basic needs, in full breach of our foundational medical ethics, which mandate that medical professionals disregard any prejudice in our treatment of patients (4).   Instead, cannabis patients are left to make these vital decisions on their own, resulting in extended experimentation with multiple products, while facing many added barriers compromising their ability to meet the desired health goals with cannabis (3).  

Driving my staunch advocacy and determination to educate cannabis science to patients and medical professionals is the complete lack of Endocannabinoid System science education.  Neither doctors nor nurses learn the science supporting the therapeutic potential of cannabis in their formal training, even though this master regulator system was discovered in 1992 patients (5).    Lack of cannabis science education spawns rampant stigma and misconceptions among our medical community, inhibiting their ability to support cannabis patients.  Those practitioners who happen upon the therapeutic potential of cannabis must independently pursue medical cannabis knowledge and education.  This drives my current professional roles, which include creation and delivery of accredited medical cannabis education for nurses, and college-level curricula teaching cannabis science to integrative medicine students.   

Many practitioners hear cannabis is “good for everything” and automatically write it off as a snake oil, not understanding that cannabis activates our EndoCannabinoid System, resulting in promotion of balance or homeostasis in EVERY other system in the body.   Medical professionals also fail to recognize that all chronic illnesses are linked to EndoCannabinoid Deficiency, (Russo), which creates imbalances contributing to the root cause of disease.   This clearly explains why cannabis may be effective for many different medical uses, as it seamlessly fills a vital nutrient deficiency linked with all illnesses (6).   Practitioners who read the objective scientific education discover the rampant stigma and unwarranted restrictions on medical cannabis don’t apply, and realize the false stigma presents a major hindrance to supporting patients properly.   It’s important that medical professionals understand and review the 35K + valid research articles, presenting strong evidence that cannabis is a safe and effective tool that may benefit dozens of conditions 

Ethical cannabis patient care includes weighing risk vs benefit of all therapeutic options, and when cannabis is objectively considered vs the risks of pharma, it’s typically the first logical choice for those suffering chronic illness thanks to its unsurpassed safety profile, minimal side effects, and profound research-supported efficacy.  Ethically, all practitioners in legal medical cannabis states must be educated on ECS science, in order to uphold our ethics and professional oaths to objectively guide and educate patients on ALL possible therapeutic options.  

Federal Schedule I placement is another deterring fear factor for medical professionals, who wrongly assume that cannabis (in the form of THC) meets these criteria for justifying harsh accessibility restrictions:  1. Harmful  2. Addictive/Potential for Abuse 3. No accepted medical use (7).    

Then there’s the reality:

1. Cannabis has an unsurpassed safety profile, evidenced by thousands of years of historical use, without a single patient being harmed (8).  Great hypocrisy lies in the dichotomy that the same government freely allowing access to opioids, which statistically kill patients every 18 minutes, is restricting access to cannabis which represents a safe and effective alternative for pain management.    Additionally, research in states allowing medical cannabis access reflects that opioid deaths decreased, further supporting that federal descheduling of cannabis may be a solution to our current opioid crisis (9).
2. Research supports that cannabis is less physically addictive and less harmful than commonly used substances like sugar, coffee, and cigarettes, substances for which access is freely allowed nationwide (10).
3. More than 35,000 reputable research studies supporting acceptable medical uses of cannabis for dozens of conditions, and our federal government even holds multiple patents for cannabis as medicine, with the most notorious being #6630507 (11, 12).

As early as 1988, we’ve had multiple federal judges rule in favor of descheduling cannabis, when presented with the above objective evidence that it doesn’t meet the criteria for Schedule I placement (13) .  Yet here we are in 2022, with cannabis still under federal Schedule I restriction, effectively disallowing cannabis access for most patients in our country who might otherwise benefit.   “When politics lack logic, follow the money” is the only clear rationale for this 34-year delay in patient justice.    

Cannabis obviously competes with pharmaceutical profits, and from my experience educating thousands of cannabis patients, it’s common for patient success in medical cannabis therapy to concurrently reduce their reliance on prior pharmaceuticals.   The leading contributor to politician recipients is pharmaceutical lobbyists, constituting more than double the next leading industry of oil and gas (14)    This sure could explain why cannabis is still plagued by federal level restrictions, despite 60% of the country being pro-medical cannabis use (15).

Becoming a medical cannabis practitioner also requires overcoming the seemingly deliberate barriers to medical professionals service of cannabis patients.  In Oregon, despite longstanding legal cannabis access for our patients, the medical and nurse licensing boards are notoriously discriminatory towards practitioners serving those who choose cannabis therapy (16).  Ethical practitioners determined to serve cannabis patients must disregard the fear of possible licensure ramifications, and choose to follow their oath and serve patients without prejudice.  Historically, many Oregon physicians and nurses have been subject to harassment, investigation, and even license discipline or retraction (17, 18, 19).   

Oregon licensing boards are capitalizing on their own failure to adopt guidelines for their licensees working with medical cannabis patients, forcing ethical practitioners to operate in a licensure gray area.   This entails risking our license to abide by our ethical oath to provide nondiscriminatory service to patients in need (16).  This situation exists despite nearly 25 years of legal patient access to medical cannabis, representing ample opportunity for our state’s licensing boards to support practitioner’s needs.   As a result, Oregon practitioners serving medical cannabis patient’s needs entails risk unwarranted ramifications.

Here’s an example of the poor handling of this issue, by the Oregon State Board of Nursing (OSBN), which effectively placed a gag order on nurse education of Oregon cannabis patients in November of 2019.  This decision effectively amplified the severity of the already critical educational gap experienced by our cannabis patients in Oregon.  Nurses are uniquely qualified to provide patient education, and screen pharmaceuticals for possible interactions with cannabis, which represents the primary risk of cannabis therapy today.  

This discriminatory OSBN cannabis nurse gag order increased the likelihood that medical cannabis patients would fail to meet reasonable therapeutic goals, or potentially suffer negative effects of combined pharmaceuticals (4).  This ridiculous mandate resulted in Oregon nurses being legally allowed to administer cannabis to patients, meanwhile being strictly prohibited from educating these same patients about the substance being administered. 

After 18 months of advocacy, OSBN adhered to forcible retraction of their proven unlawful cannabis nurse gag order in April 2021 (20), which was further supported by passage of HB3669 in May 2021, specifically protecting nurses from license discipline for providing cannabis education.   While this may appear as progress, we are effectively back to pre-2019 conditions, where nurses are forced to interpret nonexistent parameters to guide their health education practice and ensure preservation of their license status.  This, despite the 2018 release of National Counsel State Board of Nursing (NCSBN) guidelines, which specify the requirements of nurses education of cannabis patients, presented to every state board of nursing for adoption (21).   

All of my attempts to educate or converse with OSBN board members on this topic since 2015 have been ignored, and deliberate ignorance and stigma are the main issue.   The Oregon Medical Board is not handing this topic any better, and they have historically investigated and even rescinded cannabis physician licenses in response to their attempts to serve medical cannabis patient’s needs.    It’s logical that these boards should accept some responsibility rather than order discipline, and instead examine how they are failing to support and guide the medical professionals serving patients in the cannabis industry.   

Oregon boards’ refusal to examine the prolific medical cannabis education and science resources, and failure to adopt scope of practice guidelines for those serving this specialty cohort of patients, is a major contributor to the current disarray in handling the needs of our vulnerable medical cannabis patient population.   There is no excuse for licensing board’s discrimination against, and continued disenfranchisement of, our Oregon medical cannabis patients.  We are bound by medical ethics, and patient autonomy and informed consent are both compromised as a result of our licensing boards’ cognitive dissonance.

It’s well past time that Oregon legislators, patients, and medical professionals advocate for medical cannabis patients and those bravely serving their profound unmet needs.    This entails providing best practice guidelines to medical professionals, and allowing them to provide non-discriminatory service as dictated by medical ethics, without fear of retaliation.  Lacking this progress, the ones who suffer most are vulnerable medical cannabis patients.

References

1. Americans for Safe Access (2021).   2021 State of the States Report, p. 96.   Retrieved online at:  https://american-safe-access.s3.amazonaws.com/sos2021/StateoftheStates21_Web2.22.pdf
2. OMMP Qualifying Conditions (2021).   Retrieved from:  https://www.oregon.gov/oha/ph/diseasesconditions/chronicdisease/medicalmarijuanaprogram/pages/physicians.aspx
3. ATrain Education – Medical Professional Code of Ethics (2021).   Retrieved at:  https://www.atrainceu.com/content/2-professional-codes-ethics
4. Temple, L., Lampert, S., Ewigman, B. (2019). Barriers to achieving optimal success with medical cannabis: opportunities for quality improvement. The Journal of Alternative and Complementary Medicine.Jan 2019, 5-7.http://doi.org/10.1089/acm.2018.0250  Retrieved from:  https://www.liebertpub.com/doi/10.1089/acm.2018.0250
5. Devane WA, Hanus L, Breuer A, Pertwee RG, Stevenson LA, Griffin G, Gibson D, Mandelbaum A, Etinger A, Mechoulam R. Isolation and structure of a brain constituent that binds to the cannabinoid receptor. Science. 1992 Dec 18;258(5090):1946-9. doi: 10.1126/science.1470919. PMID: 1470919.   Retrieved from:  https://pubmed.ncbi.nlm.nih.gov/1470919/
6. Russo E. B. (2016). Clinical Endocannabinoid Deficiency reconsidered: current research supports the theory in migraine, fibromyalgia, irritable bowel, and other treatment-resistant syndromes. Cannabis and cannabinoid research, 1(1), 154–165. https://doi.org/10.1089/can.2016.0009  Retrieved from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576607/
7. 21 US Code 812 – Federal schedule of controlled substances.   Retrieved online at: https://www.law.cornell.edu/uscode/text/21/812
8. Americans for Safe Access (2021). Patient’s history of medical cannabis.   Retrieved from:  https://www.safeaccessnow.org/patients_history_of_medical_cannabis
9. Hsu G, Kovács B. Association between county level cannabis dispensary counts and opioid related mortality rates in the United States: panel data study  BMJ  2021;  372 :m4957 doi:10.1136/bmj.m4957  Retrieved from:  https://www.bmj.com/content/372/bmj.m4957
10. Mic.com (2021).  5 substances that are far more addictive than marijuana — that are legal.   Retrieved from:  https://www.mic.com/articles/137800/5-substances-that-are-far-more-addictive-than-marijuana-that-are-legal
11. NORML.org (2020).  Record number of scientific papers published in 2020 About cannabis.  Retrieved from:  https://norml.org/blog/2020/12/16/record-number-of-scientific-papers-published-in-2020-about-cannabis/
12. https://pubchem.ncbi.nlm.nih.gov/patent/US-6630507-B1
13. NORML.org (2013).  25 years ago: DEA’s own administrative law judge ruled cannabis should be reclassified under federal law.   Retrieved from:  https://norml.org/news/2013/09/05/25-years-ago-dea-s-own-administrative-law-judge-ruled-cannabis-should-be-reclassified-under-federal-law/
14. Kennedy, Robert F. (2015).  Vermont legislature testimony, retrieved from: https://legislature.vermont.gov/Documents/2016/WorkGroups/House%20Health%20Care/Bills/H.98/Witness%20Testimony/H.98~Robert%20Kennedy~Testimony%20of%20Robert%20F.%20Kennedy%20Jr.~5-5-2015.pdf
15. NORML.org (2021).  Poll of Americans support of legalizing marijuana.  Retrieved from:  https://norml.org/marijuana/library/surveys-polls/
16. Stutsman, E. (2016).  Marijuana, the practice of medicine, and the Oregon Medical Board.  Retrieved from:  https://elistutsman.com/2016/07/marijuana-the-practice-of-medicine-and-the-oregon-medical-board/
17. OMB Board Action Report (2016).   Brian Lane Dossey MD investigation for furnishing OMMP certification to a qualifying minor.  https://www.oregon.gov/omb/BoardActions/May%2016,%202016%20-%20June%2015,%202016.pdf
18. OMB Board Action Report (2019).  Brian Land Dossey MD forced retirement of medical license (cannabis specialty physician).  https://www.oregon.gov/omb/BoardActions/September%2016,%202016%20-%20October%2015,%202016.pdf
19. Clark, C. (2021).   Cannabis:  A handbook for nurses.   Wolters Kluwer Health.   Laurel James RN, p. 382.  Retrieved at:  https://books.google.com/books?id=d7ISEAAAQBAJ&pg=PT378&lpg=PT378&dq=osbn+laurel+james+RN+discipline&source=bl&ots=3JWOdYpU6z&sig=ACfU3U3sxTlg1kUa534I24NPdf0OwCj60A&hl=en&sa=X&ved=2ahUKEwjNmezxm-f1AhVhJUQIHaExA8YQ6AF6BAgXEAM#v=onepage&q=osbn%20laurel%20james%20RN%20discipline&f=false
20. Berger, L. (2021).  Retraction of OSBN’s cannabis nurse gag order.  Retrieved from:  https://www.facebook.com/plugins/post.php?href=https%3A%2F%2Fwww.facebook.com%2Fleland.berger%2Fposts%2F10159306954144104
21. The NCSBN National Nursing Guidelines for Medical Marijuana (2018).   Retrieved online at:  https://www.ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf