The Stigma of Medical Cannabis from the Clinician’s Perspective
I took care of my mother in my home for the last four years of her life. She had end stage Parkinson’s Disease (PD). It was during this time that I learned aboutcannabis as a medicine. Prior to that I only knew it as a drug, a way to get “high” and a recreation that I took part in when I was in my late teens and early twenties. As soon as I took my boards for nursing, I never touched it again. So it was quite a shock 30 years later, when I learned about cannabis as a medicine from a physician friend. I was intrigued as I slowly engaged with a community of people who understood the plant as the therapeutic medicine it was. Gradually, I began to understand that medical cannabis could change lives and be a part of healing.
One person in the community asked me if I was using cannabis to improve the quality of life for my mother. I knew that cannabis could help people with PD, but the thought of giving this medicine to my mother was frightening and unsettling. This friend persisted and asked me in multiple meetings, until I finally had to ask myself this question. “Why was I opposed to considering medical cannabis to improve my mother’s quality of life?”
As I look back on my personal experience, I must ask myself, could it have been a stigma reaction? There has been concern in healthcare for the effects of stigma on patient care. Stigma is defined as:
The co-occurrence of its components–labeling, stereotyping, separation, status loss, and discrimination.1
All healthcare workers bring with them a historical bias that is unique and affects how they give care. It includes their history, their experiences and the foundations for all their thoughts and beliefs. One prominent issue that brings stigma into healthcare is illicit drug use like cannabis. Though cannabis is legal in many states, it is still illegal at the federal level. In nursing, each person has their own historical experience around illegal drugs. It could have been an addiction crisis in the family or a personal experience with drugs or alcohol. It may have included a person close to them being incarcerated and the subsequent fear of arrest. There is also the reality of racial risk for arrest or possibly loss of life. Unconscious biases and stigma around cannabis exist with all of us, pro, con and in between. Nurses have a professional responsibility to explore their biases and how they influence providing patient care. We must develop a self awareness of these biases in order to empower patients to make the decisions that work best for them.
Research supports the importance of addressing stigma in healthcare. One such study was done in Canada to review the stigma against mental health. A review of 22 anti-stigma programs showed that an emphasis on recovery as well as the inclusion of multiple forms of social in-person contact were particularly important for maximized effectiveness of decreasing stigma.2 What follows are some examples of cannabis stigma research.
ISRAEL
A qualitative interview study (n=15) of chronic pain patients using medical cannabis found that medical cannabis is not yet normalized in Israel and suggested the necessity to manage stigma. Patients found themselves needing to separate their experience from recreational users, and to present as “responsible normative individuals” emphasizing their discrete use for the specific medical benefits.3
Another study done in Israel included a questionnaire sent out to physicians. There were over 240 responses and results showed the intentions of physicians to recommend medical cannabis to a cancer clinical vignette were higher than intentions to recommend to the chronic pain vignette. Intentions to recommend medical cannabis were associated with factors beyond clinical practice and knowledge, such as provider attitudes, norms, and perceived control (belief in ability to recommend). Family physicians perceived knowledge was lower when compared to oncologists and pain specialists.4
UNITED KINGDOM
In the UK, doctors have been able to prescribe cannabis flower, oil, capsules and cartridges to support a number of conditions since 2018. A study of over 2300 patients receiving medical cannabis prescriptions looked at the patients’ perceived stigma. Participants felt a high prevalence of perceived stigma from society and healthcare. Of these patients, 40% were afraid of what the justice system, the police, government agencies and healthcare professionals thought. Only 38% thought that healthcare was approving or even somewhat approving of their prescription.5
CANADA
The University of British Columbia studied stigma around medical cannabis and found that patients were labeled irresponsible and unreliable by society including healthcare providers. The stigma of medical cannabis use had a negative impact on the relationship between patients and healthcare workers and this was a barrier to receiving needed care.6
US
The profession of nursing in the US has been affected by the stigma of medical cannabis especially because of its Schedule I status. It takes a great deal of courage to stand out among others in the profession proclaiming to be a medical cannabis advocate. Eloise Theisen, a Board Certified Nurse Practitioner and leader in the cause of nursing’s role in medical cannabis advocacy states:
“Often I hear from other healthcare professionals that they don’t want to discuss it or even learn about it because of that schedule and status. It does prohibit them from exploring it. I’ve seen more nurses and nurse practitioners’ sort of lead the change and get educated, which is not surprising.”7
I was faced with my own stigma bias when my friend asked me about providing the option of cannabis to my mother. "Why would you not want to improve her quality of life?" he asked. I replied tearfully.
“I don’t know how to answer that question. I don’t know why I can’t talk to my mother about cannabis! I don’t know where to start. What am I supposed to tell her? It’s illegal and her doctors don’t prescribe it. Should I be truthful? How do I even begin to get her to take it? I believe she will be against it. Should I just do it secretively?”
I was tormented by this dilemma. I had a way to help my mother suffer less, but I was afraid to even approach the topic. My mother was in the early stages of dementia, but she was still engaged and included in her care. The conversations with any of her doctors about cannabis were at best discouraging. Her neurologist claimed it was “hogwash” and two other providers just shrugged and said they did not know. The fear of talking to her about it was gripping, but living with the regret of not trying cannabis to help her, kept me up at night.
The nursing profession is trusted and relied upon by healthcare systems and patients. Part of the role of the nurse is to overcome bias and stigma, and educate, empower and support patients to make their best decisions without fear of judgment. Accordingly, the National Council of State Boards of Nursing, the sixth Principle of Essential Knowledge of medical cannabis for nurses is:
The nurse shall approach the patient without judgment regarding the patient’s choice of treatment or preferences in managing pain and other distressing symptoms.8
However, even in healthcare systems in states where medical cannabis is legal, there is bias and stigma that causes a barrier to this non-judgmental relationship. How do we overcome this vast invisible unspecified barrier to providing care?
PERSONAL AWARENESS
Nurses must bring their own personal awareness to raising consciousness of our own fears and beliefs, bias and stigma about medical cannabis and the patients who use it.
Knowledge and education is the language of the mind. But stigma goes deeper, for it is believed in the heart and the spirit. There was a time that each of us first learned about this medicine, and it is possible that, out of fear, we did not speak about it beyond our small circles. Just as I was hesitant to speak to my mother about cannabis, others may find barriers in speaking to family, physicians, pastors, neighbors and friends.Gratefully, many have found the courage to do the necessary inner work, gain education, find professional communities that support access to medical cannabis, and engage in advocacy.
SOCIAL AWARENESS
An important first step is awareness that cannabis stigma exists and that it is a barrier. This awareness provides an opportunity to ask questions and start researching the depth of the issues and how to solve them. The trend with other stigmas has been that eventually, with enough education and advocacy, society will change its outlook, setting an agenda based on common values. Though this has not yet happened, research shows that cannabis stigma can be reduced by appealing to common values like healing, reducing suffering and patients’ rights10 - all areas in which nursing plays a critical role. Knowing what the end result feels and looks like is also helpful to reaching the goal. Newhart and Dolphin describe this shift:
“Social scrutiny shifts from the person being stigmatized to those who impose the judgments. The once stigmatized person is now defined as being unfairly discriminated against.”9
WHERE DO WE GO FROM HERE
There is a magic wand of hope. Nurses are having their own experiences facing stigma. Cannabis nurses understand with empathy what it feels like for patients who face cannabis related stigma. We are able to act as peers with our patients. We can use our experiences and professional expertise in relationship with patients to help guide those who are taking their own discovery journey. We can be patient with our patients just as we may have needed to be patient with ourselves.
I will remember and learn from the inner torment I had when faced with the cannabis stigma I experienced with my mother. Those feelings are valuable for they allow me to feel empathy in caring for others faced with their own decisions clouded by stigma. As a nurse I can approach patients without judgment regarding their treatment choices or preferences in managing their health. By rejecting bias and stigma and replacing them with awareness, education, empathy, non-judgement and peer relationship cannabis nurses build bridges to change.
Acknowledgement
I am grateful to Meg Little, EdD for providing encouragement, inspiration, and editing support.
References