Medical Use of Marijuana
by Allan Barsky, PhD, JD, MSW
In various parts of the United States, medical use of marijuana (MuM) is both legal and prohibited. According to the National Conference of State Legislators, 36 states have approved comprehensive programs for MuM and 13 states have approved low-THC/high-CBD products for medical use. Fifteen states have legalized marijuana for recreational use by adults (National Conference of State Legislatures, 2020). States differ in terms of which conditions qualify for MuM. They also differ in terms of how MuM is regulated, monitored, and dispensed.
Federally, marijuana remains a banned substance under the Controlled Substances Act. In 2009, President Barack Obama issued a memo to federal prosecutors encouraging them not to prosecute people who distribute marijuana for medical purposes; still, it is legally possible to be prosecuted for possessing, producing, or trafficking marijuana, whether for medical or non-medical purposes (National Conference of State Legislatures, 2019).
To further complicate the situation, some employers, businesses, and social agencies prohibit their employees from using marijuana. Although some organizations offer exceptions permitting MuM, others do not. For social workers, the question arises, “From an ethics perspective, how should social workers help clients navigate systems when MuM may be legalized by the state, but prohibited by federal laws, the laws of other states and countries, and possibly prohibited by the organizations where they work or go to school?”
The short answer is “informed consent” (NASW [2018] Code of Ethics, s.1.03). As with any form of assistance, social workers should ensure that clients are familiar with the nature of the intervention, its potential benefits, and its potential risks. These risks include physical, psychological, legal, and social risks (including problems that may arise within their families and workplaces). Clients have a right to self-determination, including the right to determine whether MuM is appropriate for them. Although social workers do not prescribe MuM (or any other medications), they may be involved in helping clients make decisions about whether to use MuM and how to maximize the benefits of MuM and reduce the risks of MuM.
Consider, for instance, a clinical social worker who diagnoses a client with a mental illness that may be treated with MuM. The worker may refer the client to a psychiatrist or other physician who can prescribe MuM. In this role, social workers should learn about which physicians act ethically in assessing clients and prescribing MuM, as well as which physicians may be over-prescribing MuM without due consideration of the patient’s actual medical needs and the potential risks of MuM.
Facilitating Informed Consent in a Caring, Objective Manner
Social workers should be caring, nonjudgmental, and objective in their MuM discussions with clients. Social workers may have strong convictions about MuM. For instance, some social workers may feel strongly that psychoactive drugs are risky and should be avoided. These beliefs may stem from personal or family experiences, or from professional experience with clients with substance use disorders. These social workers may provide clients with information about the risks of marijuana. They should not impose their personal beliefs on clients, but rather, engage them in honest discussions about the risks and benefits of marijuana use, focusing on each client’s wishes, situation, needs, strengths, and vulnerabilities (NASW Code of Ethics, s. 1.01). Conversely, some social workers may feel strongly that marijuana is beneficial and low-risk. They may support both recreational and medical use of marijuana. Again, these social workers should avoid imposing their personal beliefs and respect the client’s choices about whether to use MuM.
Before discussing MuM with clients, social workers should inform themselves about the different uses of marijuana (National Institute on Drug Abuse, 2019). Although there is significant support for the effectiveness of MuM in helping people with some conditions (e.g., nausea, pain, anxiety), the research is less clear in relation to treating other conditions (e.g., epilepsy, inflammation, and substance use disorders). Social workers should consult current research on various methods of using MuM (e.g., edibles, smoking, vaping). Although vaping was originally thought to be a relatively low-risk method of ingesting marijuana, for instance, recent deaths among people who vape have caused considerable concern about the risks of vaping.
When referring clients to speak with physicians about MuM, social workers may offer clients a list of questions to discuss:
- What does current research say about MuM for treating patients with my condition? How can I obtain access to these studies?
- What benefits should I experience from MuM? How will I know if MuM is helping me?
- What risks or possible complications of MuM should I consider? How can I minimize these risks?
- What types of situations or activities may affect my ability to use or benefit from MuM (e.g., pregnancy, prior mental health or addiction issues, operating machinery for work, driving, crossing state or international boundaries, taking care of young children, noncitizens seeking visas or citizenship)?
- What is the cost for MuM, and how will it be paid? (Note: health insurance companies do not cover MuM, because it is prohibited federally as a Schedule 1 drug. Also, dispensaries typically require cash payment rather than check or credit card.)
Clients may not know, for instance, that they may be violating federal and state laws if they travel across state or international boundaries with their MuM. They may also not know that their ability to drive or engage in other activities may be impaired when they are using MuM.
Mezzo and Macro Responses
In addition to helping clients on an individual level, social workers should consider how they can help on mezzo and macro levels. Given the historical associations of marijuana with crime and deviant behavior, people who use MuM may face stigma within their families, workplaces, communities, and other social circles. If a spouse or employer, for instance, disapproves of the client’s MuM, the social worker could offer information, advocacy, and support on behalf of the client.
Under the Americans with Disabilities Act, for instance, employers may not discriminate against employees on the basis of medical or mental health conditions. If an employer disciplines or fires an employee for a positive drug test for MuM, this might constitute a violation of the Americans with Disabilities Act or particular state statutes. The laws and court rulings on this issue have varied from state to state. Social workers could provide clients with basic information about the relevant laws. They could also connect clients with attorneys for legal advice, including options for responding to the employer’s actions.
Some people may have misconceptions about MuM. For instance, they might view marijuana as a gateway drug; that is, a person who uses MuM may be destined to use and become addicted to more potent and more dangerous drugs. Social workers may respond to these misconceptions by noting that most people who use marijuana do not become addicted to other licit or illicit psychoactive drugs. Although some people who use marijuana do go on to use other psychoactive substances, there are various reasons for this progression of use. The individual may be more vulnerable to drug use because of psychological or social conditions (stress, trauma, poverty, isolation). One of the advantages of MuM is that the client receives monitoring and counseling, which can address underlying psychological or social issues.
Self-Awareness
According to the principle of respect for the dignity and worth of all people, social workers know that they should not impose their beliefs on others. Being respectful of client beliefs and wishes requires social workers to have a high level of awareness of their own beliefs, feelings, and convictions. To help raise awareness about your own attitudes and beliefs toward MuM, consider the following questions:
- What do I think about the benefits, appropriateness, and risks of MuM?
- How did I form my beliefs and convictions about MuM (e.g., through personal or family experience, professional experiences with clients, formal education, reviewing the research)?
- On a scale of 1 to 5, how difficult would it be for me to respect a client’s beliefs or decisions about MuM if these beliefs or decisions conflicted with my own?
- Which types of assistance could I access to ensure that I am being respectful of my client’s beliefs and wishes (e.g., personal reflection, supervision, counseling)?
- When engaging a client in a discussion about MuM, what can I do to ensure that I am following the ethical principles of respect, care, honesty, and informed consent?
You may consider similar questions with regard to other medication-assisted treatments, for instance, methadone or buprenorphine for opiate addiction, antidepressants for depression, LSD for PTSD, chemotherapy for cancer, or PrEP for pre-exposure prevention to HIV. Consider why we may have different beliefs and stigma about different forms of medication. Consider, also, how our clients may be affected by the ways our laws regulate or prohibit substances that could be used to treat various bio-psycho-social conditions.
Feel free to share your thoughts in the comments section. Please continue the dialogue.
References
National Academies of Sciences, Engineering, and Medicine. (2017). The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2017/Cannabis-Health-Effects/cannabis-conclusions.pdf?_ga=1.153874296.1929557111.1484251916
National Association of Social Workers. (2018). Code of Ethics. https://www.socialworkers.org/about/ethics/code-of-ethics/code-of-ethics-english
National Conference of State Legislatures. (2020). State medical marijuana laws. https://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx
National Institute on Drug Abuse. (2019). Drug facts: What is medical marijuana? https://www.drugabuse.gov/publications/drugfacts/marijuana-medicine
Allan Barsky, PhD, JD, MSW, is Professor of Social Work at Florida Atlantic University and author of Social Work Values and Ethics (Oxford University Press).
The views expressed in this article do not necessarily represent the views of any of the organizations to which the author is affiliated, or the views of The New Social Worker magazine or White Hat Communications.