The Marijuana Opportunity Reinvestment and Expungement Act
The Marijuana Opportunity Reinvestment and Expungement Act, or the MORE Act, was introduced on July 23, 2019, and on December 4, 2020, the U.S. House of Representatives voted in its favour (Marijuana Opportunity Reinvestment and Expungement Act, 2019-2020). On December 7, 2020, this legislation was received by the Senate and read twice before being referred to the Committee of Finance (Marijuana Opportunity Reinvestment and Expungement Act, 2019-2020). This is where this legislation currently stands today.
The goal of this paper is to describe, analyze and evaluate this policy decision. First, an analysis of the policy will be provided for the reader. This paper will then go on to discuss the policy’s impact and effectiveness, any unintended effects on the target population, healthcare-related costs, as well as the effects on the role of the nurse practitioner.
We chose to analyze this policy with the consideration that if passed, this legislation will impact public health and the practice of nurse practitioners in the United States. After careful analysis, we have decided to support the MORE Act because of its benefits to the medical cannabis community as well as the general population.
Analysis of the MORE Act
The main purpose of the MORE Act is to federally decriminalize marijuana, which in the legislature has been referred to as both “marihuana” and “cannabis” (Marijuana Opportunity Reinvestment and Expungement Act, 2019-2020). For clarity purposes, throughout this paper, “marijuana” or “marihuana” will be referred to as “cannabis”. Furthermore, if passed, this legislation would remove cannabis from the list of scheduled substances under the Controlled Substances Act (Marijuana Opportunity Reinvestment and Expungement Act, 2019-2020). Under current federal law, cannabis is classified as a Schedule I controlled substance besides drugs like heroin, lysergic acid diethylamide (L.S.D.), and ecstasy. Some of the factors considered when classifying a drug as a controlled substance include a drug’s potential for abuse, its pharmacological effect, and the risk it poses to public health. Specifically, to be classified as a Schedule I drug, there must be a high potential for abuse, there must not be any accepted medical use for the drug in the United States, and there must be a lack of accepted safety for the use of the drug under medical supervision (Schedules of Controlled Substances, 2018).
If passed, it would end the criminalization of cannabis for adults by removing it from the list of controlled substances, eliminating related criminal penalties, and taking several other major steps toward criminal justice reform, social justice, and economic development (Marijuana Policy Project, 2021).
The MORE Act was introduced in the House on July 23, 2019, and on December 4, 2020, it was passed in the House. From the House, it was referred to the Committee on Finance. It was co-sponsored by one hundred and twenty Democratic representatives and one Republican representative. It has addressed the fact that there have been communities that have been harmed by the “War on Drugs,” a Nixon-era slogan that instituted harsh punitive measures against drug users and drug dealers. It has addressed the racial injustices that have come to fruition because of the war on drugs, including incarceration, racial profiling by government agencies, and even a cause of deportations. Written into the Act is how to retroactively adjudicate those who have already served time or been otherwise punished by cannabis laws (Congress.gov, n.d.).
The Act stipulates that tax received from sales of cannabis go into a trust fund. The trust fund, known as the Opportunity Trust Fund, would go to funding a Cannabis Justice Office. This Cannabis Justice Office would be in charge of a Community Reinvestment Grant Program that would serve the community by way of literacy programs, reentry programs, and substance abuse treatments. The Act would also fund a Cannabis Opportunity Grant Program, which would fund small businesses in the cannabis industry. The third grant funded would be the Equitable Licensing Grant Program. This program addresses cannabis licensing for those seeking employment that uses cannabis (U.S. House Committee on the Judiciary, 2019).
Effective Health Benefits of Cannabis
There are many reasons that cannabis is relevant and appropriate for use in the healthcare setting. One major reason is there is a correlation between reduced body mass among cannabis users (Clark et al., 2018). Obesity is one of the major factors in many disease processes in developed countries. It is a risk factor for conditions such as diabetes, hypertension, metabolic syndrome, chronic pain, and arthritis. Along with obesity, there is evidence, too, that cannabis use can be correlated with lower levels of fasting insulin (Penner et al., 2013).
Many people seek out cannabis for pain management. It is often prescribed for pain in cancer patients, treatment for multiple sclerosis (M.S.), as well as other disease processes that other analgesics are ineffective against. Research shows that it is effective for pain management, with an average reduction of three points in pain on a scale of one to ten (Li et al., 2019).
Interestingly enough, there is some evidence that cannabis can stimulate brain cell growth, as well (University of Saskatchewan, 2005). This older study showed that when rats were exposed to a synthetic strain of cannabis, there was neurogenesis in the hippocampus. This finding is also supported by more recent studies that show that, while the mechanism is still unknown, there is promising evidence that cannabinoids play a role in some phases of adulthood. neurogenesis (Prenderville et al., 2015). Both studies surmise that cannabis and cannabinoids can play an important role in the treatment of memory disorders and mood disorders.
Not only does cannabis have merit in physical medicine, but it can also play a major role in psychiatric medicine. There has been evidence that patients diagnosed with bipolar I disorder and a history of cannabis use disorder scored better for overall neurocognitive performance (Braga et al., 2012). Research has also been done that shows cannabis can be an effective treatment for some types of schizophrenia, as it can target the neuroinflammation often associated with schizophrenia (Diviant et al., 2018).
In the same vein, neuroinflammation is seen in Alzheimer’s disease. Research has also shown that THC-CBD combined can be effective in treating and preventing the disease. It has shown increased memory, and it is postulated that it could even be an effective preventative measure for those at risk (Kim et al., 2019).
Unintended Effects on the Target Population
Reduction in Opioid-Related Deaths
Research suggests a potential association between the increased prevalence of cannabis dispensaries and a reduction in opioid-related overdose deaths (Hsu & Kovács, 2021). Research published in the British Medical Journal shows that between 2014 and 2018, there was a seventeen per cent reduction in opioid deaths in regions with at least one cannabis dispensary (Hsu & Kovács, 2021). Data further showed when the number of shops in the area increased from one to two, opioid deaths in the area fell by twenty-one per cent (Hsu & Kovács, 2021). Furthermore, an additional eight-point five per cent reduction in opioid deaths was seen in regions when a third dispensary was present in the area (Hsu & Kovács, 2021). This collection of data shines a light on how medicinal cannabis can assist in reducing opioid-related overdose deaths in communities.
Effects on Older Patients
Providers must always consider the age of patient populations when considering the use of medicinal cannabis treatment. Abuhasira et al. (2019) conducted a study to evaluate the effectiveness and safety of medical cannabis in patients over the age of sixty-five. What was found was that eighty-four-point-eight per cent of respondents reported some sort of degree of relief from pain (Abuhasira et al., 2019). Of note, thirty-three-point six per cent of respondents reported adverse events to medical cannabis, of which the most common were dizziness, sleepiness, and fatigue (Abuhasira et al., 2019). Providers must also be cautious with older adults because of polypharmacy, pharmacokinetic changes, nervous system impairment, and increased cardiovascular risk (Abuhasira et al., 2019).
Pediatric and Pregnancy Concerns
The legalization of cannabis will directly increase the availability and prevalence of its use, and it is important to consider other unintended effects on populations. One main concern to consider is what effect legalizing cannabis will have on pediatric populations. Pediatric patients are at risk as they will likely be more susceptible to unintentional exposure to cannabis, which can occur prenatally, in childhood, and all the way through adolescence.
Pregnant women sometimes use cannabis during pregnancy to treat common symptoms experienced during pregnancy, like depression, anxiety, stress, pain, nausea, and vomiting (Wang, 2017). It is known that tetrahydrocannabinol (T.H.C.) rapidly crosses the human placenta when mothers use cannabis during pregnancy (Wang, 2017). Although research is limited on the effects of cannabis exposure in utero, there is some evidence that indicates prenatal exposure leads to decreased I.Q. scores, cognitive function, and attention (Wang, 2017).
There is also a concern for unintentional exposure in young children, specifically related to the risk of accidental edible ingestion. From 2005 to 2011, poison control centres saw a significant increase in calls by thirty-point-three per cent in decriminalized states compared to non-legal states had an increase of one-point-five per cent per year (Wang, 2017). Furthermore, exposure in legal states had more major and moderate effects and admissions to critical care units due to cannabis exposure in children (Wang, 2017).
Adolescents will also be affected by the legalization of cannabis. Research has shown that adolescents who use cannabis are more likely to have impaired cognitive and academic abilities despite twenty-eight days of abstinence (Wang, 2017). Other studies also show that adolescents who use cannabis are less likely to graduate high school and attain a college degree (Wang, 2017). Furthermore, the likelihood of addiction to other drugs after adolescence, including tobacco, alcohol, and opioid analgesics, increases in adolescent cannabis users (Wang, 2017).
Effects on the Role of the Nurse Practitioner
Nursing Implications
The National Conference of State Legislatures (NCSL) (2021) notes that currently, there are a total of thirty-six states that have approved comprehensive, publicly available medical cannabis programs in addition to the following territories: District of Columbia, Guam, Puerto Rico, and U.S. Virgin Islands. A comprehensive medical cannabis or “marijuana” program (M.M.P.) is one that provides protection from criminal penalties for using cannabis for medical purposes and provides access to cannabis, whether it be through home cultivation, dispensaries, or some other system (NCSL, 2021). Such programs also allow for a variety of strains and products, allow for the product to be smoked or vaped, and comprehensive programs cannot be considered limited trial programs such as the ones in South Dakota and Nebraska (NCSL, 2021).
Nurse practitioners need to be aware, though, of the rules that govern the state in their practice. There are several federal, state, and local laws that the nurse practitioner needs to be aware of to protect himself or herself from any sort of legal recourse. Each individual state has what are known as qualifying conditions for marijuana use, and it is important to be informed of the specific conditions in the state in which one practices.
NCSBN National Nursing Guidelines for Medical Marijuana
Nurses need practical information to care for the increasing number of patients who utilize cannabis via a medical marijuana program (M.M.P.) as well as the larger population who self-administer cannabis as a treatment for various symptomatology or for recreational purposes (NCSBN, 2018). As noted previously, evidence for cannabis use in described conditions is limited by inadequate study and limited legal availability of cannabis for research purposes since it has been a Schedule I controlled substance. Statutory authorization of cannabis use for certain conditions has been influenced by advocacy for the necessity of the drug as a therapeutic tool, and as a result, some qualifying conditions are present in statutes without evidence of their actual effect. Regardless of existing evidence, individuals are using cannabis, and nurse practitioners will care for these patients. The NCSBN (2018) reviewed the studies and literature and compiled the six principles of essential knowledge, which are suggestions to support and inform nursing practice that represents the best interests of the patient surrounding the use of cannabis.
Six Principles of Essential Knowledge
Critical to the care of patients who utilize cannabis is a “working knowledge of the current state of legalization of medical and recreational cannabis use” (NCSBN, 2018, p.19). Knowledge of the federal government prohibitions and any guidance from the federal government allows the nurse practitioner to be well-informed regarding potential questions about the legality of the use of cannabis as a medical treatment.
The nurse practitioner will need to have “working knowledge of the jurisdiction’s M.M.P., including the rules and statutes specific to the individual jurisdiction” (NCSBN, 2018, p.19). Each jurisdiction has vastly different laws, rules, and regulations regarding medical cannabis. The jurisdiction’s M.M.P. or Department of Health will provide specific details in each jurisdiction (NCSL, 2021). The laws regarding the M.M.P.s are frequently changing, and adopting safe nursing practices includes an awareness of any regulatory changes that may affect their practice.
As future providers with prescriptive authority, one would prescribe a medication with a specific dose, route, and frequency. However, a healthcare provider cannot prescribe medical cannabis, the provider only certifies that the patient has a state-qualifying condition that may benefit from the use of cannabis (NCSBN, 2018). Several jurisdictions identify an advanced practice registered nurse (APRN) as one of the health care providers who can certify that a patient has a qualifying condition. Access to medical cannabis can only be obtained once the patient visits a state-authorized cannabis dispensary with a valid registration to the M.M.P. (NCSBN, 2018). NCSBN (2018) notes that the nature of the certification process is different from any other substance recommended to a patient by a healthcare provider, and the NCSL (2021) notes that an M.M.P.’s certification process presents a unique set of implications.
Healthcare practitioners who certify that a patient has a qualifying condition need to consider all aspects of the patient’s history, diagnostic information, and mitigating concerns, including the fact that cannabis is a known substance of abuse and therefore possesses a potential risk for addiction (NCSBN, 2018). Additionally, NCSBN (2018) notes that because medical cannabis is not covered by insurance or Medicare, the use of medical cannabis may impose a significant financial burden on the patient and due consideration must be given to this potential financial and social impact. Patients that utilize M.M.P.s are frequently debilitated by their condition and so some state laws and rules have allowed for “designated caregivers” to assist with the patient’s medical use of cannabis (NCSL, 2021). Massachusetts is one of the few states that permits assistance in the medical use of cannabis by a visiting nurse, home health aide, or employee of a hospice provider to assist in the qualifying patient’s cannabis administration (NCSL, 2021).
NCSBN (2018) highlights the importance of nurses “understanding the endocannabinoid system, cannabinoid receptors, cannabinoids, and the interactions between them” in full prior to certifying a patient eligible for an M.M.P. (p.20). Endocannabinoids are naturally occurring substances within the body, while phytocannabinoids (plant substances that stimulate cannabinoid receptors) are found in cannabis. The most well-known of these cannabinoids is T.H.C.; however, according to NCSBN (2018), CBD and CBN are gaining interest in therapeutic use and are all present in raw cannabis.
Research related to cannabis use in humans is limited due to government restrictions on research involving cannabis. Therefore, information regarding the medicinal use of cannabis must be derived from credible research using randomized placebo-controlled studies. NCSBN (2018) notes that the nurse should have an “understanding of cannabis pharmacology and the research associated with the medical use of cannabis” (p.20). Present available scientific evidence exists for the use of cannabis in the specific qualifying conditions: cachexia, chemotherapy-induced nausea and vomiting, pain related to cancer or rheumatoid arthritis, chronic pain resulting from fibromyalgia, neuropathies resulting from HIV/AIDS, multiple sclerosis (M.S.), or diabetes, and spasticity from M.S. or spinal cord injury (NCSBN, 2018).
Other important considerations are the adverse effects of cannabis, specifically the risks to various patient groups, concerns regarding abuse of drug or license, dependence, overdose, and withdrawal, as well as drug-to-drug interactions. Most cannabis preparations are not included in F.D.A. drug resources. The only FDA-approved dosing guidelines for cannabinoids are for the drugs dronabinol and nabilone, which are synthetically derived T.H.C. (NCSBN, 2018). As stated previously, patients do not receive a prescription for medical cannabis, noting the specific dosage, dosing schedule, or recommended delivery method. Nurse practitioners must be aware and knowledgeable of the general information regarding various methods of administration and the principles of self-titration dosing. The state-authorized cannabis dispensary often gives the patient advice regarding route and dosage, following the self-titration method of dosing, but the continual assessment of perceived efficacy and adverse effects is recommended by the provider (NCSBN, 2018).
According to the NCSBN (2018) suggestions, the nurse needs to be able to “identify the safety considerations for patient use of cannabis” (p.20). Administration of medical cannabis can only be carried out by the certified patient or the designated caregivers registered to care for the patient, according to the M.M.P. (NCSBN, 2018). Healthcare professionals may administer medical cannabis according to the M.M.P. and facility policy (NCSL, 2021). Proper storage and safety education needs to be addressed, including keeping out of the reach of children, minors, and non-registered individuals, storing all cannabis products in a locked area, keeping cannabis in child-resistant packaging from the store, and how to properly store raw cannabis so that it stays fresh for proper use (NCSBN, 2018).
The final and sixth suggestion noted by the NCSBN (2018) was that the nurse should “approach the patient without judgment regarding the patient’s choice of treatment or preferences in managing pain and other distressing symptoms” (p.20). As future APRNs, one must uphold the core nursing values and provide care that resonates with the moral principles that guide one’s conduct. One must acknowledge their own moral principles and ethics that guide the care, in addition to the standards of practice that guide one’s professional values.
Awareness of one’s own beliefs and attitudes about any therapeutic intervention is vital, as nurses are expected to provide patient care without the personal judgment of patients (NCSBN, 2018). NCSBN (2018) highlights how the evolution of legislation, social acceptance, and scientific evidence can create ethically challenging patient care situations and being able to know where one stands with these more controversial patient scenarios will prepare one to provide more competent care for the population they serve.
Recommendations
For nursing to embrace the holistic approach, it touts as its core philosophy, the inclusivity of marijuana as a treatment option should be paramount. There are, as aforementioned, significant benefits for cannabis as an alternative treatment option in a variety of settings; obesity management, psychiatric treatment, pain management, and even a reduction in opioid-related deaths. Opioids are a current public health crisis, as well as obesity and mental health. To have an alternative option, such as marijuana, that has been researched and proven to have good outcomes is something to be acknowledged, not only by those in the medical field but by the people who stand behind the laws and policies that define its boundaries. Aside from the historic propaganda and stigma attached to cannabis use, it is an effective treatment modality, and the time has come for the drug to be used in a setting to benefit the health and well-being of those who utilize it.
Another benefit to the MORE Act is the release of offenders and the establishment of a trust fund for communities that have suffered from drug criminalization. The African American community, for example, has what is referred to as the school-to-prison pipeline theory. Harsh punishments for cannabis have contributed to this pipeline for the African American community, and as nurses, advocating for those who are unable to advocate for themselves is another tenet of the nursing philosophy (ACLU, n.d.).
Recommendations, at this time, would be to wholly support the MORE Act, educate other providers about the numerous benefits of cannabis as a treatment, and educate patients who would benefit from the use of cannabis, as well as patients whose lives have been affected by criminalized cannabis. Up-to-date and relevant continuing education should be provided to nurse practitioners, medical doctors, physician assistants, staff nurses, and any other necessary healthcare personnel certifying M.M.P.s or caring for patients using the drug. The pros and cons of the use of marijuana should be weighed, just as any other medication would be, and a personalized plan of care should be used for everyone who is certified to utilize it. Patients who use it recreationally should not be admonished or afraid to confide in their healthcare providers, and providers should understand any reactions or effects recreational use would have on other treatment modalities currently prescribed to patients.
As far as more specifics, it should be recommended that practitioners consult with lawyers and have specific policies in place in their places of work to protect them from any legal repercussions. Other specific recommendations would be for nurse practitioners to evaluate their own ethics and do what they are comfortable with while promoting beneficence for the patients they care for.
References
Abuhasira, R., Ron, A., Sikorin, I., & Novack, V. (2019). Medical Cannabis for Older Patients-Treatment Protocol and Initial Results. Journal of clinical medicine, 8(11), 1819. https://doi.org/10.3390/jcm8111819
ACLU. (n.d.). War on drugs. Retrieved from: https://www.aclu-wa.org/drug-policy?page=10 Braga, R. J., Burdick, K. E., Derosse, P., & Malhotra, A. K. (2012). Cognitive and clinical Outcomes associated with cannabis use in patients with bipolar I disorder. Psychiatry Research, 200(2-3), 242–245. https://doi.org/10.1016/j.psychres.2012.05.025
Clark, T., Jones, J., Hall, A., Tabner, S., & Kmiec, R. (2018). A theoretical explanation for reduced body mass index and obesity rates in cannabis users. Retrieved from: https://www.liebertpub.com/doi/pdf/10.1089/can.2018.0045
Congress.gov. (n.d.). H.R. 3884 – MORE Act of 2020. Retrieved from: https://www.congress.gov/bill/116th-congress/house-bill/3884
Diviant, J. P., Vigil, J. M., & Stith, S. S. (2018). The role of cannabis within an emerging perspective on schizophrenia. Medicines (Basel, Switzerland), 5(3), 86. https://doi.org/10.3390/medicines5030086
Hsu, G. & Kovács, B. (2021). Association between county-level cannabis dispensary counts and opioid-related mortality rates in the United States: panel data study. B.M.J., m4957. https://doi.org/10.1136/bmj.m4957
Kim, S. H., Yang, J. W., Kim, K. H., Kim, J. U., & Yook, T. H. (2019). A review on studies of marijuana for Alzheimer’s disease – focusing on CBD, T.H.C. Journal of Pharmacopuncture, 22(4), 225–230. https://doi.org/10.3831/KPI.2019.22.030
Li, X., Vigil, J., Stith, S., Brockelman, F., Keeling, K., & Hall, B. (2019, October). The effectiveness of self-directed medical cannabis treatment for pain. Complementary Therapies in Medicine, 46, 123-130. https://doi.org/10.1016/j.ctim.2019.07.022.
Marijuana Opportunity Reinvestment and Expungement Act, H.R. 3884, 116th Cong. (2019- 2020). https://www.congress.gov/bill/116th-congress/house-bill/3884
Marijuana Policy Project. (2021). The MORE act. https://www.mpp.org/policy/federal/the-more- act/
National Conference of State Legislatures (NCSL). (2021). State medical marijuana laws. https://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.
NCSBN. (2018, July). APRNs are certifying a medical marijuana qualifying condition. Retrieved from: https://www.journalofnursingregulation.com/article/S2155-8256(18)30097-8/pdf Penner, E., Buettner, H., & Mittleman, M., (2013, July 1). The impact of marijuana use on glucose, insulin, and insulin resistance among U.S. adults. The American Journal of Medicine. 126(7), 583-589. https:// https://doi.org/10.1016/j.amjmed.2013.03.002
Prenderville, J. A., Kelly, Á. M., & Downer, E. J. (2015). The role of cannabinoids in adult neurogenesis. British Journal of Pharmacology, 172(16), 3950–3963. https://doi.org/10.1111/bph.13186
Schedules of Controlled Substances, 21 U.S.C. § 812 (2018). https://www.govinfo.gov/content/pkg/USCODE-2018-title21/html/USCODE-2018- title21-chap13-subchapI-part-sec812.htm
The University Of Saskatchewan. (2005, October 16). University of Saskatchewan research suggests marijuana analogue stimulates brain cell growth. ScienceDaily. Retrieved February 8, 2021 from www.sciencedaily.com/releases/2005/10/051016083817.htm
U.S. House Committee on the Judiciary. (2019, November 18). Chairman Nadler announces markup of the MORE Act. Retrieved from: https://judiciary.house.gov/news/documentsingle.aspx?DocumentID=2152
Wang, G. S. (2017). Pediatric concerns due to expanded cannabis use: unintended consequences of legalization. Journal of medical toxicology: official journal of the American College of Medical Toxicology, 13(1), 99–105. https://doi.org/10.1007/s13181-016-0552-x
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Question 
Describe a model that you might use to introduce a policy change related to the Marijuana Opportunity Reinvestment and Expungement Act (MORE) of 2019.
The Marijuana Opportunity Reinvestment and Expungement Act
How would you implement that model? (The model can be nursing or non-nursing related)
Instructions: This is a discussion post; 1 or 1 1/2 pages of content is enough. Please, it has to be in APA format, and it MUST provide 3 references or more.