Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

Mount Hood, Oregon as seen from the Washington State side of the Columbia River Gorge/photo by Julianna Paradisi

Mount Hood, Oregon, as seen from the Washington State side of the Columbia River Gorge/photo by Julianna Paradisi

Wednesday, July 9, 2014, marked the first day of legal, recreational marijuana sales in the state of Washington, not long behind similar new laws in Colorado earlier this year. As in Colorado, the marijuana supply in Washington was initially insufficient to keep up with demand; stores ran out of cannabis before all customers waiting hours in line got through the front door.

The following weekend, my husband and I (we live in Portland, Oregon) took a road trip through the Columbia Gorge on the Washington side of the river.

“Hey, we could buy a joint here, and share it,” I joked. (Neither of us actually partakes.)

My husband, a pharmacist, remarked, “It may be legal, but testing positive at work could get either of us fired or invite state board investigation.”

For my husband and me, as Oregon residents, the point is moot: no amount of THC in our urine or blood is legal. For Washington and Colorado residents, however, the newly legalized status of marijuana creates confusion for employers and employees alike. In Washington and Colorado, a drug test positive for THC is no longer illegal, but being under the influence of legal substances like alcohol, for instance, violates employer policies.

This fact was illustrated in the news on the very first day of marijuana sales in Washington. A Spokane resident was fired when his purchase became public. Since then, the man has been rehired. After considerable media coverage, the company decided that, since he had the day off when he made the purchase, he was not under the influence while at work, the possibility of which is the underlying rationale for their drug testing policy.

Does being a nurse or health care provider add another layer of complexity to this issue? I think so. Positive drug tests are not acceptable for the majority of nurses and health care professionals. Smoking a joint legally in Washington over the weekend means that THC may remain detectable in urine for about a week, and longer for regular smokers.

You can see the dilemma: It may be legal for a nurse, pharmacist, or surgeon to smoke cannabis in Washington, or Colorado, but you probably also want to know that they are not under the influence of any mind-altering substances, legal or otherwise, during patient care. And, crucially, a positive drug level indicating intoxication has not been established for cannabis, as it has for alcohol.

What I foresee as an initial solution is that hospitals and clinics may make clean drug tests a requirement of employment (many already do). This may sound invasive or behind the times, but remember, marijuana use, recreational or medical, remains illegal on the federal level. The current administration takes a relatively lenient approach to the matter, but future administrations are under no compulsion to do likewise. Then there’s the issue of workmen’s compensation insurance, which often requires drug tests to differentiate employee or employer liability for on-the-job injuries.

Further, compare hospital policies requiring drug-free employees to those applied by a rapidly growing number of hospitals to tobacco, which is legal throughout the United States. (See this recent AJN post on the ethics of such no-smoking policies.) In the same manner, hospital employers may be able to independently establish work policies that exclude the use of marijuana.

Recreational marijuana use may come to be restricted by state boards of nursing in a way that parallels their approach to alcohol use: impairment on the job will not be tolerated and will result in license suspension.

Surveys suggest that most people support decriminalization of recreational marijuana; however, the enforcement of safe workplace standards where it is legal is still in development. The presence of THC in blood or urine is not an indication of intoxication, but without an agreed upon blood level by which to measure intoxication, a more conservative approach to positive tests may win out in health care until a more nuanced approach becomes possible.

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