On Feb 19, 2017, an article entitled, “When Retirement Comes with a Daily Dose of Cannabis” was published in the New York Times. It discussed how a 98-year-old woman who lived in a nursing home was using medical marijuana for her neuropathy. She is allowed to buy medical marijuana from a dispensary, keep it locked in a box in her room and administer it to herself. In the past year, there has been a 250% increase in the use of medical marijuana in those ages 65 and older. In the state of Washington, Assisted living facilities have medical marijuana policies due to the increase in popularity. However, patients in states with no formal policy living in a skilled nursing or assisted living facility do not have access solely based on where they live despite the fact they may be candidates for medical cannabis.
Unfortunately, I think if formal policies are not adopted, patients might choose to use marijuana without their facility, physician, or nurse being aware. The push back may stem from the fact that most skilled nursing facilities are federally governed and funded by Medicare and Medicaid, and medical marijuana is still federally illegal. In addition, medical cannabis is not covered by insurances therefore patients in these facilities would have to purchase this on their own.
The research is well known that medical marijuana is therapeutic for treating a multitude of conditions that are not uncommon to the elderly population such as nausea and vomiting, chronic pain, muscles spasms, and neuropathy. It aids in sleep, increases appetite, works as an anti-inflammatory, antioxidant, anti-anxiolytic and neuroprotectant. Americans over 65 years of age account for fourteen percent of the nation’s population but use more than 30 percent of all prescription drugs. Medicare saved more than $165 million in 2013 on prescription drugs in DC and 17 states that allowed cannabis to be used as medicine. If every state in the nation legalized medical marijuana, the study forecast that the federal program would save more than $468 million a year on pharmaceuticals for disabled Americans and those 65 and older.
In my personal practice, I have seen many elderly with chronic pain that cannot tolerate opioids due to sedation, cognitive impairments, constipation who have done well with low-THC and/or Medical Cannabis. Subsequently, the caregivers and family’s responses have also included an additive benefit of an improvement in sleep, decrease anxiety/ in depression. Donald Smith is a 96-year-old gentleman that I initially met at Aventura Hospital and Medical Center in Jan 2016. I had performed a Kyphoplasty due to a lumbar compression fracture he sustained from a fall. He was discharged from the hospital with a prescription for Percocet and returned a few weeks later secondary to another fall resulting in another lumbar compression fracture and multiple rib fractures. We performed a paravertebral block for pain relief and tried topical analgesics. His daughter was adamant about not using opioids including hydrocodone and tramadol as a result of confusion, multiple falls and constipation.
I saw Donald in the office after he was discharged and he was miserable. He was experiencing intractable pain with every inspiration, at a high risk of developing pneumonia. He could not find a comfortable position and his daughter was frustrated in search of help. I started Donald on a topical and sublingual CBD hemp oil trying to layer the effects and abide by current law that states a Physician must have a 90-day relationship with the patient prior to recommending medical marijuana. He had minimal relief from these alternatives and his motivation and mood was deteriorating. I started him on a low THC tincture with still minimal improvement in his pain, sleep and mood. His daughter and I decided to escalate quickly to medical cannabis as it seemed he had limited time. Within days of him starting Trulieve’s Medical cannabis syringe, his daughter’s response to me in a text was, “20% THC seems to make a very big difference. We are just SO very grateful that he can enjoy his life without pain and without opioids.” He celebrated a recent birthday and anniversary with his wife in which his daughter sent me a picture of them eating ice cream cones, smiling. I saw him back in the office recently only to find him making jokes and expressing his gratitude with such positive, vibrant energy. His daughter’s biggest fear now is running out of products and she looks forward to a nearby dispensary opening soon. My only caveat is that I cannot stress the importance of monitoring these patients and communicating with their family as to educate them on the proper way of using medical cannabis, dosing and its many routes of delivery. The family must be in support of this decision and communicate with a Physician knowledgeable in Cannabis Medicine.
Learning about Cannabis has become addictive as it has changed my current treatment algorithm. For example, specifically, Cannabidiol (CBD) as it is non-psychoactive may be the preference when treating neurodegenerative diseases. CBD reduces nitric oxide synthase, suppressing inflammation and reduces lipid peroxidation and affects tau phosphorylation involved in progression of Alzheimer’s Disease (AD). In addition, activation of CB1 receptors can promote axonal growth response and neurogenesis.
THC has been shown to inhibit aggregation of plaques that are the hallmark for AD and autopsy studies have demonstrated an increase in expression of CB1 and CB2 receptors in these plaques. “Delusions, agitation, aggression, irritability, apathy, sleep and caregiver distress, were decreased when THC was added in an attempt to relieve symptoms of dementia in a recent 2016 Israeli study. Current treatment of AD involves drugs called AChE inhibitors that cause GI problems as well as hepatotoxicity.
Edibles may be the best option for seniors as they complain about not wanting to take one more pill. Poor nutrition and dehydration contribute to infection, constipation and health deterioration. Perhaps a small chocolate would be pleasurable and therapeutic as a delivery route. There has to be more emphasis on making their food choices appealing, preparing soft, tasty options to increase their appetite. Edibles have the benefit of lasting longer than other routes of administration therefore an edible after dinner may allow a patient to sleep well throughout the night.
Many other medical conditions affecting the elderly such as Cancer, Osteoporosis and Parkinson’s disease are well researched in terms of cannabis’ thereapeutic uses in treating symptoms or decreasing progression of disease. The beauty of Medical Cannabis especially in the elderly is the inability to cause an overdose or lead to death as opposed to many pharmaceuticals. Unfortunately, many times wonderful options and policies are not born until one suffers a personal, close to home tragedy and I hope it does not take watching a family member suffer but rather witnessing a family or friend survive due to this possible use of medical cannabis.
Dr. Michelle Weiner, is an Interventional Pain Management Physician board certified in Physical Medicine and Rehabilitation. She completed her residency and fellowship training at the University of Miami. Her specialty is focused on prevention, treatment, reversal of health deterioration, increasing function and managing pain. Dr. Weiner focuses on diagnosing and treating spine and musculoskeletal pain as well as chronic migraines.