Medical Cannabis in the Skilled Nursing Facility: A Novel Approach to Improving Symptom Management and Quality of Life.

Journal of the American Medical Directors Association Home

“Throughout the millennia, the cannabis plant has been utilized as a recognized therapy for pain relief and symptom management.

Following the Prohibition-era stigmatization and criminalization of all forms of cannabis of the early 20th century, there has been a recent nationwide and worldwide resurgence in interest and use of the cannabinoid compounds extracted from the cannabis plant, that is, medical cannabis.

Although at the Federal level, cannabis remains a Schedule I substance, 31 states have already decriminalized possession and use of medical cannabis for specific diagnoses.

It is noteworthy that many of these indicated diagnoses are prevalent in the skilled nursing facility (SNF). This creates regulatory concerns as SNFs and other healthcare facilities must maintain compliance with Federal laws, while balancing the individual resident’s rights to utilize medical cannabis where indicated.

The authors developed an innovative program that affords their residents the ability to participate in a state-approved medical cannabis program while remaining compliant with Federal law. As medical cannabis use becomes more widespread and accepted, clinicians providing medical care in healthcare facilities will encounter residents who may benefit from and request this alternative therapy.

Studies examining older adults that are utilizing medical cannabis legally have demonstrated significant decreases in prescription medication use, most notably a reduction in opioid analgesic usage. As such, medical cannabis should be viewed as an additional option in the clinician’s toolbox of therapeutic interventions for symptom relief.”

https://www.ncbi.nlm.nih.gov/pubmed/30580820

https://www.jamda.com/article/S1525-8610(18)30662-5/fulltext

Alcohol Use and Risk of Related Problems Among Cannabis Users Is Lower Among Those With Medical Cannabis Recommendations, Though Not Due To Health.

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“A small body of work has started developing cannabis use “typologies” for use in treatment and prevention.

Two potentially relevant dimensions for classifying cannabis use typologies are medical versus recreational cannabis use and the co-use of cannabis and alcohol.

Here we compare alcohol use and related problems between cannabis users with and without medical cannabis recommendations.

Cannabis users with medical cannabis recommendations drink less and have fewer alcohol-related problems than those without recommendations, even after adjusting for health status.”

https://www.ncbi.nlm.nih.gov/pubmed/30573025

Cannaboinoid Antiemetic Therapy.

Cover of StatPearls

“There are currently three cannabinoids available on the pharmaceutical market.  Dronabinol and Nabilone are both synthetic tetrahydrocannabinol (THC) which the FDA has approved for treatment of chemotherapy-induced nausea and vomiting (CINV) after the failure of a trial of first-line anti-emetics.  Both are also FDA approved to treat anorexia associated with AIDS.  Recently, the FDA has also approved a cannabidiol (CBD) product to treat seizures associated with Lennox-Gastaut Syndrome and Dravel Syndrome in pediatric patients. However, there is no FDA approved indication for its use as an anti-emetic.  Independently produced cannabidiol extracts are being used increasingly in the general population for many non-FDA approved indications, frequently including nausea and emesis.  In states that have decriminalized marijuana, both in recreational and medicinal contexts, products with varying ratios of cannabidiol and THC are also used for their anti-emetic properties.”

https://www.ncbi.nlm.nih.gov/pubmed/30571051

https://www.ncbi.nlm.nih.gov/books/NBK535430/

Use of marijuana exclusively for medical purposes.

Drug and Alcohol Dependence

“To characterize the socio-demographic characteristics, medical conditions, and psychiatric comorbidities of users of marijuana for medical and non-medical purposes.

RESULTS:

In relation to non-medical only users (n = 3339), combined (n = 362) and medical only (n = 82) users had higher prevalence of every medical condition examined. As compared to the combined use group, those using marijuana only for medical purposes were much less likely to have anxiety, alcohol, or non-medical prescription opioid use disorders.

CONCLUSIONS:

Medical-only users appear to use it for evidence-based medical reasons and have lower prevalence of substance use disorder than other marijuana users. Nonetheless, because most medical marijuana users also use non-medically, screening for psychiatric disorders and prevention efforts for cannabis use disorder should be implemented when authorizing medical marijuana.”

https://www.ncbi.nlm.nih.gov/pubmed/30557813

https://www.sciencedirect.com/science/article/pii/S0376871618305660?via%3Dihub

Medical Cannabis.

Mayo Clinic

“Medicolegal realities surrounding “medical marijuana” or “medical cannabis” are rapidly evolving in the United States. Clinicians are increasingly being asked by patients to share information about or certify them for medical cannabis. In order to engage in informed discussions with patients or be comfortable certifying them in states with medical cannabis laws, clinicians may benefit from an understanding of the current state of medical knowledge about medical cannabis. Intended for the generalist and subspecialist, this review provides an overview of the legal status, pharmacology, benefits, risks, and abuse liability of medical cannabis along with a general framework for counseling patients.”

Cannabinoids and Pain: New Insights From Old Molecules.

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“Cannabis has been used for medicinal purposes for thousands of years.

The prohibition of cannabis in the middle of the 20th century has arrested cannabis research.

In recent years there is a growing debate about the use of cannabis for medical purposes.

The term ‘medical cannabis’ refers to physician-recommended use of the cannabis plant and its components, called cannabinoids, to treat disease or improve symptoms.

Chronic pain is the most commonly cited reason for using medical cannabis.

Cannabinoids act via cannabinoid receptors, but they also affect the activities of many other receptors, ion channels and enzymes.

Preclinical studies in animals using both pharmacological and genetic approaches have increased our understanding of the mechanisms of cannabinoid-induced analgesia and provided therapeutical strategies for treating pain in humans.

The mechanisms of the analgesic effect of cannabinoids include inhibition of the release of neurotransmitters and neuropeptides from presynaptic nerve endings, modulation of postsynaptic neuron excitability, activation of descending inhibitory pain pathways, and reduction of neural inflammation.

Recent meta-analyses of clinical trials that have examined the use of medical cannabis in chronic pain present a moderate amount of evidence that cannabis/cannabinoids exhibit analgesic activity, especially in neuropathic pain.

The main limitations of these studies are short treatment duration, small numbers of patients, heterogeneous patient populations, examination of different cannabinoids, different doses, the use of different efficacy endpoints, as well as modest observable effects.

Adverse effects in the short-term medical use of cannabis are generally mild to moderate, well tolerated and transient. However, there are scant data regarding the long-term safety of medical cannabis use.

Larger well-designed studies of longer duration are mandatory to determine the long-term efficacy and long-term safety of cannabis/cannabinoids and to provide definitive answers to physicians and patients regarding the risk and benefits of its use in the treatment of pain.

In conclusion, the evidence from current research supports the use of medical cannabis in the treatment of chronic pain in adults. Careful follow-up and monitoring of patients using cannabis/cannabinoids are mandatory.”

https://www.ncbi.nlm.nih.gov/pubmed/30542280

https://www.frontiersin.org/articles/10.3389/fphar.2018.01259/full

What does the ecological and epidemiological evidence indicate about the potential for cannabinoids to reduce opioid use and harms? A comprehensive review.

 Publication Cover

“Pre-clinical research supports that cannabinoids reduce opioid dose requirements, but few studies have tested this in humans. This review evaluates ecological and epidemiological studies that have been cited as evidence that medical cannabis use may reduce opioid use and opioid-related harms. Medline and Embase were searched for relevant articles. Data were extracted on study setting, analyses approach, covariates, and outcomes. Eleven ecological and 14 epidemiological studies were found. In ecological studies, states that allow medical cannabis laws have reported a slower rate of increase in opioid overdose deaths compared with states without such laws. These differences have increased over time and persisted after controlling for state sociodemographic characteristics and use of prescription monitoring programmes. Few studies have controlled for other potential confounders such as opioid dependence treatment and imprisonment rates. Some epidemiological studies provide evidence that cannabis availability may reduce opioid use, but are limited by selection bias, cross-sectional designs, and self-reported assessments of the opioid-sparing effects of cannabis. Some epidemiological and ecological studies suggest that cannabis may reduce opioid use and harms, although important methodological weaknesses were identified. Well-designed clinical studies may provide more conclusive evidence on whether cannabinoids can reduce opioid use and related harm.”

https://www.ncbi.nlm.nih.gov/pubmed/30522342

https://www.tandfonline.com/doi/abs/10.1080/09540261.2018.1509842?journalCode=iirp20

Cannabis-related cognitive impairment: a prospective evaluation of possible influences on patients with cancer during chemotherapy treatment as a pilot study.

 

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“In patients with cancer, the use of medical cannabis has increased significantly during the recent years. There is evidence that cannabis consumption may affect cognitive performance; however, this potential effect has not been investigated prospectively in patients with cancer to date.

We aimed to evaluate the effect of cannabis consumption on cognitive abilities as well as on symptom relief in patients with cancer during chemotherapy treatment.

RESULTS:

Improvement in executive functioning was demonstrated in the case group. In aspects of symptoms, improvement in fatigue, appetite and sleep disorder was demonstrated after cannabis consumption. Patients consuming cannabis did not differ from the control group in cognitive functioning over 3 months of use. No significant cognitive decline was observed in either group over time.

CONCLUSION:

These preliminary findings suggest that the short-term use of cannabis during chemotherapy treatment improved disease-related symptoms and did not affect cognitive skills in patients with cancer.”

Health-related quality of life across cancer cachexia stages.

“Cancer cachexia (CC) is common in advanced cancer and is accompanied by negative effects on health-related quality of life (HRQOL).

However, methods to identify the impact of CC on HRQOL are limited.

Finally, the use of cannabinoids in treating appetite loss was examined,

54 patients underwent cannabinoid treatment for appetite loss within a community-based, physician-lead, medical cannabis clinic.

Edmonton Symptom Assessment System (ESAS) score for lack of appetite significantly improved between baseline and follow-up after cannabinoid treatment, with no significant difference in weight.

Improvement of HRQOL via appetite stimulation, may be achieved through a multidisciplinary approach, which includes cannabinoid therapy.”

Medical Cannabis for Older Patients.

“Interest in the medicinal use of cannabis and cannabinoids is mounting worldwide. Fueled by enthusiastic media coverage, patients perceive cannabinoids as a natural remedy for many symptoms. Cannabinoid use is of particular interest for older individuals who may experience symptoms such as chronic pain, sleep disturbance, cancer-related symptoms and mood disorders, all of which are often poorly controlled by current drug treatments that may also incur medication-induced side effects. This review provides a summary of the evidence for use of cannabinoids, and medical cannabis in particular, for this age group, with attention to efficacy and harms. Evidence of efficacy for relief of an array of symptoms is overall scanty, and almost all study participants are aged < 60 years. The risk of known and potential adverse effects is considerable, with concerns for cognitive, cardiovascular and gait and stability effects in older adults. Finally, in light of the paucity of clinical evidence and increasing patient requests for information or use, we propose a pragmatic clinical approach to a rational dialogue with older patients, highlighting the importance of individual benefit-risk assessment and shared patient-clinician decision making.”

https://www.ncbi.nlm.nih.gov/pubmed/30488174

https://link.springer.com/article/10.1007%2Fs40266-018-0616-5

“Our study finds that the therapeutic use of cannabis is safe and efficacious in the elderly population. Cannabis use may decrease the use of other prescription medicines, including opioids.” https://www.ncbi.nlm.nih.gov/pubmed/29398248

“Medical cannabis significantly safer for elderly with chronic pain than opioids: study” https://medicalxpress.com/news/2018-02-medical-cannabis-significantly-safer-elderly.html