Older patients and medicinal cannabis Or, why the boomers (and older) are tuning in and turning on
As a primary care physician who has been advising patients on medical cannabis for one-quarter of a century, it is notable how many silver-haired patients are coming in these days to express interest in this treatment. They are hearing about it from friends and family members, or from popular television shows. They wish to explore how to use medical marijuana to alleviate many of the most troubling afflictions of aging.
Most commonly, these include chronic pain, anxiety, and insomnia. Cannabis, if used wisely, is particularly well suited to address these. Medical marijuana is often a less risky or noxious alternative to the Pharma options, with fewer side effects. Studies have consistently shown that it can greatly improve health-related quality of life.
Cannabis use among older adults in the US has been growing exponentially. Rates were estimated to be 0.4% between 2006 and 2007, climbing sharply to 2.9% in 2015 and 2016. According to a recent study in the Journal of the American Medical Association, past-year cannabis use in this population increased from 2.4% to 4.2% from 2015 to 2018. The real numbers are likely higher once one factors in the residual stigma which limits people’s ability to honestly discuss their cannabis use. These numbers, to me, are astounding when I consider that these patients are by and large doing this on their own, without the help of their physicians, who rarely know enough about this to suggest or advise patients on medical marijuana.
Why are older patients tuning in and turning on, what benefits are they deriving, and what are the potential harms?
Polypharmacy
Modern medicine is in some ways a victim of its own successes. In antiquity, we died naturally in our twenties or thirties. Now, we often live to our eighties and beyond. This is far longer than our evolutionary history prepared our bodies to last. Things break down, such as our joints, our cells, and our nervous system.
As we age, we accumulate diagnoses, specialists, symptoms, and medications. More than a third of older Americans take at least five medications – this is a common definition of ‘polypharmacy’.
I have several older patients who are on a dozen or more medications. I’m a true believer in the ability of medications to improve and prolong life, yet, taking this many medications is expensive and time-consuming. It also can be confusing and dangerous. It is easy to mix up one’s meds as they can look and sound alike, and they all have different instructions.
Studies consistently show that cannabis can facilitate the process of patients lowering the use of other pharmaceuticals in older populations. Cannabis is a complicated plant and it has the ability to address many different types of symptoms simultaneously and as a consequence, it can substitute for several medications at once.
For example, if a patient is suffering from fibromyalgia, cannabis can help lessen a patient’s pain, and dampen their perception of pain (i.e., my back hurts but it’s not really bothering me that much), their lack of appetite, their anxiety, and their insomnia. This can equate to many fewer medications.
According to a 2018 study from Israel called, ‘Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly’, 93.7% of participants experienced an improvement in their condition at six months, with an average drop in pain scale from an 8 to a 4 (on a ten-point scale). But also, 18.1% of the patients eliminated their usage of opioids or reduced their dose. Not even the most bunkered-in, Uber-Prohibitionists from the early 1970s, who firmly believe that cannabis is the Devil’s Lettuce rotting the minds of our youth, could possibly criticize these results!
Effectiveness
Another factor propelling older patients toward weed is that the Pharma pills that we utilize (and commonly overutilize) aren’t always particularly effective or safe, especially in treating the common symptoms associated with aging. The side effects of common medications, such as medications for insomnia, can be increasingly debilitating as we age and can affect balance and memory. Often the benefits of these meds are exaggerated by Pharma while complacent, harried doctors prescribe this stuff out of habit or default, without much deep consideration over whether cannabis might be a safer alternative.
Let’s take a commonly utilized drug gabapentin (Neurontin) – used for nerve pain -- as an example. I would have to search far and wide to find a medication that has been more fluffed up beyond its actual clinical effectiveness. The 2019 article in Medscape sums up why we use it so frequently, “Industry Money Fuels Gabapentin Prescribing” which demonstrated that, “between 2014 and 2016, the manufacturers of the three brand-name gabapentinoids made 509,874 general payments ($11.5 million) to 51,005 physicians.” Hmm…I wonder if that had any effect on prescribing practices? Answer: it is one of the top twenty prescribed medications in the U.S. despite being such a crappy medication.
In my experience, Gapapentin can help somewhat diminish the nerve pain in some patients, but it primarily causes a feeling of sleepiness and muzzy-headedness - which many do not like. When I have taken it, such as when I had sciatica, I felt like a pithed frog. It is increasingly found in opioid overdoses - about ten percent of the time. In my clinical (and personal) experience, gabapentin pales in comparison to cannabis both in terms of side effect profile and in terms of effectiveness in treating chronic pain, such as nerve pain.
Main uses of medical cannabis
Cannabis is frequently used by older Americans for issues such as anxiety, insomnia, symptoms of M.S. (such as spasticity), Parkinson’s, weight loss, poor appetite, cancer symptoms (or chemotherapy-related symptoms), and end-of-life care.
In my book ‘Seeing Through the Smoke’ I detail how it helped both my brother Danny, during his losing battle with leukemia, and my father, as he battled, at the age of ninety-two, dozens of different pathologies. It vastly alleviated their suffering and helped them die with peace and dignity.
A common indication for medical cannabis is chronic pain, as this affects about a third of older patients. Let’s consider the main pharmacological options available to treat chronic pain (besides gabapentin). Tylenol is useless for anything but the mildest pain, unless you wish to affect your liver, which Tylenol can destroy. Opioids, besides being potentially deadly, present a poor quality of life for older patients who generally aren’t eager to be plagued by itchiness, constipation, drowsiness, falls, and confusion. There isn’t very good data to support the effectiveness of chronic opioid therapy for chronic pain with any patients, let alone older patients who are more vulnerable to the side effects.
The non-steroidals (NSAIDS) such as ibuprofen, Advil, naproxen, Alleve, and diclofenac, are arguably even more lethal than opioids in this patient population, as they can cause heart attacks, bleeding ulcers, bleeding in general, and, quite commonly, kidney damage. I see kidney problems associated with NSAID use every day in my primary care clinic – much of which could have been avoided with the judicious use of cannabis products during the decades prior.
Overall, as a relatively non-toxic, natural alternative to the typical Pharma offerings, cannabis looks quite good, and this is why so many older Americans are incorporating it into their care, and why so many more are ‘canna-curious’ and wish to learn more.
Safety and tolerability
There is no free lunch with any medication, including medical cannabis, as they all have potential side effects to watch out for. When initiating cannabis as a medicine in older patients, one must be extra careful to ‘start low and go slow’, to educate patients in advance about potential medication-related problems, to carefully integrate cannabis with the rest of their care, and to monitor patients closely as they initiate cannabinoid therapy.
Doctors need to know their patients and to be available to them in follow-up. This is a large part of why I feel it is generally safer for primary care doctors – who know the patients, their specialists, and their history - to be prescribing medicinal cannabis, rather than random cannabis doctors who operate on a fee-for-service basis. This, of course, presupposes that the primary care doctors know something helpful about cannabis, which we are working on.
A 2019 study of cannabis in older adults, ‘Medical Cannabis for Older Patients – Treatment Protocol and Initial Results’, sums up the potential adverse effects:
33.6% reported adverse events, the most common of which were dizziness (12.1%) and sleepiness and fatigue (11.2%). Of the respondents, 84.8% reported some degree of improvement in their general condition. Special caution is warranted in older adults due to polypharmacy, pharmacokinetic changes, nervous system impairment, and increased cardiovascular risk.
Dizziness might be a minor side effect in a younger patient but is potentially dangerous in the elderly, as falls can be deadly and are to be avoided at all costs. Dizziness is best prevented with upfront education, by titrating up the medicine very slowly, and by using as low a dose of THC as possible. As for sleepiness or fatigue, if a patient experiences this, we might try a different strain of cannabis which is more energizing, or a different ratio of CBD to THC.
With medical cannabis, medication interactions are something else to watch out for as CBD acts exactly like grapefruit juice in the sense that it competes for the same liver enzymes that remove other medicines from our blood. As such, CBD can raise the levels of other medications in one’s bloodstream. This is particularly important if one is on a blood thinner or another medication that needs to be kept within a narrow therapeutic range, such as an immunosuppressant or an anti-epileptic. Potential medication interactions are why patients and doctors need to communicate in an open and clear manner about medical cannabis. The doctors don’t always make this easy, particularly the ‘old-school’ psychiatrists who still think that the movie ‘Reefer Madness’ was a documentary, but things are slowly getting better.
While the current data on cannabis and its effects on the heart are somewhat conflicting, medical cannabis needs to be used with caution in anyone with active cardiac disease, as cannabis can increase heart rate and blood pressure, which puts more stress on the heart. Smoking cannabis is not the safest way to consume medicinal cannabis and if there are cardiac concerns, I would strongly recommend a tincture or an edible instead.
The psychoactivity, or the high that cannabis causes is another potential concern for older adults, especially those at risk for confusion and dementia. These days, with the ability to buy legal cannabis in state-regulated medical dispensaries, there is more control over the types or strains of cannabis that one can buy and consume. It is easier to reliably avoid or minimize the high by controlling the dose and keeping the THC content low. Strains or formulations that are low in THC (the chemical that causes the high) and higher in CBD, which is non-intoxicating, may be preferable to minimize the psychoactive experience of marijuana. If an older person has experienced delirium, or symptoms suggestive of psychosis in the past, they and their doctors should proceed with extreme caution.
Interestingly, there is some research that cognitive functioning can actually improve when older patients use medical cannabis, due to (among other things) improved sleep and pain control and less reliance on confusion-inducing painkillers and sleeping medications. There is also data that CBD-predominant cannabis preparations can be helpful in addressing the anxiety and behavioral disturbances of patients afflicted with dementia.
Future Directions
As medical cannabis becomes legal and accepted, older patients are increasingly being afforded a highly versatile and relatively non-toxic tool to help them address the many discomforts of aging. The data bears out that this has been, so far, a nearly unqualified success. Personally, I’ve seen these exact benefits in hundreds of patients. I’ve also seen them with several of my own family members, including my father, who’s end of life care was vastly improved by medicinal cannabis. (Of course, of all people, one never had to twist my father’s arm to get him to use cannabis…).
Yet, we have much more work to do. In order to make medical cannabis more accessible, and the treatment more effective, we need to:
1) Further reduce the stigma associated with its use, so people don’t feel bad about using it, aren’t anxious about using it, and aren’t afraid to ask about it.
2) Educate doctors about the benefits of medical cannabis (not to mention the very basics of the endocannabinoid system…) and about how to advise patients on the nuts and bolts of cannabinoid medicine.
3) Ensure legal access everywhere, not just in the more enlightened states.
4) Find a way to make medical cannabis more affordable to people living on fixed incomes, such as many older Americans, likely by forcing health insurance and Medicare to cover it.
5) Improve communication between doctors and patients.
6) Educate patients about the many different ways in which cannabis can be consumed that do not involve smoking it (which is always more dangerous) such as: under the tongue tinctures, carefully dosed edibles, and topical preparations. (There are also skin patches, inhalers, and suppositories for people who are interested.)
What's the bottom line?
Cannabis use among the elderly is growing exponentially, as there is overwhelming public acceptance, an abundance of witnessed clinical successes, a growing body of research documenting the benefits, and reduced stigma.
Medical cannabis is increasingly viewed as an effective option for managing insomnia, anxiety, chronic pain, loss of appetite, and other discomforts that accompany aging. As a psychiatrist friend of mine once said, “Aging is not for sissies”. Cannabis often can help. It is important to educate yourself (and your doctor) as much as possible about cannabis before starting to use it. Most of the adverse effects associated with cannabis usage are dose-related, so it is important to know the strength of the marijuana you are taking, to "start low and go slow", and to take your time working your way up to a dose that alleviates your symptoms with a minimum of side effects.