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What to Expect When Cannabis Comes to Your State

      Support for legalization of medical cannabis is gaining speed in Mississippi. Supporters have collected nearly 40,000 signatures to get the issue on the state’s 2020 ballot; they just need another 45,000 by September. To date, 33 states and the District of Columbia have approved the use of medical cannabis for various conditions, and the number is expected to grow. As more states are legalizing medical cannabis, more practitioners have to consider how this will impact their patients, their facilities, and their work moving forward.
      Medical director Zachary Palace, MD, FACP, CMD, and his team at the Hebrew Home at Riverdale in Bronx, NY, developed an innovative program that affords residents the ability to participate in a state-approved medical cannabis program while complying with federal laws. His experiences offer a useful path for post-acute and long-term care practitioners and their care communities who are preparing for legal medical cannabis use in their states.

      Buy-In From the Top and Beyond

      Buy-in from the top is essential, and Dr. Palace noted that he was fortunate to have this in abundance. “Our president and CEO, Daniel Reingold, saw the benefits of it with his own father. He was very excited. He came to me, and I had been thinking about it already.” The more he researched and learned about medical cannabis, the more Dr. Palace was struck by the indications for its use. “The diagnoses were so germane to the issues we see in our patient population — most specifically, neuropathy, Parkinson’s disease, and pain.”
      That medical cannabis has potential benefit for some of his patients was without question. However, ensuring compliance with state and federal laws took a little more thought and planning. “No one wants to be in violation of federal or state laws or do anything to jeopardize Medicare or Medicaid funding,” said Dr. Palace. “The two main issues were administration and storage, and we devised a plan to address each.” This started with a policy and procedure that detailed issues such as who is eligible for the medical cannabis program, how the cannabis is obtained and stored, how it is administered and by whom, where the product can be consumed, and so on. The staff were educated on these new policies and procedures.
      Each resident registered in the medical cannabis program at Hebrew Home must purchase his or her own cannabis products directly from a state-certified dispensary. The cannabis must be stored by the resident securely. Each registered individual has his or her own lockbox for this purpose, and only that resident can access it. The cannabis can only be self-administered or given to the resident by his or her designated caregiver.
      The nurses know which residents are registered in the cannabis program, but no nurse, other practitioner, or staff member can administer the cannabis or handle it in any capacity.

      Mining the Myths, Focusing on Facts

      As medical cannabis in nursing homes is still fairly uncharted territory, nurses and other staff are likely to have some questions and concerns. Dr. Palace said, “Occasionally a nurse would ask, ‘Is the patient going to get high? What effects will it have?’” Educating them can ease some of their worries. “We aren’t giving any patients formulations with a significant amount of THC [tetrahydrocannabinol], which is responsible for the feelings of euphoria and other effects of recreational marijuana use. Sharing the facts and research with staff helped ease their concerns.”
      It also is helpful to share some of the background on medical cannabis with staff. The U.S. Food and Drug Administration has approved three cannabinoids as medications: Epidiolex (cannabidiol or CBD), an oral solution for treating seizures associated with epilepsy; and dronabinol and nabilone to treat nausea and vomiting associated with cancer chemotherapy. Dronabinol is also approved to treat loss of appetite and weight loss in people with acquired immunodeficiency syndrome (AIDS). Dronabinol contains synthetic delta-9-THC, and nabilone involves a similar chemical structure. The FDA approved a liquid form of dronabinol in 2016.
      Various professional societies have weighed in on the use of medical cannabis. For instance, the American Academy of Neurology (AAN) issued a formal position statement that states, in part: “The AAN acknowledges interest in medical marijuana from patients and physicians and notes that several states have moved to legalize medical marijuana in some form. The AAN also recognizes that medical marijuana may be useful in treating neurologic disorders.” Elsewhere, the American Medical Association’s current policy states, “Our AMA urges that marijuana’s status as a federal schedule I controlled substance be reviewed with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods. This should not be viewed as an endorsement of state-based medical cannabis, the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for a prescription drug product.”
      AMDA — The Society for Post-Acute and Long-Term Care Medicine doesn’t currently have a formal policy about the use of medical cannabis, but JAMDA has published numerous articles discussing the documented and potential benefits of this treatment for nursing home and other PALTC patients. “The favorable side effect profile makes it a viable option for this patient population. We haven’t seen any adverse side effects,” said Dr. Palace. “We haven’t seen patients become dependent, lethargic, or constipated the way they sometimes do with opioids.”
      “A major game changer will be when the FDA recognizes that medical cannabis shouldn’t remain as a Schedule I substance,” Dr. Palace added. While it’s difficult to speculate if and when such a change will happen, he suggested, “I would hope that as more studies come out demonstrating the therapeutic benefits of medical cannabis, the FDA will reconsider.”

      “I Never Smoked Pot!”

      Educating residents and families was another top priority for Dr. Palace and his team. They kicked off the program with a town hall meeting for residents. They also distributed fact sheets to family members and held meetings for them as well. “People were concerned about the stigma of medical cannabis,” said Dr. Palace, adding, “Many people — residents and family members alike — didn’t realize that medical cannabis isn’t like smoking recreational marijuana and getting ‘high.’ In truth, it’s nothing like that. This program is very clean and structured. We know exactly what people are getting, what the standardized dose is, and the exact concentration of active ingredients.” Dr. Palace further observed, “It’s a highly regulated program, and we have a high degree of confidence in it.”
      Dr. Palace noted, “I’ve had patients who are absolutely resistant to it. They say, ‘I’ve never tried marijuana in my life, and I’m certainly not going to try it now.’” Sometimes, he said, family members — such as adult children — are instrumental in convincing their parents to consider medical cannabis. They are often more open to alternative therapies and can influence their older family members, Dr. Palace suggested.

      The Success Stories

      Ultimately, the patients and their outcomes tell the story. “We had one resident who had pain and was withdrawn and isolated. Since he started using medical cannabis, his pain has lessened, he comes out of his room more, and his quality of life has improved,” said Dr. Palace. “Another resident on opioids for pain complained consistently. She had been active and creative at one time, and we encouraged her to get out and participate in activity programs. Instead, she stayed in her room and obsessed about when she would get her next dose of pain medication.” After the move to medical cannabis, the resident started to come out of her room and get involved in activities such as painting. Her complaining has diminished.
      There are many more stories like these. For instance, the New York Times published an article about Dr. Palace’s facility featuring a 98-year-old resident in the medical cannabis program (Feb. 2, 2017; https://nyti.ms/2UuPhy8). She is now 100, he said, and she is still participating.

      Jump In, or Dip a Toe

      If medical cannabis is in your facility or in your future, said Dr. Palace, “The most important thing is to become educated. There are lots of resources and numerous articles in the literature. The actual cannabinoid pathways in the brain have been thoroughly articulated. Learn about it, and understand how cannabis is used for medical purposes.” He added, “Treat it as an alternative therapy, a complementary approach to pain and symptom relief.”
      As with any medication, start low and go slow, said Dr. Palace. “See if there is a response, then increase the dose gradually as appropriate. Watch for side effects, and assess and manage risks for problems such as falls. As with any medication, there is always a risk–benefit analysis the practitioner has to do.”
      To learn more about the program, read an article authored by Dr. Palace and Mr. Reingold in the January issue of JAMDA (https://bit.ly/2SDXUdh).