ArticlePDF Available

Will medical cannabis treatment reduce pharmaceutical residues in the aquatic environment? A case study from an elderly nursing home

Authors:
Adv Health Behav, 2020, 3(1): 118-124
DOI: 10.25082/AHB.2020.01.003
RESEARCH ARTICLE
Will medical cannabis treatment reduce pharmaceutical residues in the
aquatic environment? A case study from an elderly nursing home
Dror Avisar1Zach Klein1Gefen Ronen-Eliraz1
Abstract:
High drug consumption and polypharmacy, especially in the elderly, is one of the 21
st
century
phenomenon. It has different undesirable side effects, which may directly affect the environment. It is known
that pharmaceutical residues are excreted via patients’ urine or feces to waste water, which is then discharged
to the environment. Therefore high drug consumption is contributing to the continual rise in pharmaceutical
residues in the aquatic environment, and address a rising cause for concern. Alternative treatments that can relieve
or improve the patient’s clinical condition, thereby reducing the consumption of pharmaceuticals, hold great
potential for reducing drug residues in the environment. The purpose of this research was to evaluate the reduction
in pharmaceutical consumption in a nursing home for the elderly, as a result of treatment with medical cannabis.
With time, medical cannabis treatment dramatically improved patients’ symptoms and their medical indexes. As
a result, the local physicians stopped prescribing drugs that were defined as unnecessary. Overall, 39 dosages of
prescription drugs were cancelled for the 19 elderly individuals included in this research, indicating that medical
cannabis can be an effective treatment that also reduces the environmental drug load, thereby preventing water
pollution.
Keywords:
contamination, medical cannabis, pharmaceutical residue, water resource, pain, symptoms
improvement, prescribing drug reduction
1 Introduction
In the last two decades, drug manufacture has con-
tinuously increased, with the renovation and expansion
of pharmaceutical compounds reflecting growing con-
sumption worldwide. The pharmaceutical pain-medicine
industry in the United States is worth up to
$
635 billion
per year and affects more than 100 million Americans
[1,2]
.
Aside from pharmaceuticals’ direct effects on their con-
sumers, this reflects a more global problem of non-fatal
diseases and an over-demand for medicines, with the as-
sociated drawback of the growing environmental threat
hazardous pharmaceutical residues.
Polypharmacy is a situation in which a patient is be-
ing treated with more than five drugs, simultaneously.
It has been associated with increased risk of unsuitable
Received: February 11, 2020; Accepted: April 9, 2020; Published: April 23, 2020
Correspondence to
: Dror Avisar. Porter School of the Environment and Earth Sci-
ences, Faculty of Exact Sciences, Tel Aviv University, Tel Aviv 69978, Israel; Email:
droravi@tauex.tau.ac.il
1
Porter School of the Environment and Earth Sciences, Faculty of Exact Sciences, Tel
Aviv University, Tel Aviv 69978, Israel
Citation:
Avisar D, Klein Z and Ronen-Eliraz G. Will medical cannabis treatment reduce
pharmaceutical residues in the aquatic environment? A case study from an elderly nursing
home. Adv Health Behav, 2020, 3(1): 118-124.
Copyright: ©
2020 Dror Avisar, et al. This is an open access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are
credited.
medications, medication non-adherence, drug duplication,
drug-drug interactions, higher healthcare costs, and ad-
verse drug reactions
[25]
. At its extreme, it is associated
with fatal overdoses
[6]
, and it has therefore been coined
the “opioid epidemic”
[1]
. The above situation is quite ex-
treme for the older adult population (over the age of 65),
50% of which are taking at least one superfluous drug.
Some of these medicines are given to prevent illnesses,
even though there is no proof of their effectiveness[7].
Active pharmaceutical ingredients (APIs) have been
identified in the environment since the 1980s
[8,9]
, in sur-
face water and groundwater, and ultimately in drink-
ing water and agricultural products
[1013]
. They reach
the environment via various routes, including industrial
plants, household waste, and landfill leachate; their pri-
mary source is effluent from wastewater-treatment plants
that is reused in agriculture or to dilute surface water re-
sources
[14]
. In the last decade, numerous studies have
shown incomplete elimination of many pharmaceuticals
in wastewater treatment plants (WWTPs), and therefore
the effluent contains APIs[11,1518].
The use of medical cannabis (MC) as an alternative
to mainstream and traditional pharmaceutical treatments
has already been reported in a number of studies
[19,20]
.
The main conclusion is generally that substitution of tradi-
tional pain medications with MC causes fewer side effects
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
Dror Avisar, et al. Will medical cannabis treatment reduce pharmaceutical residues in the aquatic environment? 119
and an improvement in medical symptoms
[19,21,22]
. Some
studies have shown the replacement of other prescrip-
tion pharmaceuticals by MC as well
[2325]
. However, it is
important to emphasize that many of those studies were
limited in terms of statistical indexes, database volume,
and the perspective of time, calling for further explo-
ration
[26]
. Regardless, the reported positive results may
play a significant role in the “opioid crisis”, as through
promotion of treatment with MC, overdoses of prescrip-
tion opioid medications will decrease, thereby reducing
the staggering statistics of deaths from overdose
[26,27]
.
Simultaneously, it curbs the amount of hazardous phar-
maceutical residues spilling into and threatening water
sources and the environment.
The following case study evaluates the reduction in
prescription drugs in a nursing home for the elderly as
a result of MC treatment. This evaluation was based
on patients’ clinical improvement, and the reduction of
pharmaceutical residues in the environment.
2 Materials and methods
2.1 Participants
Compassionate treatment care with MC was initiated
in July 2010 at Hadarim nursing home in Kibbutz Naan,
Israel. This program was run under the supervision of the
nursing home manager and the Israel Medical Cannabis
Agency, a division of the Israeli Ministry of Health. The
research included 27 participants from the nursing home,
selected to receive treatment with MC based on their
symptoms.
2.2 Cannabis
Four types commercial strains of MC were used in this
case study: Erez, Hadarim, Avidkal, and Midnight, which
differ in their proportions of the three active cannabi-
noids: tetrahydrocannabinol (THC), cannabidiol (CBD),
and cannabinol (CBN) (Table 1).
Table 1. Cannabis types strains and their cannabinoid composi-
tion
Cannabis types
(commercial names)
THC
(%)
CBD
(%)
CBN
(%)
Erez 23 0 0.1
Hadarim 8 0 -
Avidkal 0.8 16.5 -
Midnight 12 12 -
The MC was obtained from Tikun Olam Ltd. (Israel),
which is the largest authorized and licensed supplier of
MC in Israel. The composition of each cannabis type
strain was analyzed and quantified in an authorized labo-
ratory at the Hebrew University of Jerusalem.
There were three possible routes of MC administra-
tion: smoking, inhalation with a vaporizer, and ingestion
by mixing ground cannabis in foods (cakes, cookies or
candies).
2.3 Procedures and measures
Detailed documentation was collected during the 12
months research period (2011-2012) for each patient who
received MC in this study. Patient health status and mea-
surements (e.g., weight, blood pressure, heart rate, body
temperature, and periodic blood tests) were documented
weekly by the medical team, and was continuously up-
date. Patient life quality before, during, and after MC
treatment was reported by the nursing home staff and the
patient’s family members with an interviews, and sup-
ported and verified by the local physicians. Technical
details regarding the MC type’s strains and admissions
format for each patient, as well as a list of drugs that were
stopped following MC treatment for each patient, were
recorded by the nursing home staff during the year of the
study.
2.4 Measured outcome
The potential of MC use as an alternative for a variety
of traditional drug treatments was examined. Evaluation
was based on the patients’ life quality, expressed as im-
provement in their clinical parameters, in parallel to a
decrease or complete cessation of traditional drug treat-
ments. Life-quality improvement reported by the nursing
home staff and physicians was based on continuously
measured clinical parameters, close interactions and im-
pressions. Therefore, a decrease or cessation in the use of
traditional drugs was the immediate effect and outcome of
the study, associated with a reduction in pharmaceutical
residues in the environment.
2.5 Ethics statement
It should be noted that a written consent form was
obtained from all patients and their relatives before the
treatment with MC. The participants’ information was
remained confidential.
3 Results
3.1 Characterization of participants
All 27 participants were dependent on nursing home
care and poly-pharmaceutical treatment-they were being
treated with at least five different drugs before they were
selected to use MC. Records regarding prescription phar-
maceutical consumption of 8 of the 27 participants were
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
120 Advances in Health and Behavior, February 2020, Vol. 3, No. 1
Table 2. Opiates targeted prior to the start of the study for reduction or cessation, classified by purpose of treatment
Acamol Xanax Seroquel Dopicar Ameryl
Lyrica Trazodil Haldol Exelon Laxadin
Percocet Clonex Bondormin Ebixa Insulin
Tramadex Recital Phenergan Levopar
Duragesic Lorivan Clopixol Memorit
Oxycodin Vaben
Cipralex
Ataxia/gout Alzheimer's &
Parkinson's
Colchicine
Antipsychotic &
sedative
Antidiabetic &
laxative
Opiates
target Pain Anxiolytic Anticonvulsant/
depression
Opiates Depalept
incomplete. Thus, only 19 participants (67%) were eli-
gible for the statistical analysis of drug dose reduction
and cessation. Of all of the prescription medicines being
taken by the 19 participants before they began the MC
treatment, 28 opiates (Table 2) were targeted for reduc-
tion.
The symptom criteria for compassionate MC treatment
were: pain (67%), anxiety (11%), depression (4%), lack
of appetite (33%), spasticity (26%), immobility and lim-
ited movement (4%), ataxia (4%), Alzheimer’s or Parkin-
son’s (7%), and insomnia/sleep disorders (4%); thus, the
most common symptom was chronic pain, mostly caused
by spasticity.
For most of the patients, MC administration was oral,
as a powder mixed in with porridge (81%). Some of the
patients received supplemental MC by inhalation with a
vaporizer (13%) or smoking (13%), as needed (Figure
1). Only 4 patients (15%) were administered cannabis
by vaporizer only, and 1 patient (4%) by smoking only
(Figure 1).
Figure 1. Routes of MC administration to the study patients
With respect to types strains of MC administered, 17
patients (63%) received Hadarim, 8 patients (30%) con-
sumed Erez, and Midnight and Avidekel were consumed
by 4 (15%) and 5 (19%) patients, respectively some of
the patients received more than one strain of cannabis.
3.2 Outcomes of MC treatment
Improvements due to MC treatment were examined
and evaluated for symptom indications before and after
treatment (Figure 2). All patients experienced immediate
relief with MC usage.
Figure 2 shows that some of the patients got relief from
symptoms that were not included in their first indication
list. Effects such as increased appetite, intense improve-
ment of spasticity, much better mood, better sleep, and
decreased anxiety and tremors, were seen. Furthermore,
all 18 patients that suffered from pain, got relief, while
15 of those patients experienced improvement with at
least one more symptom (Figure 2b). Additionally, all
15 patients that their appetite improved, experienced im-
provements with at least one more symptom (Figure 2b).
All 4 patients that their depression got relief, improved
their appetite as well (Figure 2b). The dramatic improve-
ment of spasticity enabled the patients to sit upright, use
their hands to hold objects, eat by themselves, and suf-
fer much less pain (Figure 3). All of these symptoms
improved rapidly (in minutes), in patients who had them
before compassionate MC treatment, as well as in patients
who were receiving the cannabis to treat other symptoms.
Moreover, patients treated with MC who suffered from
post-traumatic stress disorder or inflammation - disorders
that were not included in the first indication list - experi-
enced relief of these symptoms as well. After many years
of suffering, several of these patients went back to interact-
ing with their family members, talking, communicating,
listening to music, playing, and drawing. The effect of
MC treatment on those patients was almost “magical”.
An immediate ameliorative effect on patients’ med-
ical and clinical symptoms was expressed by their no
longer needing various prescription drugs. Before treat-
ment and according to the patients’ indications, 23 drugs
were targeted for dosage reduction or cessation. By the
end of the study, the 19 patients had discontinued 39 of
the drugs that they had been taking (Figure 4). Most of
the drugs that were completely eliminated were opiates,
given for pain relief, to relieve anxiety, and as antidepres-
sants. In addition, dosages of a few of the drugs given to
treat ataxia and muscle coordination were decreased, due
mainly due to the relief and release from spasticity, and
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
Dror Avisar, et al. Will medical cannabis treatment reduce pharmaceutical residues in the aquatic environment? 121
Figure 2. Indication for MC treatment. (A) Indication for MC treatment compared to improvement in that indication after one year of
MC treatment; (B) Symptoms improvements for each patient
Figure 3. The intense effect of MC treatment on spasticity
routine treatment with drugs for Alzheimer’s, Parkinson’s
and other disorders (inflammation, diabetes, and drugs
given as laxatives) was discontinued.
Figure 4. Distribution of the 39 drugs that were no longer taken,
or were reduced, following treatment with MC, according to symp-
toms
4 Discussion
We evaluated the potential of MC treatment to improve
patients’ clinical and medical parameters and general
condition, resulting in a reduction in prescription drug
dosages and as a result, a decrease in the environmen-
tal risk of pharmaceutical residues contaminating water
sources and the environment. The research group was
composed of hospitalized elderly patients in a nursing
home, i.e., dependent patients, 65 years or older. This
population group tends to suffer from a variety of symp-
toms, and are usually highly likely to be associated with
polypharmacy. For these people, MC might offer a way of
managing symptoms with fewer side effects, in a situation
with a good possibility of decreasing administered drug
usage
[3,7,28,29]
. Moreover, although some recent studies
have shown increasing use of cannabis by the elderly,
only a few such populations have been analyzed
[23,30,31]
and to the best of our knowledge, no one has analyzed the
use of MC in a nursing home.
Symptom relief as a result of MC treatment was promi-
nent and distinctly noticeable for most of the patients.
Relief of symptoms such as pain, anxiety, moodiness, and
spasticity was evident, agreeing well with many previous
studies
[22,24,25,3234]
. Relief was obtained not only for the
specific indications serving as criteria for each patient,
but also for additional symptoms and side effects (e.g.,
sleep disorders, ataxia, depression, and lack of appetite),
as shown previously by Boehnke et al. (2016).
Spasticity, which restricts patients’ movements and
complicates their treatment, improved dramatically with
MC treatment. Consequently, patients’ movements
(ataxia) improved significantly, along with their communi-
cation with family members. This also contributed consid-
erably to their independence, enabling them to eat unas-
sisted and to use their hands (Figure 3). The improvement
in the patients’ appetite and eating abilities, accompanied
by the elimination of feeding tubes, rendered the daily
and unpleasant enema unnecessary. According to the
physicians, MC treatment improved most of the patients’
clinical parameters, eliminating the anxious atmosphere
and frequent shouting that characterized the nursing home
before MC treatment; the treatment especially increased
their general self-confidence.
Gradually, with symptom relief and improvement, phar-
maceutical dosages were reduced and sometimes elimi-
nated, under the physician’s advice. In total, the consump-
tion of 39 drug dosages was stopped and that of 5 others
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
122 Advances in Health and Behavior, February 2020, Vol. 3, No. 1
reduced. Termination of pharmaceutical consumption as-
sociated with MC treatment has also been shown in other
studies. Abuhasira et al. (2018) showed that after 12
months of treatment with cannabis, most patients stopped
or reduced their intake of chronic medications. Vigil et al.
(2017) also presented cessation and reduction of drugs
concomitant with MC treatment.
We present a novel aspect of MC treatment, in that it
integrates other implications of this alternative treatment,
focusing on its possible benefits to the environment. For
better assessment and quantification of these implications,
further research needs to be done. It is also important to
emphasize that the participant group was limited, making
statistical analysis limited.
Our results showed that even pharmaceuticals that were
not included on the main target list for cessation or re-
duction were stopped 23 pharmaceuticals defined as tar-
gets, and 39 pharmaceutical dosages actually eliminated).
These results might explain the findings of Nielsen et
al. (2017)
[35]
, who showed that when cannabinoids are
co-administered with opioids, they might allow reduction
of opioid doses without loss of analgesic treatment effi-
cacy. The positive effects of MC on diverse conditions
might explain the cessation of additional drugs (e.g., con-
stipation and enema treatment, drugs for sleep disorders,
etc.). Despite the study’s limitations, the fact that MC
treatment led to a total reduction of prescription drugs
remains salient.
It is possible that with the recent increase in MC treat-
ment in many western countries, the synergistic effects
of the many cannabinoids present in the cannabis (not
only THC and CBD) will have an overall positive effect
on human health. This will be expressed in the improve-
ment of various health symptoms, the reduced need for
prescription drugs and finally, in the long term, a reduc-
tion of pharmaceutical residues in the environment, water
resources and food.
5 Summary and conclusions
The focus of this study was the reduction in pharma-
ceutical usage as a result of MC treatment. We found an
overall improvement in the patients, including of their
symptoms and medical conditions, cessation or reduction
of traditional drug usage, and a general improvement in
life quality. The alternative treatment with MC provided
an actual solution for pain symptoms, lack of appetite,
and other side effects of traditional drugs. Quality of life
improved for all patients not only personally, but also in
terms of the nursing home atmosphere, since shouting
and agitation diminished. The sharp decrease in prescrip-
tion drug usage was clear, with the 19 patients ceasing
39 different drugs and decreasing the dosage of another
5. As an added benefit, the environmental threat posed
by hazardous APIs from consumed drugs may sharply
decrease, demonstrating the potential of MC to keep our
freshwater resources free of pharmaceutical residues.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors deeply thank to the medical team at Na’an
elderly nursing home and to the patient’s families for their
assistance and care.
References
[1] Carey ET, Hill C and Carolina N. Opioid Use, Misuse and
Abuse: The Rise and Fall of a National Opioid Epidemic.
Clin Obstet Gynecol, 2019, 62(1): 1-2.
https://doi.org/10.1097/GRF.0000000000000426
[2] Zimmermann S, Gruber L, Schlummer M, et al. Determina-
tion of phthalic acid diesters in human milk at low ppb lev-
els. Food Addit Contam Part A. 2012, 29(11): 1780-1790.
https://doi.org/10.1080/19440049.2012.704529
[3] Komiya H, Umegaki H, Asai A, et al. Factors associated
with polypharmacy in elderly home-care patients. Geriatrics
& Gerontology International, 2018, 18(1): 33-41.
https://doi.org/10.1111/ggi.13132
[4] WHO. The Role of Education in the Rational Use of
Medicines. SEARO Technical Publication Series No. 045
[Internet]. New Delhi, 2006.
http://apps.who.int/medicinedocs/en/m/abstract/Js16792e
[5] Wieczorkiewicz SM, Kassamali Z and Danziger LH. Be-
hind Closed Doors: Medication Storage and Disposal in the
Home. Ann Pharmacother, 2013, 47(4):482-489.
https://doi.org/10.1345/aph.1R706
[6] Jones CM, Mack KA and Paulozzi LJ. Pharmaceutical Over-
dose Deaths, United States, 2010. JAMA, 2013, 309(7):
657.
https://doi.org/10.1001/jama.2013.272
[7] Bradley MC, Fahey T, Cahir C, et al. Potentially inappro-
priate prescribing and cost outcomes for older people: a
cross-sectional study using the Northern Ireland Enhanced
Prescribing Database. Eur J Clin Pharmacol, 2012, 68(10):
1425-1433.
https://doi.org/10.1007/s00228-012-1249-y
[8] Halling-Srensen B, Nielsen SN, Lanzky PF, et al. Occur-
rence, fate and effects of pharmaceutical substances in the
environment- A review. Chemosphere, 1998, 36(2): 357-
393.
https://doi.org/10.1016/S0045-6535(97)00354-8
[9] Richardson ML and Bowron JM. The fate of pharmaceutical
chemicals in the aquatic environment. Journal of Pharmacy
& Pharmacology, 1985, 37(1): 1-12.
https://doi.org/10.1111/j.2042-7158.1985.tb04922.x
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
Dror Avisar, et al. Will medical cannabis treatment reduce pharmaceutical residues in the aquatic environment? 123
[10] Aus der Beek T, Weber FA, Bergmann A, et al. Pharmaceu-
ticals in the environment-Global occurrences and perspec-
tives. Environ Toxicol Chem, 2016, 35(4): 823-835.
https://doi.org/10.1002/etc.3339
[11] Avisar D, Lester Y and Ronen D. Sulfamethoxazole con-
tamination of a deep phreatic aquifer. Science of The Total
Environment, 2009, 407(14): 4278-4782.
https://doi.org/10.1016/j.scitotenv.2009.03.032
[12] Madikizela LM, Ncube S and Chimuka L. Uptake of phar-
maceuticals by plants grown under hydroponic conditions
and natural occurring plant species: A review. Science of
The Total Environment, 2018, 636: 477-486.
https://doi.org/10.1016/j.scitotenv.2018.04.297
[13] Rowney NC, Johnson AC and Williams RJ. Erratum: Cyto-
toxic drugs in drinking water: a prediction and risk assess-
ment exercise for the Thames catchment in the United King-
dom. Environmental toxicology & chemistry, 2011, 30(7):
1729-1729.
https://doi.org/10.1897/09-067.1
[14] K¨
ummerer K. Pharmaceuticals in the Environment. Annual
Review Environment Resource. 2010, 35(1): 57-75.
https://doi.org/10.1146/annurev-environ-052809-161223
[15] Coetsier CM, Spinelli S, Lin L, et al. Discharge of phar-
maceutical products (PPs) through a conventional biologi-
cal sewage treatment plant: MECs vs PECs? Environment
International, 2009, 35(5): 787-792.
https://doi.org/10.1016/j.envint.2009.01.008
[16] Kostich MS, Batt AL and Lazorchak JM. Concentrations
of prioritized pharmaceuticals in effluents from 50 large
wastewater treatment plants in the US and implications for
risk estimation. Environment Pollution, 2014, 184(1): 354-
359.
https://doi.org/10.1016/j.envpol.2013.09.013
[17] Lester Y, Avisar D and Mamane H. Ozone Degradation of
Cyclophosphamide Effect of Alkalinity and Key Effluent
Organic Matter Constituents. Ozone: Science & Engineer-
ing, 2013, 35(2): 125-133.
https://doi.org/10.1080/01919512.2013.761107
[18] Shafrir M, Avisar D. Development Method for Extract-
ing and Analyzing Antibiotic and Hormone Residues from
Treated Wastewater Sludge and Composted Biosolids. Wa-
ter Air & Soil Pollution, 2012, 223(5): 2572-2587.
https://doi.org/10.1007/s11270-011-1049-5
[19] Boehnke KF, Scott JR, Litinas E, et al. Pills to pot: ob-
servational analyses of cannabis substitution among medi-
cal cannabis users with chronic pain. Journal of Pain, 2019,
20(7): 830-841.
https://doi.org/10.1016/j.jpain.2019.01.010
[20] Kruger DJ and Kruger JS. Medical Cannabis Users’
Comparisons between Medical Cannabis and Mainstream
Medicine. Journal of Psychoactive Drugs, 2019, 51(1): 31-
36.
https://doi.org/10.1080/02791072.2018.1563314
[21] Haroutounian S, Ratz Y, Ginosar Y, et al. The Effect of
Medicinal Cannabis on Pain and Quality-of-Life Outcomes
in Chronic Pain: A Prospective Open-label Study. Clinical
Journal of Pain, 2016, 32(12): 1036-1043.
https://doi.org/10.1097/AJP.0000000000000364
[22] Lucas P and Walsh Z. Medical cannabis access, use, and
substitution for prescription opioids and other substances:
A survey of authorized medical cannabis patients. Interna-
tional Journal of Drug Policy, 2017, 42: 30-35.
https://doi.org/10.1016/j.drugpo.2017.01.011
[23] Abuhasira R, Schleider BL, Mechoulam R, et al. Epi-
demiological characteristics, safety and efficacy of medi-
cal cannabis in the elderly. European Journal of Internal
Medicine, 2018, 49: 44-50.
https://doi.org/10.1016/j.ejim.2018.01.019
[24] Boehnke KF, Litinas E and Clauw DJ. Medical Cannabis
Use Is Associated with Decreased Opiate Medication Use
in a Retrospective Cross-Sectional Survey of Patients with
Chronic Pain. Journal of Pain, 2016, 17(6): 739-744.
https://doi.org/10.1016/j.jpain.2016.03.002
[25] Romero-Sandoval EA, Fincham JE, Kolano AL, et al.
Cannabis for Chronic Pain: Challenges and Considerations.
Pharmacotherapy: The Journal of Human Pharmacology
and Drug Therapy, 2018, 38(6): 651-662.
https://doi.org/10.1002/phar.2115
[26] Campbell G, Hall W and Nielsen S. What does the ecolog-
ical and epidemiological evidence indicate about the poten-
tial for cannabinoids to reduce opioid use and harms? A
comprehensive review. International Review of Psychiatry,
2018, 30(5): 91-106.
https://doi.org/10.1080/09540261.2018.1509842
[27] Vyas MB, Lebaron VT and Gilson A. The Use of Cannabis
in Response to the Opioid Crisis: A Review of the Literature.
Nursing Outlook, 2018, 66(1): 56-65.
https://doi.org/10.1016/j.outlook.2017.08.012
[28] Briscoe J and Casarett D. Medical Marijuana Use in Older
Adults. Journal of the American Geriatrics Society, 2018,
66(5): 859-863.
https://doi.org/10.1111/jgs.15346
[29] Kojima T, Akishita M, Kameyama Y, et al. High risk of ad-
verse drug reactions in elderly patients taking six or more
drugs: Analysis of inpatient database. geriatrics & gerontol-
ogy international, 2012, 12(4): 761-762.
https://doi.org/10.1111/j.1447-0594.2012.00868.x
[30] Kaskie B, Ayyagari P, Milavetz G, et al. The Increasing Use
of Cannabis Among Older Americans: A Public Health Cri-
sis or Viable Policy Alternative? Gerontologist, 2017, 57(6):
1166-1172.
https://doi.org/10.1093/geront/gnw166
[31] Mahvan T, Hilaire M, Mann A, et al. Marijuana Use in the
Elderly: Implications and Considerations. Consult Pharm ,
2017, 32(6): 341-351.
https://doi.org/10.4140/TCP.n.2017.341
[32] Haroutounian S, Ratz Y, Ginosar Y, et al. The Effect of
Medicinal Cannabis on Pain and Quality of Life Outcomes
in Chronic Pain: A Prospective Open-label Study. The Clin-
ical journal of pain, 2016, 32(12): 1036-1043.
https://doi.org/10.1097/AJP.0000000000000364
[33] Reiman A, Welty M and Solomon P. Cannabis as a Substi-
tute for Opioid-Based Pain Medication: Patient Self-Report.
Cannabis & Cannabinoid Research, 2017, 2(1): 160-166.
https://doi.org/10.1089/can.2017.0012
[34] Vigil JM, Stith SS, Adams IM, et al. Associations between
medical cannabis and prescription opioid use in chronic
pain patients: A preliminary cohort study. PLoS One, 2017,
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
124 Advances in Health and Behavior, February 2020, Vol. 3, No. 1
12(11): e0187795.
https://doi.org/10.1371/journal.pone.0187795
[35] Nielsen S, Sabioni P, Trigo JM, et al. Opioid-Sparing Effect
of Cannabinoids: A Systematic Review and Meta-Analysis.
Neuropsychopharmacology, 2017, 42: 1752-1765.
https://doi.org/10.1038/npp.2017.51
Advances in Health and Behavior © 2020 by SyncSci Publishing. All rights reserved.
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Chronic pain is common, costly, and challenging to treat. Many individuals with chronic pain have turned to cannabis as an alternative form of pain management. We report results from an ongoing, online survey of medical cannabis users with chronic pain nationwide about how cannabis affects pain management, health, and pain medication use. We also examined whether and how these parameters were affected by concomitant recreational use, and duration of use (novice: <1 year vs experienced: ≥1 year). There were 1,321 participants (59% female, 54% ≥50 years old) who completed the survey. Consistent with other observational studies, approximately 80% reported substituting cannabis for traditional pain medications (53% for opioids, 22% for benzodiazepines), citing fewer side effects and better symptom management as their rationale for doing so. Medical-only users were older (52 vs 47 years old; P <.0001), less likely to drink alcohol (66% vs 79%, P <.0001), and more likely to be currently taking opioids (21% vs 11%, P <.0001) than users with a combined recreational and medical history. Compared with novice users, experienced users were more likely to be male (64% vs 58%; P <.0001), take no concomitant pain medications (43% vs 30%), and report improved health (74% vs 67%; P =.004) with use. Given that chronic pain is the most common reason for obtaining a medical cannabis license, these results highlight clinically important differences among the changing population of medical cannabis users. More research is needed to better understand effective pain management regimens for medical cannabis users. Perspective: This article presents results that confirm previous clinical studies suggesting that cannabis may be an effective analgesic and potential opioid substitute. Participants reported improved pain, health, and fewer side effects as rationale for substituting. This article highlights how use duration and intentions for use affect reported treatment and substitution effects.
Article
Full-text available
Background: Current levels and dangers of opioid use in the U.S. warrant the investigation of harm-reducing treatment alternatives. Purpose: A preliminary, historical, cohort study was used to examine the association between enrollment in the New Mexico Medical Cannabis Program (MCP) and opioid prescription use. Methods: Thirty-seven habitual opioid using, chronic pain patients (mean age = 54 years; 54% male; 86% chronic back pain) enrolled in the MCP between 4/1/2010 and 10/3/2015 were compared to 29 non-enrolled patients (mean age = 60 years; 69% male; 100% chronic back pain). We used Prescription Monitoring Program opioid records over a 21 month period (first three months prior to enrollment for the MCP patients) to measure cessation (defined as the absence of opioid prescriptions activity during the last three months of observation) and reduction (calculated in average daily intravenous [IV] morphine dosages). MCP patient-reported benefits and side effects of using cannabis one year after enrollment were also collected. Results: By the end of the 21 month observation period, MCP enrollment was associated with 17.27 higher age- and gender-adjusted odds of ceasing opioid prescriptions (CI 1.89 to 157.36, p = 0.012), 5.12 higher odds of reducing daily prescription opioid dosages (CI 1.56 to 16.88, p = 0.007), and a 47 percentage point reduction in daily opioid dosages relative to a mean change of positive 10.4 percentage points in the comparison group (CI -90.68 to -3.59, p = 0.034). The monthly trend in opioid prescriptions over time was negative among MCP patients (-0.64mg IV morphine, CI -1.10 to -0.18, p = 0.008), but not statistically different from zero in the comparison group (0.18mg IV morphine, CI -0.02 to 0.39, p = 0.081). Survey responses indicated improvements in pain reduction, quality of life, social life, activity levels, and concentration, and few side effects from using cannabis one year after enrollment in the MCP (ps<0.001). Conclusions: The clinically and statistically significant evidence of an association between MCP enrollment and opioid prescription cessation and reductions and improved quality of life warrants further investigations on cannabis as a potential alternative to prescription opioids for treating chronic pain.
Article
An evidence-based approach is needed to shape policies and practices regarding medical cannabis, thereby reducing harm and maximizing benefits to individuals and society. This project assesses attitudes towards and utilization of medical cannabis and the mainstream healthcare system among medical cannabis users. The research team administered brief hard copy surveys to 450 adults attending an annual public event advocating for cannabis law reform. Among usable responses (N = 392), the majority (78%) reported using cannabis to help treat a medical or health condition. Medical cannabis users reported a greater degree of use of medical cannabis and a greater degree of trust in medical cannabis compared to mainstream healthcare. In comparison to pharmaceutical drugs, medical cannabis users rated cannabis better on effectiveness, side effects, safety, addictiveness, availability, and cost. Due to the medical use of cannabis, 42% stopped taking a pharmaceutical drug and 38% used less of a pharmaceutical drug. A substantial proportion (30%) reported that their mainstream healthcare provider did not know that they used medical cannabis. Other issues identified included lack of access to mainstream healthcare, self-initiated treatment of health issues, little knowledge of psychoactive content, and heavy cannabis use.
Article
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.
Article
Symptom management in older adults, including pain and distressing non-pain symptoms, can be challenging. Medications can cause side effects that worsen quality of life or create other symptoms, and polypharmacy itself can be detrimental in older adults. Cannabinoids may offer a way of managing selected symptoms with fewer side effects. Medical marijuana is an important area of study for older adults because of the side effects of other medications. It is also important for Baby Boomers, who are likely to have more experience with marijuana than older adults of previous generations. Therefore, geriatricians should understand medical marijuana's clinical indications, adverse effects, and legal context. This article reviews the evidence regarding indications for and risks of medical marijuana use in older adults.
Article
The National Academies of Sciences, Engineering, and Medicine has found substantial evidence that cannabis (plant) is effective for the treatment of chronic pain in adults, and moderate evidence that oromucosal cannabinoids (extracts, especially nabiximols) improve short‐term sleep disturbances in chronic pain. The paradoxical superiority of the cannabis plant over cannabinoid molecules represents a challenge for the medical community and the established processes that define modern pharmacy. The expanding and variable legalization of cannabis in multiple states nationwide represents an additional challenge for patients and the medical community because recreational and medicinal cannabis are irresponsibly overlapped. Cannabis designed for recreational use (containing high levels of active ingredients) is increasingly available to patients with chronic pain who do not find relief with current pharmacologic entities, which exposes patients to potential harm. This article analyzes the available scientific evidence to address controversial questions that the current state of cannabis poses for health‐care professionals and chronic pain patients, and sets the basis for a more open discussion about the role of cannabis in modern medicine for pain management. A critical discussion on these points, the legal status of cannabis, and considerations for healthcare providers is presented. This article is protected by copyright. All rights reserved.
Article
Introduction: There is a substantial growth in the use of medical cannabis in recent years and with the aging of the population, medical cannabis is increasingly used by the elderly. We aimed to assess the characteristics of elderly people using medical cannabis and to evaluate the safety and efficacy of the treatment. Methods: A prospective study that included all patients above 65 years of age who received medical cannabis from January 2015 to October 2017 in a specialized medical cannabis clinic and were willing to answer the initial questionnaire. Outcomes were pain intensity, quality of life and adverse events at six months. Results: During the study period, 2736 patients above 65 years of age began cannabis treatment and answered the initial questionnaire. The mean age was 74.5 ± 7.5 years. The most common indications for cannabis treatment were pain (66.6%) and cancer (60.8%). After six months of treatment, 93.7% of the respondents reported improvement in their condition and the reported pain level was reduced from a median of 8 on a scale of 0-10 to a median of 4. Most common adverse events were: dizziness (9.7%) and dry mouth (7.1%). After six months, 18.1% stopped using opioid analgesics or reduced their dose. Conclusion: 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. Gathering more evidence-based data, including data from double-blind randomized-controlled trials, in this special population is imperative.
Article
Background: A staggering number of Americans are dying from overdoses attributed to prescription opioid medications (POMs). In response, states are creating policies related to POM harm reduction strategies, overdose prevention, and alternative therapies for pain management, such as cannabis (medical marijuana). However, little is known about how the use of cannabis for pain management may be associated with POM use. Purpose: The purpose of this article is to examine state medical cannabis (MC) use laws and policies and their potential association with POM use and related harms. Methods: A systematic literature review was conducted to explore United States policies related to MC use and the association with POM use and related harms. Medline, PubMed, CINAHL, and Cochrane databases were searched to identify peer-reviewed articles published between 2010 and 2017. Using the search criteria, 11,513 records were identified, with 789 abstracts reviewed, and then 134 full-text articles screened for eligibility. Findings: Of 134 articles, 10 articles met inclusion criteria. Four articles were cross-sectional online survey studies of MC substitution for POM, six were secondary data analyses exploring state-level POM overdose fatalities, hospitalizations related to MC or POM harms, opioid use disorder admissions, motor vehicle fatalities, and Medicare and Medicaid prescription cost analyses. The literature suggests MC laws could be associated with decreased POM use, fewer POM-related hospitalizations, lower rates of opioid overdose, and reduced national health care expenditures related to POM overdose and misuse. However, available literature on the topic is sparse and has notable limitations. Conclusions: Review of the current literature suggests states that implement MC policies could reduce POM-associated mortality, improve pain management, and significantly reduce health care costs. However, MC research is constrained by federal policy restrictions, and more research related to MC as a potential alternative to POM for pain management, MC harms, and its impact on POM-related harms and health care costs should be a priority of public health, medical, and nursing research.