Understanding Medical Marijuana for Seniors
Matthew Mintz, MD, FACP Internal Medicine & Primary Care
DC Senior Resource Group 11/5/2018 Washington, DC About Me
• Full time faculty at GW for 20 years • Internal Medicine practice opened July 2017 • Concierge Practice – Same day/Next day appointments – 24/7 phone access Journey to Medical Marijuana Multiple Medications Have Come From Plants • Digitalis purpurea – fox glove - CHF • Papaver somniferum – opium poppy • Atropa belladonna – nightshade -IBS • Ephedra sinica – ephedrine - hypotension • Salix alba – willow tree - ASA • Taxis brevifolia – Pacific Yew tree – breast cancer History of Cannabis • Ancient – Earliest Chinese medicinal texts (centuries BC) – Indian ayurvedic medicine – Green and Roman (Galen) • Dr. William O’Shaughnessy – “On the preparation of Indian hemp or gunja” (1839) • Late 19th and early 20th Century manufactured for medicinal use • Refer Madness and the Marihuana Tax Act of 1937
Medical Marijuana in the 20th Century
• Post ‘60’s re-discovery • Anecdotal reports from cancer patients with post-chemo nausea • Dr. Mechoulam isloates Δ-9 tetrahydrocannabionol (THC) 1964 • Controlled Substances Act of 1970 – Marijuana Schedule 1 • High abuse/No accepted use – 1972 Commission recommends decriminalization, but Nixon & congress keep is Schedule 1 Medical Marijuana in the 20th Century • Marinol (dronabinol) first synthetic oral THC approved in 1986 • 1990’s use for AIDS wasting syndrome San Francisco – Buyer’s club in 1993, doctor’s note • California Prop 215-Medical Legalized in 1996 (possess and cultivate) “for any illness” where MJ provides relief; other states follow • Starts use/research for Cannabis Medicine for nausea, chronic pain, muscle spasms, MS, PTSD, etc.
Endocannabinoid System
CB receptors are G-protein Receptors with functional selectivity • Open and close channels • Stimulate or block adenyl cyclase. Endocannabinoid Basics: Summary • CB1 and CB2 receptors found throughout the body • Anadamide (AEA) and 2-AG synthesized on- demand for homeostatic functions • Complex effects of cannabinoids due to functional selectivity and overlap with other systems Components of Medical Marijuana Effects of the Cannabinoids
• THC- mimics AEA and 2AG, acts as partial agonist on CB1 and CB2 receptors • CBD- low affinity for CB1 and CB2- antagonizes CB1 and CB2 agonists • Dronabinol and Nabilone are synthetic THC
CBD vs. Medical Marijuana • Marijuana contains both CBD and THC • Legal medically and/or recreationally in many states • Available in varieties that have both low amounts of THC (i.e. 14:1) or high amounts (1:1)
• Hemp is a related plant that has CBD bout only trace amounts of THC • Legal in most states • Available online (Amazon)
• CBD alone has medicinal properties • Evidence suggest even small amounts of THC more effective
The Entourage Effect
Specialized Strains and Multiple Formulations Certain strains high in cannabidiol (CBD) and low in THC Therapeutic Uses of Medical Marijuana
Medical Marijuana in the Treatment of Pain
Uses of Medical Marijuana in Cancer • Help reduce symptoms caused by cancer • Help reduce symptoms from cancer treatment • Help in treating cancer • Help in preventing cancer (maybe) Why we should consider medical cannabis for seniors
Cannabis for Seniors • Treats a variety of common conditions in the elderly- pain, anxiety, insomnia, anorexia, agitation. • Low side effect profile • Low toxicity or risk of addiction • Limited interactions with other prescription medications – Reduce polypharmacy • Prospective study of 2736 patients 65 years and older who received medical cannabis from 1/15-10/17. • Survey • Outcomes were pain intensity, QOL, adverse events at six months Safety and Efficacy of Medical Cannabis in the Elderly Safety and Efficacy of Medical Cannabis in the Elderly
97% of patients reported improvement in their condition, and reported pain level was reduced from a median of 8 (0-10) to 4. After 6 months, 18% stopped opioid analgesics or reduced dose. Safety and Efficacy of Medical Cannabis in the Elderly Safety and Efficacy of Medical Cannabis in the Elderly Safety and Efficacy of Medical Cannabis in the Elderly Drug interactions with cannabis
• Cannabis enhances CNS depressant effects when combined with alcohol, barbiturates and benzodiazepines, but probably not opioids • THC induces CYP1A2, and can reduce levels of drugs metabolized by CYP1A2. – clozapine, duloxetine, naproxen, cyclobenzaprine, olanzapine, haloperidol, and chlorpromazine • CBD inhibits CYP3A4 and CYP2D6, and can increase levels of drugs metabolized by these isoenzymes. – macrolides, calcium channel blockers, benzodiazepines, cyclosporine, PDE5 inhibitors, antiretrovirals How Can Patients Get Medical Marijuana? • Process slightly different in MD vs. DC. – Varies in each state, not yet available in VA • Need to register with the state/district • Need to be certified by a provider who is registered with the state/district – Not just physicians • Once registered and certified, can go to a dispensary to get product – NOT a prescription Questions???
Matthew Mintz, MD, FACP 10401 Old Georgetown Road, #305 Bethesda, MD 20814 1-855-MINTZMD (855-646-8963) www.drmintz.com [email protected]