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FREE WEBINAR July 22, 2019 12:00 – 1:00 pm

Medical in Minnesota – Thoughts for Those Who Work with Seniors

By: Charles Reznikoff, MD, Addiction Specialist, Hennepin Healthcare

Handouts: mngero.org

Tweet: @mngero

Facebook: Type your questions /mngerosociety during the webinar

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Webinar Sponsors

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Cannabis (Marijuana) Update Charles Reznikoff, MD Addiction medicine internal Medicine Hennepin Healthcare July 2019

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Increasing use mostly older folks

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Generational Effect - Cannabis Use

• People born before 1945 (Silent Gen) • 30% have ever used cannabis • People born after 1945 (Boomers and after) • 70% have used cannabis

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Overview

• What is cannabis? • What is CBD? • How does MN program work? • Who is eligible for MN Medical cannabis? • How might cannabis hurt older patients?

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What is Cannabis? (AKA Marijuana: mostly a source of THC)

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What is Cannabis

• Ancient plant– primary source of fabric before 1492 • Recently, bred for potency of the drug THC • Other chemicals are present in cannabis that may cause effects, but are not well characterized • Smoked as a plant product (, bong, pipe, spliff) • THC can be extracted various ways • High potency THC extract eaten or vaporized

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Examples of Vape Pens

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What does cannabis do?

• Alter mood • Joy, pleasure • Anxiety, panic • Alter time/space perception • Alter ones thought processes • Minimal effect on judgment • Impairs new memory formation • Change physical sensations • Pain relief, increased appetite, aphrodisiac et c. • Dilate blood vessels

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Cannabis receptors in the brain: ubiquitous

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Cannabis receptors in the body: immune cells

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Andrew Weill described mild predictable physical effects, and variable psychological

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Cannabis metabolized by the liver… Difficult to predict the response to eaten cannabis

Psychopharmacology, Nov2006, Vol. 188 Issue 4, p425-444, 20p, 1 chart, 3

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Cannabis withdrawal: mild symptoms for a week

Budney et al, J of Abnl Psyche 2003 vol 112 #3 p393

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What is CBD? (, the “other” )

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What is CBD?

• Chemical found in cannabis and • Does not stimulate the cannabis receptor like THC • Unknown medical effects • Anti-seizure very likely • Non-euphoric likely • Anti-addictive possible • Anti-inflammatory iffy • Many other unproven claims…

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Where does CBD come from?

Recreational cannabis • Bred for low % CBD Medical cannabis • Bred for high % CBD Hemp derived supplements • Legal under 2018 Ag law A new FDA approved medication: Epidiolex • Synthetic CBD • Indication childhood epilepsy syndromes

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CBD Craze: -2018 law made CBD from hemp legal federally (CBD from cannabis not legal federally) -FDA has not yet regulated hemp-based CBD -“Mad dash” to cash in before FDA regulation -OTC in food co-ops, head shops, online -Unproven medical claims -Pesticide contamination -Suspiciously high THC content Likely from cannabis, not hemp -Rare synthetic drug adulteration

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https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm484109.htm https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm6 11046.htm

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>$50

>$4

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Bottom line: CBD is a fad

Other than cost, it is mostly harmless

There may be some therapeutic potential

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THC vs CBD

Both naturally occurring components of cannabis and hemp.

THC- more in cannabis, less in hemp. Intoxicant, well known

CBD- more in hemp, less in cannabis Non-intoxicant, mostly a fad

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Minnesota’s Medical Cannabis Program

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A provider can maintain professionalism while recommending cannabis…. But only if they maintain professionalism while they recommend cannabis!

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“Medical” Edibles in Colorado

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Cannabis Clinic in California

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Medical Cannabis in Minnesota

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MDH website: helpful

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July 1st 2019 Alzheimer's disease added to this list!

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Two medical cannabis manufacturers: Law prohibits recommending one over the other

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How do you get approved for MN medical cannabis • The medical provider caring for the qualifying condition can register with the state and certify that the patient has a qualifying medical condition • There are no “cannabis clinics” or “cannabis referrals” • Medical providers are not obligated to certify conditions for their patients • Medical providers may opt out • Medical providers may determine medical cannabis is not right for the patient who otherwise qualifies • Once certified the patient works with the state to start medical cannabis

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Cost is High

• Insurance does not cover medical cannabis • Patient state registration fee $50-$200 • Medical assistance patients get a discount • Monthly cost of medication is variable • $100 to $500 per month depending on product and dose

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What are the harms of cannabis for older patients?

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Commonest emergency caused by marijuana ingestion?

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Commonest emergency caused by marijuana ingestion? Panic Attack

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Is marijuana and/or medical cannabis addictive?

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Is Marijuana Addictive?

If <18 years, risk of addiction increased to 17% www.drugabuse.gov/publications/research- reports/marijuana/marijuana-addictive

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Cannabis dilates blood vessels

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My biggest concern about geriatric patients on cannabis?

• Dizziness and falls

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Work place accidents associated with cannabis use

• Macdonald S, Hall W, Roman P, Stockwell T, Coghlan M, Nesvaag S. Testing for cannabis in the work-place: a review of the evidence. Addiction. 2010;105:408- 416.

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Marijuana use doubles in anxiety disorders and depression • Cannabis use increases anxiety and depression symptoms over time • Panic, depression, general anxiety

• Cannabis is also anxiety relieving • Social anxiety and PTSD

Buckner, Journal of Psyche Research, 2007 J. Of American Academy of Child and adol psych 46(3) 2007

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Marijuana and Psychosis

• Worsening of preexisting schizophrenia • Increased psychiatric hospitalizations • Acute reversible psychotic reaction • Increased likelihood of eventual schizophrenia • Acute irreversible psychotic reaction • Psychotic break, Schizophrenia

Zammit brit journal of psyche nov 2008 193 (5) p357 D’souza, int. review of neurobiology 2007 (78) p289 Moore et al. LANCET July 28, 2007 P.319

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http://www.startribune.com/university-of-minnesota-survey-links-marijuana-to-lower- grades/506125982/

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Medical cannabis warnings

• Caution when eating cannabis • Cannabis addiction and withdrawal is real! • Cannabis causes dizziness and falls • It is unsafe to drive on cannabis • Cannabis is associated with increased mental health symptoms, and mental health emergencies • People with psychosis should not take cannabis • Cannabis worsens memory • Hyperemesis syndrome increasingly recognized

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For which geriatric patients would I recommend medical cannabis? • Patients who have experienced cannabis in their life and tolerated its effects • Terminal illness, HIV/AIDS and/or cancer with symptoms • Patients with chronic pain wishing not to be on opioids (not in addition to opioids!) • Patients with symptomatic Alzheimer's? • Caution with fall risk • Be aware of memory effects • Best for advanced symptomatic disease, i.e. palliative

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Thank you! Questions?

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Questions? contact [email protected]

Next Webinar: August 13, 2019, Noon – 1:00 pm

Palliative Care – It’s Not Just for the Dying Anymore

By: Pat Berry, PhD, NP, MSN

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New Zealand Dunedin Study >1000 cohort studied over 38 years

 Updated summer 2012  Neur opsychiatr ic declines acr oss the boar d in MJ user s Age and dose dependent Mental health Verbal IQ Academic achievement and job satisfaction

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Students at risk of failing most negatively affected by access to legal marijuana

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