Cbd oil risk factors for elderly woman with vertigo

Are marijuana and seniors a bad combination?

Geriatrician Jennifer Watt opened the elderly man’s file. She was doing a follow up appointment with him after he’d come to an emergency room with delirium, a type of confusion that’s common in the elderly, and been admitted to the hospital. The notes said the issue had resolved itself, and it wasn’t clear what set it off. “There are lots of different risk factors for delirium, and he had things that would put him at risk,” she explains. But the trigger was unclear – until they started discussing his drug use.

He’d been looking for pain relief, and sought out some marijuana himself. “He began taking it, and got confused,” she says. “He was very honest with me when I asked. It was just that no one had asked before.”

Gabriella Gobbi, a professor of psychiatry at McGill University and psychiatrist at McGill University Health Centre, says she’s also seen several elderly patients with delirium caused by cannabis use.

We often hear about the potentially negative health effects of marijuana on young people, especially on developing adolescent brains. But some doctors, like Watt and Gobbi, believe we need more research on its effects on the elderly. They are concerned that we don’t know enough about its potential side effects, including confusion and an increased risk of falling.

Many seniors use cannabis for medicinal reasons, including pain and insomnia. Medical marijuana has been legal in Canada since 2001 – some dispensaries even offer seniors’ discounts. And its use is on the rise, with almost 130,000 Canadians registered to purchase it as of 2016, up from 7,900 in 2014. General use may also rise as the federal government moves to legalize marijuana by July 2018.

The elderly are significantly less likely to use marijuana than the regular population. But as cannabis becomes more generally accepted and aging Boomers hit retirement, more seniors may use it in the future. The U.S., which has legalized marijuana in eight states, has seen a rise in cannabis use in people over 50: in 2006/07, three percent of people in that age bracket said they’d used marijuana in the past year; in 2012/13, that number rose to five percent.

“I t’s use has become a very important issue,” says Gobbi. “More regulated research must be done in the elderly, to understand how cannabis can be used in this vulnerable population without side effects.”

The health effects of cannabis

There has been quite a bit of research into the health effects of marijuana in general, with more than 60 systematic reviews on the subject. Some studies have found it can help with treating nausea and vomiting from chemotherapy, reducing spasticity from multiple sclerosis, helping with Tourette’s syndrome, and reducing sleep disorders, though the evidence tends to be mid- to low-quality and vulnerable to bias. Cannabis is also often used for pain reduction, but the evidence around that is mixed.

There are some negatives: marijuana may increase the risk of testicular cancer and some mental health problems and it’s not safe during pregnancy. There have also been studies that suggest cannabis might be associated with problems like depression, anxiety, bladder cancer, bone loss or brain changes, among others, but the evidence around all of this is still inconclusive.

Elderly people may have distinct risks: A 2014 review on marijuana and older people pointed out that drowsiness and dizziness were two known side effects of marijuana that could contribute to falling in older people. It also pointed to an increased risk of arrhythmia.

Other studies have shown that marijuana might trigger a stroke in people with coronary artery disease. Marijuana’s cognitive effects could have a larger impact on older people who are already struggling cognitively. And cannabis can cause side effects when mixed with other medications, such as increasing the risk of bleeding, lowering blood pressure, and affecting blood sugar levels.

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It’s difficult to research marijuana in the U.S., where it’s classified, federally, as a Schedule 1 narcotic. It’s much easier to do studies on it in Canada, but it still hasn’t gone through the same rigorous process as a regular pharmaceutical drug would have. “ Cannabis took this strange pathway,” says Gobbi. “I think that cannabis should go through clinical phases, as all drugs do, which would include testing on the elderly population.”

Effects on the elderly

The vast majority of cannabis research is done for the population in general and either doesn’t include the elderly at all or doesn’t report on them separately. A 2014 editorial in the Journal of the American Geriatrics Society made the argument that we need more research on the elderly and pot, as they’re likely to have adverse effects that are specific to them.

Mona Sidhu, a geriatrician who works out of Hamilton Health Sciences, knows this issue well. She routinely prescribes marijuana for seniors, mostly for pain management in people without cancer. “I fell into this,” she says. “I was asked to see patients that would be potential candidates for cannabis use, and having very little background knowledge, I didn’t know the potential.

“I learned from some other physicians, and after trying it on some seniors, and seeing how their fentanyl and morphine use started to reduce, I started prescribing it more.” She says it has helped many of her patients manage their pain, sleep better, and reduce anxiety.

She does start seniors on a lower dose than she uses for other people, she says, in the same way as she would modify the dose of a pharmaceutical drug. She also recommends seniors use a vaporizer or oral dose. She’s swayed by her personal experience, and by the anecdotal research out there supporting it. “Even though the high quality data is not out there, we should not ignore the anecdotal evidence that supports the use of marijuana,” she says.

Brian Kaskie, a researcher at the University of Iowa and the author of a 2016 paper that looked at the trends around marijuana usage in seniors, agrees. His paper pointed out that more older adults are using cannabis, and many of them are using it for medicinal reasons, and in place of prescription medications. While he acknowledges that may lead to some side effects, like falls, he’s excited about the possibility it brings, too. Many of these issues, like pain, “aren’t as relevant to people under 50,” he says. “The potential here is compelling.”

Fiona Clement, director of the Health Technology Assessment Unit at the University of Calgary and co-author of a review of the evidence around cannabis, looks at it differently. “If we held marijuana to the same standards as the other drugs we allow on the market, I don’t think it would meet the bar [for effectiveness as a treatment],” she says.

And everyone agrees that the evidence around all of this is still hazy. As Watt says, “At the end of the day, when it comes to knowing the potential benefits and harms and having that conversation with patients, right now we’re quite hindered by the lack of evidence.”

More Than Half of People Using Cannabis for Pain Experience Multiple Withdrawal Symptoms

Minority experience worsening of symptoms over time, especially younger people.

More than half of people who use medical marijuana products to ease pain also experience clusters of multiple withdrawal symptoms when they’re between uses, a new study finds.

And about 10% of the patients taking part in the study experienced worsening changes to their sleep, mood, mental state, energy and appetite over the next two years as they continued to use cannabis.

Many of them may not recognize that these symptoms come not from their underlying condition, but from their brain and body’s reaction to the absence of substances in the cannabis products they’re smoking, vaping, eating or applying to their skin, says the University of Michigan Addiction Center psychologist who led the study.

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When someone experiences more than a few such symptoms, it’s called cannabis withdrawal syndrome – and it can mean a higher risk of developing even more serious issues such as a cannabis use disorder.

In the new research published in the journal Addiction, a team from the University of Michigan Medical School and the VA Ann Arbor Healthcare System reports findings from detailed surveys across two years of 527 Michigan residents. All were participating in the state’s system to certify people with certain conditions for use of medical cannabis, and had non-cancer-related pain.

“Some people report experiencing significant benefits from medical cannabis, but our findings suggest a real need to increase awareness about the signs of withdrawal symptoms developing to decrease the potential downsides of cannabis use, especially among those who experience severe or worsening symptoms over time,” says Lara Coughlin, Ph.D., the addiction psychologist who led the analysis.

Long-term study in medical cannabis use

The researchers asked the patients whether they had experienced any of 15 different symptoms – ranging from trouble sleeping and nausea to irritability and aggression – when they had gone a significant time without using cannabis.

The researchers used an analytic method to empirically group the patients into those who had no symptoms or mild symptoms at the start of the study, those who had moderate symptoms (meaning they experienced multiple withdrawal symptoms) and those who had severe withdrawal issues that included most or all of the symptoms.

They then looked at how things changed over time, surveying the patients one year and two years after their first survey.

At baseline, 41% of the study participants fell into the mild symptoms group, 34% were in the moderate group and 25% were classed as severe.

Misconceptions about medical cannabis

Many people who turn to medical cannabis for pain do so because other pain relievers haven’t worked, says Coughlin, an Assistant Professor in the Department of Psychiatry who sees patients as part of U-M Addiction Treatment Services . They may also want to avoid long-term use of opioid pain medications because they pose a risk of misuse and other adverse health consequences.

She notes that people who experience issues related to their cannabis use for pain should talk with their health care providers about receiving other pain treatments including psychosocial treatments such as cognitive behavioral therapy.

The perception of cannabis as “harmless” is not correct, she says. It contains substances called cannabinoids that act on the brain – and that over time can lead the brain to react when those substances are absent.

In addition to a general craving to use cannabis, withdrawal symptoms can include anxiety, sleep difficulties, decreased appetite, restlessness, depressed mood, aggression, irritability, nausea, sweating, headache, stomach pain, strange dreams, increased anger and shakiness.

Previous research has shown that the more symptoms and greater severity of symptoms a person has, the less likely they are to be able to reduce their use of cannabis, quit using it or stay away from it once they quit.

They may mistakenly think that the symptoms happen because of their underlying medical conditions, and may even increase the amount or frequency of their cannabis use to try to counteract the effect – leading to a cycle of increasing use and increasing withdrawal.

“Our findings suggest a real need to increase awareness about the signs of withdrawal symptoms developing to decrease the potential downsides of cannabis use, especially among those who experience severe or worsening symptoms over time.”

Coughlin says people who decide to use a cannabis product for a medical purpose should discuss the amount, route of administration, frequency and type of cannabis product with their regular health provider. They should also familiarize themselves with the symptoms of cannabis withdrawal and tell their provider if they’re experiencing them.

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Feeling the urge to use cannabis after a period without use, such as soon after waking up, can be a sign of a withdrawal syndrome, she notes. So can the inability to cut back on use without experiencing craving or other symptoms of withdrawal.

Because there is no medically accepted standard for medical cannabis dosing for different conditions, patients are often faced with a wide array of cannabis products that vary in strength and route of administration. Some products could pose more risk for development of withdrawal symptoms than others, Coughlin says. For example, people who smoked cannabis tended to have more severe withdrawal symptoms than others, while people who vaped cannabis reported symptoms that tended to stay the same or get worse, but generally did not improve, over time.

As more states legalize cannabis for medical or general use, including several states that will legalize its use based on the results of last November’s election, use is expected to grow.

More about the study

The researchers asked the patients about how they used cannabis products, how often, and how long they’d been using them, as well as about their mental and physical health, their education and employment status.

Over time, those who had started off in the mild withdrawal symptom group were likely to stay there, but some did progress to moderate withdrawal symptoms.

People in the moderate withdrawal group were more likely to go down in symptoms than up, and by the end of the study the number of the people in the severe category had dropped to 17%. In all, 13% of the patients had gone up to the next level of symptoms by the end of the first year, and 8% had transitioned upward by the end of two years.

Sleep problems were the most common symptom across all three groups, and many in the mild group also reported cravings for cannabis. In the moderate group, the most common withdrawal symptoms were sleep problems, depressed mood, decreased appetite, craving, restlessness, anxiety and irritability.

The severe withdrawal symptom group was much more likely to report all the symptoms except sweatiness. Nearly all the participants in this group reported irritability, anxiety, and sleep problems. They were also more likely to be longtime and frequent users of cannabis.

Those in the severe group were more likely to be younger and to have worse mental health. Older adults were less likely to go up in withdrawal symptom severity, while those who vaped cannabis were less likely to transition to a lower withdrawal-severity group.

The study didn’t assess nicotine use, or try to distinguish between symptoms that could also be related to breakthrough pain or diagnosed/undiagnosed mental health conditions during abstinence.

Future directions

Coughlin and her colleagues hope future research can explore cannabis withdrawal symptoms among medical cannabis patients further, including the impact of different attempts to abstain, different types of use and administration routes, and interaction with other physical and mental health factors. Most research on cannabis withdrawal has been in recreational users, or “snapshot” looks at medical cannabis patients at a single point in time.

Further research could help identify those most at risk of developing problems, and reduce the risk of progression to cannabis use disorder, which is when someone uses cannabis repeatedly despite major impacts on their lives and ability to function.

The study was funded by the National Institute on Drug Abuse (DA033397). The original study from which the data came was led by Mark Ilgen, Ph.D., the Director of the U-M Addiction Treatment Services and a co-author of the new paper. The new study’s senior author is Kipling Bohnert, Ph.D., formerly of U-M and now at Michigan State University.

Paper cited: “Progression of cannabis withdrawal symptoms in people using medical cannabis for chronic pain,” Addiction. DOI: 10.1111/add.15370