Medical Cannabis for Older Patients—Treatment Protocol and Initial Results
Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Older adults may benefit from cannabis treatment for various symptoms such as chronic pain, sleep difficulties, and others, that are not adequately controlled with evidence-based therapies. However, currently, there is a dearth of evidence about the efficacy and safety of cannabis treatment for these patients. This article aims to present a pragmatic treatment protocol for medical cannabis in older adults. We followed consecutive patients above 65 years of age prospectively who were treated with medical cannabis from April 2017 to October 2018. The outcomes included treatment adherence, global assessment of efficacy and adverse events after six months of treatment. During the study period, 184 patients began cannabis treatment, 63.6% were female, and the mean age was 81.2 ± 7.5 years (median age-82). After six months of treatment, 58.1% were still using cannabis. Of these patients, 33.6% reported adverse events, the most common of which were dizziness (12.1%) and sleepiness and fatigue (11.2%). Of the respondents, 84.8% reported some degree of improvement in their general condition. Special caution is warranted in older adults due to polypharmacy, pharmacokinetic changes, nervous system impairment, and increased cardiovascular risk. Medical cannabis should still be considered carefully and individually for each patient after a risk-benefit analysis and followed by frequent monitoring for efficacy and adverse events.
The recent interest and use of medical cannabis (MC) are growing substantially in many countries. The regulations on its use vary among countries, affecting medical practice and experience . Current public opinion is that cannabis has the therapeutic potential to treat and cure a long list of diseases, but there is a large gap between that opinion and the current evidence in the medical literature . Another common opinion is that MC is mainly used by young adults. However, the use of MC by older adults is increasing , and studies show variable prevalence, ranging from approximately 7% to more than one-third, depending on the country [4,5]. Recreational use of cannabis by older adults is also increasing substantially, especially in the United States .
Relief of suffering and promotion of functional status and quality of life are major goals of geriatric medicine. Chronic pain, Parkinson’s disease, depression, sleeping disorders, and malnutrition are all common among older adults [7,8,9,10,11,12]. Current medical treatments of these syndromes can have serious adverse events, frequently endangering patients’ health. For example, some non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal bleeding, renal impairment, and cardiovascular adverse events . Sedative hypnotics can cause psychomotor impairment, dizziness, confusion, increased risk of falls, next-day somnolence, impairment of driving skills, orthostatic hypotension, and blood electrolyte impairment . Opioid treatment causes constipation, nausea, vomiting, drowsiness, delirium, sedation, anticholinergic effects, falls, and respiratory depression, which is the most serious potential adverse effect . Beyond individual factors, current concerns about opioid-related deaths have greatly influenced our thinking about pain management and medication treatment .
1.1. Efficacy and Indications for Medical Cannabis in Older Adults
The geriatric population may benefit from cannabis treatment for a variety of symptoms, such as chronic pain, sleep difficulties, tremor, spasticity, agitation, nausea, vomiting, and reduced appetite. Cannabis may also be useful in palliative care. However, currently, there is a dearth of evidence about the efficacy of cannabis in older adults for any of these symptoms. This has been emphasized in several reviews [16,17,18] and in large reports such as the report of the National Academies of Sciences in the United States  and the Information for Health Care Professionals in Canada .
1.2. Chronic Pain
Chronic pain is one of the most common indications for prescribing MC. The report by the National Academies of Sciences concludes that cannabis is effective for the treatment of chronic pain in adults . Despite this conclusion and a large number of studies, including randomized controlled trials, the efficacy for cannabis as a chronic pain medication remains in dispute . Pain relief is very often cited as a reason for MC use among older individuals. For example, 89.7% of the older patients in the Colorado MC registry listed pain as their primary or secondary condition . All the large studies that evaluated cannabis for pain have included older adults in the inclusion criteria, but their number was small, or they were not analyzed separately for safety and efficacy [21,22].
1.3. Parkinson’s Disease
Parkinson’s disease (PD) is a common neurodegenerative disease found mostly among older adults, which is caused by dopaminergic neuron loss. It is mainly characterized by motor symptoms that include bradykinesia in combination with resting tremor or rigidity . PD also has a distinct prodromal stage identified by non-motor symptoms, such as olfactory dysfunction, constipation, urinary dysfunction, depression, anxiety, and pain . Two small-scaled randomized controlled trials failed to demonstrate the efficacy of cannabis in treating the motor symptoms of PD [25,26]. However, cannabis might improve quality of life in PD and relieve other non-motor symptoms .
1.4. Sleep Difficulties
Approximately 50% of people above age 65 complain about sleeping difficulties, and there is an increase in sleep disturbances in old age . Care must be taken not to mistake geriatric sleep complaints for physiological aging, as these complaints are mainly attributable to medical, psychiatric and health-related burdens . It should be noted that sleep disturbances are among the most frequent complaints of cannabis withdrawal, and are a major cause for continued use after attempts to quit . Both pharmacological and non-pharmacological treatments are used to address sleep disorders among older individuals . A meta-analysis evaluating the therapeutic effect of cannabis on sleeping disturbances has not reached a decisive conclusion. The effects of cannabis on the sleep–wake cycle are also unclear , though some research suggests that cannabis might aid in sleep disorders due to its anxiolytic effect .
1.5. Nausea and Vomiting
A Cochrane review concluded that “Cannabis-based medications may be useful for treating refractory chemotherapy-induced nausea and vomiting” . A more recent review states that there is low-quality evidence that cannabinoids prevent nausea and vomiting as compared to other agents or a placebo . The only study that addressed this issue in older adults was in 1982, and it found no difference between tetrahydrocannabinol (THC) and prochlorperazine in reducing nausea and vomiting .
1.6. Post-Traumatic Stress Disorder (PTSD)
The efficacy of cannabis treatment for PTSD in older individuals was not evaluated thus far in any study. Several studies evaluated the efficacy of cannabis treatment for PTSD in younger adults, but these studies also failed to demonstrate a clear effect of MC treatment for these patients .
Dementia is a prevalent condition in older adults causing cognitive decline . Small studies that used Dronabinol, oral synthetic Δ 9 -THC, or an extract of THC from plants, showed it improved neuropsychiatric symptoms, agitation, nocturnal motor activity, sleep duration, and meals consumption in dementia patients, while only a few serious adverse events were observed [37,38,39].
However, a study conducted with Namisol, an oral tablet containing ≥98% natural ∆ 9 -THC, showed it did not reduce neuropsychiatric symptoms, agitation, activities of daily living, or improved quality of life in dementia patients .
1.8. Palliative Treatment
A recent systematic review and meta-analysis were unable to make any recommendation about the use of cannabis in palliative care after evaluating studies that included mainly younger adults and a small number of older adults .
2. Special Considerations and Precautions
2.1. Pharmacokinetics, Pharmacodynamics, and Drug Interactions
It is well known that aging is associated with substantial changes in pharmacokinetics and pharmacodynamics. For instance, hepatic drug clearance, as well as renal elimination, are both decreased in older adults. Furthermore, aging is associated with increased body fat and decreased lean body mass , which increases the volume of distribution for lipophilic drugs, such as cannabis. Two small studies evaluated the pharmacokinetics and pharmacodynamics of older adults who received an oral drug containing pure THC. These phase I and phase II trials included 12 healthy older adults and 10 older adults with dementia, respectively, and found smaller pharmacodynamic effects of THC in both groups, although the pharmacokinetic data showed substantial inter-individual variation [43,44]. Interaction between cannabis products and other drugs is also largely unknown, as the current evidence from human studies is sparse . Concomitant administration of cannabis with other drugs that influence the hepatic CYP family enzymes may greatly alter the metabolism of the cannabinoids . This issue is especially important in the geriatric population, where polypharmacy is common .
2.2. Nervous System Impairment
The common adverse effects experienced by patients due to cannabis use include dizziness, euphoria, drowsiness, confusion, and disorientation . These effects are particularly important in the geriatric population, which may have conditions such as dementia, frequent falls, mobility problems, hearing, or vision impairments . The long-term effect of adult cannabis use on cognition is unclear. Two systematic reviews showed evidence that long-term use of cannabis is associated with negative effects on some cognitive functions, but evidence of enduring negative effects was weak [49,50].
2.3. Cardiovascular Risks
The effects of cannabis on cardiovascular diseases are not yet well established. In recent years, however, there has been an increasing number of case series and reports concerning young, healthy recreational cannabis users who suffer from arrhythmias, myocardial infarction, and even sudden cardiac death . Direct causality has not been proven, but the implication is that care must be taken concerning older adults since they have more cardiovascular comorbidities and risk factors.
The acute cardiovascular effects of cannabis, based on studies performed on younger individuals, include an increase in sympathetic activity that causes an increase in heart rate, cardiac output, and myocardial oxygen demand. Tolerance of the effects of cannabis on heart rate develops rather quickly in young people .
This article aims to present a novel medical cannabis treatment protocol in older adults and the initial results from its use. The protocol will be presented in the Discussion segment of the manuscript.
3.1. Patients and Methods
Israeli medical cannabis regulations include a number of indications and recommendations for its use . We have adopted the general recommendations to suit the physiological and pathophysiological needs of the elderly. In 2017, NiaMedic established a specialized geriatric clinic to provide MC therapy within a comprehensive geriatric platform. We have followed 184 consecutive patients above 65 years of age prospectively who were treated with MC from April 2017 to October 2018. The patients were followed for at least six months since treatment initiation. The inclusion criteria were age of 65 years and above and any of the following indications for cannabis treatment: chronic cancer pain and non-cancer pain, Parkinson’s disease, sleep disorders, anorexia, post-traumatic stress disorder, spasticity, and palliative treatment. The exclusion criteria were severe cardiovascular diseases, such as heart failure or a recent major myocardial infarction, liver failure, psychotic comorbidities, and those with a history of addictions. The follow-up evaluation includes detailed questioning regarding adverse events, adherence to treatment, and its efficacy.
3.2. The Treatment Protocol
As previously mentioned, the regulations of cannabis and its products vary by country, which affects the clinical experience of physicians. In Israel, cannabis can be prescribed for the following conditions: nausea and vomiting due to chemotherapy treatment, cancer-associated pain; Crohn’s disease, ulcerative colitis; neuropathic pain; AIDS patients with Cachexia; multiple sclerosis, Parkinson’s disease, Tourette syndrome, epilepsy (both adult and pediatric population); palliative treatment; post-traumatic stress disorder . The initially approved dosing is 20 grams of cannabis compound per month (0.6 grams per day), with a cannabis product that contains the lowest concentration of active ingredients, but without limitation to the ratio of the different cannabinoids. The only cannabinoid-based medicine that is approved at the time of this manuscript preparation is Nabiximols, and its use is infrequent. Thus, we provide here our approach that is based on the available literature, data analysis, and our clinical experience with treating older adults with herbal cannabis, which includes the cohort above and previously published data . We offer many recommendations consistent with Minerbi et al. and MacCallum et al. [17,54].
Our study collected all the relevant clinical data as a part of the routine medical practice. Thus, Soroka University Medical Center institutional review board (IRB) Committee approved the protocol and waived the request for informed consent (confirmation number 0036-18-SOR). All clinical investigations were conducted according to the principles expressed in the Declaration of Helsinki.
We present here initial data from a cohort of patients who initiated MC therapy between April 2017 and October 2018. Most of our patients, 83.2% (n = 153) were 75 years of age or older, and 63.6% (n = 117) were females. The demographic characteristics, the comorbidities of the patients, and the indications for cannabis treatment are detailed in Table 1 . When we evaluated the patients after six months of MC treatment, we found that 58.1% were still using cannabis, 8.1% discontinued the treatment, 10.9% were lost to follow-up, and 17.9% did not complete six months of treatment by the time of the analysis. Of the 122 patients eligible to respond, 91.8% (n = 112) globally assessed the effect of cannabis on their general condition, with 84.8% of them reporting some degree of improvement ( Figure 1 ). Of the patients who were still treated with cannabis, 33.6% reported adverse events, the most common of which were dizziness (12.1%), sleepiness and fatigue (11.2%), dry mouth (5.6%), and psychoactive sensation (5.6%). Since well-established and evaluated protocols for treatment of older adults with cannabis do not exist, we have developed our own approach based on close follow-up of effects, adverse events, and slow titration.
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The chat bar still stayed on the two messages that he asked her how to get out of the subway in the afternoon and the night scene taken during dinner at night.Where have you ariel CBD gummies Sanjay Gupta And CBD Gummies been, Mr.Boring Still no response, Damn, Mr.Boring is not allowed to hang out with some dog man for a day, forget his righteousness, and ignore my best friend all day Mabu Ten Fan, Boring kun didn t have time to look at her phone.When she got home, she took out a book from the desk drawer.There was nothing on the cover, but there were many columns in it.
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It s been picked up, so fast.When Shiraishi Zexiu was going upstairs, he happened to see Yuko Birdie hugging Mimi and rubbing her cheek against Mimi s face.Youyuko Birdie got are keoni CBD gummies legit Sanjay Gupta And CBD Gummies off the car and went to look for the neighbors.Maybe it s been a week, little The cat s face was a little raw, and when Shiraishi Zexiu stepped forward, Mimi kept waving her small paws against the air.She CBD gummies for diabetes shark tank opened the door, fortunately, there was not too much dust accumulated, but there was still one point, and the two of them decided to start cleaning.
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Our dining area is on the second floor.This is can CBD gummies help you sleep the elevator.A big city is a big city, you have to take the elevator to go to the second floor.Kuramochi told me that she was wearing a blue dress today The elevator has reached the second floor, and the elevator door slowly opened.Yuko Yuko took out her mobile phone from her what is best CBD gummies for pain bag and described to Shiraishi Zexiu what Sakura Kuramochi should be wearing today.No need, Shiraishi Zexiu interrupted.Yuko Yuko, who wants to continue describing her, I have found her.
Heh, Chiyo sneered disdainfully, looking directly what will a CBD gummy do at Zexiu Shiraishi, I ll let you touch, you Dare With a burning gaze, Shiraishi Zexiu moved his hand on his forehead down, covering Chiyo s eyes, but his gaze still pierced through his fingers.Who wouldn t dare Shiraishi Zexiu continued to move his hand down over the bridge of his delicate nose, and then to his rosy lips, and then pinched his thumb and middle finger, and the tender and white cheeks on both sides were squeezed into the middle, and Chiyo s mouth could not be reached.
There is nothing to hesitate, it is so beautiful Ichiyo Chiyo, who got a positive answer, let out a soft breath, That s what I said, if your gift is satisfactory to me, I will give you a surprise, and by the way, I will dress up the CBD gummies bears for pain bunny girl I owe you before.This dress, by sera relief CBD gummies review Chiyo Ichiyo glanced down at her pure white skin, and her bare back could Sanjay Gupta And CBD Gummies feel the Doctor Recommended Sanjay Gupta And CBD Gummies coolness of the can i give dog CBD gummies air conditioner keanu CBD gummies in the room, it s really a will CBD gummies get me high bit shady.This is art Shiraishi Zexiu clenched his right fist on his chest to express his solemnity, But the surprise is the promise before the exchange, why do I always feel that something is wrong Anyway, that s the case Ichiyo walked back to the bed and sat down.
Order.After saying do CBD gummy bears work that, Ichiro Genuchi left the classroom.Our school really attaches great importance to the face project.Takeuchi Arisu complained to Shiraishi Zexiu.All schools are like this.Life is like acting.All we have to do is to combine our own sadness and happiness Sanjay Gupta And CBD Gummies into this fake drama.Where did you copy it Zexiu.Forget it, just take it as I said it myself, Takeuchi, remember to sign my name later if you want to use it in the future.Regardless of Takeuchi s contemptuous actions, Shiraishi Zexiu poked Yuko Yuko s back.
The hero is sad about the beautiful bed.It was Suga Wulian who called Shiraishi Zexiu out of the room, because all the takeaways had arrived.Carrying a lot of food, the group went to the basement.Why are there so many, how many of us can finish it Shiraishi Zexiu sighed in surprise after spreading the food on the tablecloth.This is at least five units of Shiraishi Zexiu.Then I saw Kuramochi Sakurai, who was the most guilty, Becausebecause eating is to eat a little richer, how can you eat only a few things Maybe the eldest lady is like this, no, maybe half of the eldest ladies are like this.
You ve come too close, maybe you re beating you, right, like stay away from me or are CBD gummies keto friendly Sanjay Gupta And CBD Gummies something Those who disturb your normal life have now been punished, CBD gummies usa made gmp Ichiro Chiyo said suddenly, thinking sunny daze smoke shop CBD gummies for a second., If nothing else happens, I m still kneeling on the washboard.Ah What happened to my uncle so soon Shiraishi Zexiu was surprised for a while, recalled the night before, and asked suspiciously I didn t tell anyone, but your mother came back early that night, so your mother found it No, you don t need to worry about it, pureganic CBD gummies anyway, I m are CBD gummies from hemp as effective very sorry, CBD essence gummies my mother has given him a death order.
But I still want to call Minister Ogi to come and make los angeles stores CBD gummy bears a fool of me.There are only four dance machines in total.They are all being used now, and Shiraishi Zexiu and Suga Wulian are sitting on the long mat next to them and waiting.Shiraishi Zexiu held Suwa Wulian s hand and looked at the two groups above, learning how to play this.It seems that if you want to play well, you don t need to look at the direction given honey CBD gummies by the screen at all, just follow the rhythm, and the eyes of the girls over there smilz CBD Gummies reviews Sanjay Gupta And CBD Gummies are closed.
The road Doctor Recommended Sanjay Gupta And CBD Gummies is short, but it can go a long way.Chapter 270 Love is worth showing off.The two walked to the only shop Sanjay Gupta And CBD Gummies in this best CBD gummies for sleep no thc small street that exuded a warm glow, and only then did they know that it was a small Oden shop.Looking at each other, Shiraishi Zexiu closed his umbrella and entered, and as soon as he entered Chiyo, he walked up to him and Doctor Recommended Sanjay Gupta And CBD Gummies patted the snowflake on his shoulder.Welcome.The man who runs the shop is a slightly elderly grandfather, with kind eyes and a well trimmed gray beard.
On a summer night approaching seven o clock, the sky had already darkened, but from a distance, Shiraishi Zexiu could see the brightly lit villa, standing among the trees like a lighthouse on the coast.There are a lot of luxury cars at the door, and a large number of waiters are waiting at the door.Whenever a guest who drives by himself gets off, he will take the car key and drive to the private parking lot.Shiraishizawa Hide, who was taking a taxi, seemed out of place.Baby dog, please don t stage fright, show your momentum.
Su Wulian has already opened the rear door and got in.It seems a bit inappropriate to sit in the co best CBD gummies for relaxation pilot in this situation, and Zexiu Shiraishi also sat in the back seat.Please, Shiraishi, please report your wyld CBD gummies thc free address again, I forgot. Akiko Zuoba was basically talking to Shiraishi Zexiu on the road, and Suga Wulian kept the same silence as in the school, unlike in the daytime.Only when Shiraishi Zexiu got off the bus did he say See you next time, Shiraishi san.Holding the bag with books, Shiraishi Zexiu opened the apartment door.
The man in black and sunglasses are CBD gummies made with gelatin Sanjay Gupta And CBD Gummies at the door watched Zexiu Shiraishi and the seven people behind him the whole time.After they left, he sent someone into the second floor of the restaurant.The bodyguard who went up to the second floor waited until Yuko Kotori went to the toilet, then stepped forward how long does a 10mg CBD gummy last and whispered something in Kuramochi Sakurai s ear.Understood, let s go.Kuramochi Sakurai wiped her mouth with a napkin, looked at Shiraishi Zexiu s original position, supported her little face with both hands, and shook her head from side CBD gummies round rock to side.
Chapter 223 Is this a pure private maid But, if it s just a simple sweet MV, I still think it s a little bit meaningless.Both of his two leading actors were hood life gummies CBD reluctant to BE.After hesitating for a while, Kuramochi Sakura sunnyvale CBD gummies reviews Rei said.I think it s okay, Shiraishi Zehide rubbed the beech wood table with his hand, clearing his thoughts in his mind.It doesn t have to be a completely smooth story.There can be twists and turns diamond CBD chill gummy bears between the male and female protagonists, and they almost separated in the middle, so as to catch the audience s attention.
Fortunately, it was almost over.When I was in school last week, I filmed the related plots of the top learning department.Then when it was time for does amazon sell CBD gummies school, I had to change into my clothes again and go out to accompany CBD gummies fx Ichiyo Chiyo and Suga Wulian to play together in various scenes.No, according to their words, it was work.In order to reduce their workload, they even said after one scene that the characters of the two people amazon charlotte web CBD gummies Sanjay Gupta And CBD Gummies were still wrong and restored to their original nature.
Maybe it was because she wanted to praise seriously, but she couldn t hold back the smile she wanted to laugh.Su Wulian opened and closed her mouth several times but said nothing.Veryunique.The highest state of this dance is that it can be shaken to take can you feel CBD gummies off, but unfortunately I haven t practiced it yet, so I won t show you Hey call out call out Bright neon colors flickered on the faces of several people.At eight o clock, best thc free CBD gummies 2020 the fireworks started.Everyone s eyes were all focused on the sky, and the fireworks in Japan were still remarkable.
Shiraishi Zexiu silently distanced himself to express that he was a passerby.When Tai Ogi came back to his senses, Shiraishi Sanjay Gupta And CBD Gummies Zexiu had already sat on a chair in the waiting station and watched the monkeys in a civilized manner.Seeing that the monkey was awake, he left the station first.Aware of his embarrassing behavior, Taichi Ogi followed him out.Shiroishi kun is amazing I m so beautiful and are CBD gummies good for anxiety Sanjay Gupta And CBD Gummies I have a lot to say I like her even more Your rescue text is also very timely hehehe, thanks to you, I have an excuse for the next date.
Let s go Let s go back Sakurai Kuramochi came out of the checkout with a clearly distinguishable jubilation, walking as if she was Sanjay Gupta And CBD Gummies jumping, and Yuko Yuko, who was holding her hand, had to speed up her pace to keep up with her.Sakurai Kuramochi Felt wins 1 Shiraishi Zexiu looked at the stop smoking CBD gummies canada sudden change in the number of wins, and then looked at the excited Doctor Recommended Sanjay Gupta And CBD Gummies girl walking in front, good guy, co authoring now Kuramochi Sakurai already feels that she has won That s good, can I get it again after I m really scared We re delicious CBD gummies back.
This is CBD gummies for arousal just the tip of the iceberg.In a sense, their home is an area, not a villa.Shiraishi Zexiu, who was walking in front of Yuko Yuko, shrugged, Although it s gorgeous, it s just price of eagle hemp CBD gummies like that are CBD gummies good for quitting smoking Sanjay Gupta And CBD Gummies if I m not used to sleeping.I woke up naturally at 5 30 this morning.Uh huh Yuko Kotori, who recognizes the bed more seriously than Hide Shiraishi, naturally agrees.But if you boomer CBD gummies only talk about last night s experience, this place should be better than the apartment, right After all, there is no black silk bunny girl to watch in the apartment.
The girl s leg Maeda Shuqi frowned and said.Can their legs look as good as foxes Shiraishi Zexiu expressed disdain for his roommate s shallow heart.Thirdly, the girls are worried that you old scumbags will most likely choose to take a bath in the bath just like me.The three were speechless for a while, but Takeuchi Arisu quickly retorted Shiroishi, you This is slander, let me clarify, I am not old.Fourth, there are too many rules in hot springs, I find it troublesome.Shiraishi Zexiu ignored this do hemp gummies have CBD oil in them rebuttal.
My name is Zhenjia Dagu The fifth rule of the interviewer s code, always the same.The other two girls also cooperated very well, Suga Wulian didn t care at all, it was very interesting to CBD gummies toronto enter Chiyo.Little Bird Youyouko raised her head after lying on the ground for half a minute, CBD oil gummies houston with a blushing face that never faded away, her whole person was like a frightened deer, very cute.Then I searched on my mobile phone and started to ask more normal and interview questions Wait a minute I know, I have one last interview question If you answer CBD gummies st paul mn it right, you can join the top learning department Seeing that the interview was coming to an end, Yuko Kotori was about to lose her patience, and Kuramochi Sakurai seemed to suddenly Thinking of Doctor Recommended Sanjay Gupta And CBD Gummies something, he said aloud.
She just wanted to end her Sanjay Gupta And CBD Gummies work early.Only she green hornet gummies CBD is the only migrant worker, but fortunately she has overtime pay.The two girls in front of them were silent, their heads bad days CBD gummies review turned slightly to the outside, as if they didn t want to look at each other, and slowly, they approached Shiraishi Zexiu together, with an envelope in their hands.The snow fell, and the world became more and more quiet, gradually disappearing into the white, as if everything would be covered in dust.Only the little footsteps made by the girl s shoes stepping on the snow on the ground in real time.
It is much more lively than usual.Suga Wulian and Xiaoniao Youyouzi quickly integrated into the environment, and they started to eat after talking softly.Instead, this The owner of the house, Shiraishi Xiangmiao and Shiraishi Chuan are a little out of tune and feel a little unnatural.Chuan, eat more of this dish.Shiroishi Kanae put the blackened dish with a large chopstick into the rice bowl of Shiraishi River.Why did it burn like this today Shiroishikawa asked in surprise, and then swallowed it with rice.
Have CBD thc gummies in spokane wa you been deceived again, Zexiu Shiraishi looked at his finished product with satisfaction, slid over, and began to pat the snow off the girl s body, It s too stupid.But this is how you express your love, Shiraishi, I must accept it.Yuko Kotori said, squinting comfortably, enjoying the cleanup work by Shiraishi Zexiu.Stupid, I said that s the way a brat expresses, I m seventeen, how can I be so naive.Zexiu Shiraishi shook his head what is the best CBD gummy bears for pain firmly in denial.Too bad no one believed it.
thing.This Shiraishi Zexiu knows, because it will hang like this at home.When you go home at night, you can simply do it a little bit to get a sense of ritual for the festival.The classroom was as hot as ever, but it gradually began to be divided into more groups, because some people had already found friends to play with tomorrow, and some people were alone with anxious faces.In Japan, a country that places great importance on popularity, it is easy to CBD gummies for smoking cigarettes be looked down upon without anyone to play with.
, if you are bored, you can go and read it.Is it the kind of novels and comics that can make a teenager s are CBD gummies made with gelatin Sanjay Gupta And CBD Gummies blood burst, I want to read it.No, those things don t exist do CBD gummies help with over eating in my house.Zexiu baypark CBD gummies kept it well, and marth stewart CBD gummies the guests would never find out, I think you need to purify your mind once you enter Sang.Hot blooded comics We both know what you really want to say, and I m embarrassed to pierce you.You have pierced Shiraishi kun.Points 1865 It s been deducted so much since we talked about it.
It was not like other girls told her that boys are generally messy and stench, not clean and spotless, but definitely not dirty, Shiraishi Zexiu s room It gave her a very comfortable and natural feeling.There are several copybooks hanging on the wall opposite the bed, but there is a place to are all CBD gummies equal Sanjay Gupta And CBD Gummies hook the imitation of the Prince of Idune imitation amanda kloots CBD gummies Sanjay Gupta And CBD Gummies text.Out of the corner of the eye, he suddenly saw the wallet on the bedside table., the wallet is open.The top mezzanine is a group photo of three people.
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