April 19, 2018
Canadian Geriatrics Society Annual Scientific Meeting
Michael A. Dworkind MDCM. CCFP. FCFP.
Associate Professor Family Medicine and Palliative Care, McGill University
Medical CannabisIn the Care of the Elderly
Disclosures
Co-founder and medical director of Santé Cannabis,
Santé Cannabis receives some funding in the form of
grants from Canadian Licensed Producers of medical
cannabis and is funded for the administration of
clinical trials as a contract research organization by trial sponsor Tetra Bio-Pharma Inc.
Learning Objectives
• To better understand the complexity and
controversial history of medical cannabis
• To learn about the Endocannabinoid System
and its clinical relevance in the elderly
• To assess the [limited] evidence for potential
efficacy and possible side effects when
considering medical cannabis treatment
• Case study for review and discussion
Dx: Anorexia, attributed to major depression,
mixed dementia, stroke, coronary artery disease,
orthostatic hypotension, osteoarthritis, frailty
Symptoms: low/no appetite, weight loss 0.5-1 lb
per week, extreme fatigue, spends most days lying
in bed
Rx: Desipramine 10mg, oOlanzapine 5mg QHS PRN, Esomeprazole
40mg QD, Rosuvastin 20mg QD, Florinef
Case Study: H.R. (90y F)
A brief history of cannabis in medicine.
Cannabis has been used as a medicine by humans
for several millennia. Between 1840 and 1920-40,
cannabis tinctures and other products became a
mainstay of the pharmacopeia.
4000 BCE : Oldest evidence of cannabis and
hemp production in China.
1550 BCE: Papyrus Ebers (Egypt) first recorded
mention of cannabis in obstetrics.
19th century: Queen Victoria uses cannabis
tincture for menstrual cramps.
Cannabis was prohibited in
Canada in 1923, and in the
United States in 1937, citing
quality control issues, lack of
defined chemistry, but
ultimately both political and
ideological auspices.
This period of cannabis as
“planta non grata”
has restricted access for
researchers and clinicians,
stifling its full potential as a
medicine.
1963-64: First isolation and synthesis of active components in cannabis
THC and CBD.
1980s: Discovery of the endogenous cannabinoid system.
First pharmaceutical version of THC available by prescription (Marinol).
2000: Canada legalizes medical cannabis Marihuana Medical Access
Program
Patients could grow their own medical supply under this program
or buy from a single government supplier.
History continued…
2016: Access to Cannabis for Medical
Purposes Regulations (ACMPR)
- Current program includes commercial
sale to authorized patients and home
production by patients or caregivers
July ?, 2018: Legalization expected via
the Cannabis Act
These developments, coupled with a resurgence of anecdotal accounts and
renaissance of therapeutic clinical trials has cause a tsunami of interest.
Schauer et al., Am J Prev Med 2016
Cannabis use in the senior population
The fastest growing demographic of cannabis users (data from Colorado)
The pharmacology of medical cannabis“The discovery of the endocannabinoid system (ECS)
triggered an avalanche of experimental studies that have
implicated the ECS in a growing number of
physiological/pathological functions.”
Modulating the human endocannabinoid system in human
health and disease: successes and failures. - Pal Pasher
and George Kunos The FEBS Journal 2013 (Federation of
European Biochemical Societies)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684164/
The Endogenous Cannabinoid System (ECS)
The ECS is a system of neuromodulatory lipids
(cannabinoids), their receptors, and their associated enzymes.
CB1 receptors are found mainly in the brain and central nervous system.
CB2 receptors are found mainly in peripheral organs and cells associated with the immune system.
ECS is implicated in many physiological functions, notably:
nociception, neuroprotection, homeostasis, inflammation, memory, sleep, mood, anxiety, appetite, among others.
Expression of
GABA and
Glutamate –type
receptors change
as we age
Hypothesized to
affect brain’s
response to
endocannabinoid
phyto-cannabinoid
activity
CB1 receptors implicated in essential function
CannabinoidsCannabinoids interact with the CB1 and CB2 receptors to exert
their effects; they can be endogenous, plant-based, or synthetic.
More than 100 phytocannabinoids have been identified in
cannabis plants.
• Anandamide (AEA), and 2-arachidonyl glycerol (2-AG) are
endocannabinoids produced by the body.
• Delta-9 Tetrahydrocannabinol (THC) and Cannabidiol (CBD),
are phytocannabinoids produced by the cannabis plant.
• Dronabinol,(THC) Nabilone (CB1 receptor agonist
pharmaceutical, synthetic cannabinoids
• 105 publications of controlled trials included older subjects (>65 years)
• Only 5 reported results of older subjects separately!
• Found oral THC (3) and THC:CBD formulations
• No efficacy on levodopa induced dyskinesia, breathlessness or
chemotherapy-induced nausea and vomiting
• THC might be useful in the anorexia and behavioural symptoms of dementia
• Most common adverse effect in the elderly using cannabinoids is sedation
Considering the interest and increasing use rate in older persons,
more study is required, especially sufficiently powered trials
Abuhasira et al Eur J Intern Med 2018
Abuhasira et al Eur J Intern Med 2018
93.7% <Slight improvement> or better
Management of
Chronic neuropathic Pain
Moulin DE et. Al. Pain Research Management 2014, 19(6); 328-335
Safety of Cannabis for chronic pain
215 subjects and 216 controls, with chronic non-cancer pain
Increased risk of non-serious adverse events in the cannabis group,
however most were mild-moderate
No difference in secondary safety assessment, pulmonary and
neurocognitive function, hematology, biochemistry, renal, liver, endocrine
function
Ware MA et al. Journal of Pain. 2015 December; 16(12): 1233-42
Cancer pain
Patients with advanced cancer and inadequate analgesia despite chronic
opioid dosing were treated with THC extract or THC:CBD extract
Both groups experienced significant pain reduction vs. placebo with twice
as many patients in the THC:CBD group reporting pain reduction of 30%
Anorexia and cachexia syndrome
Dronabinol: increased appetite and weight stability in HIV/AIDs and dementia
Dronabinol versus megestrol acetate for cancer-associated anorexia:
findings in favor of megestrol
THC (2.5 mg) versus THC (2.5 mg) +CBD (1mg) versus placebo:
no significant improvements in survival, weight, or other nutritional variables
Improved taste, smell and food enjoyment
Jatoi, A et al. J Clin Oncol 2002
Strasser F, et al. Journal of Clin Onco 2006; 24: 3394-3400Beal JE, et al. J Pain Symptom Management 1995 10:89-97
http://www.hc-sc.gc.ca/dhp-mps/marihuana/med/infoprof-
eng.php
Health Canada has aggregated relevant pre-clinical and clinical evidence for the medical
use of cannabis and cannabinoids in this document.
Potential Indications
Strongest evidence base for:
○ HIV/AIDS
○ Multiple Sclerosis
○ Epilepsy
○ Spinal Cord Disease/Injury
○ Cancer cachexia, anorexia
○ Severe Arthritis
○ Severe Chronic Pain
○ Gastrointestinal disorders
Health Canada lists approximately 40 potential indications for
dried cannabis.
THC (delta-9 tetrahydrocannabinol)
Intoxicant
Analgesic
Anti-emetic
Anti-spasmodic
Anti-inflammatory
Appetite Stimulant
Anxiolytic (bi-phasic)
Sleep Aid (bi-phasic)Apoptogenic, Anti-proliferative
CBD (cannabidiol)
• Non-intoxicant
• Anti-epileptic
• Anti-inflammatory
• Mild analgesic
• Anxiolytic
• Reduces spasticity
• Antipsychotic• Apoptogenic, Anti-proliferative
The efficacy of medical cannabis is directly related to strain and/or product
selection and dosage. Patients typically undergo a trial period to determine
which strains, methods administration and dosages are most effective.
Dosing strategy: Start low, Go slow, Stay low
Medical Cannabis(Phytocannabinoids)
Cannabis is a plant medicine that comes in many forms:
• Dried cannabis flowers (aka: marijuana)
• Liquid oils, alcohol and glycerine tinctures
• Food products (aka: edibles, pot brownies)
• Topical oils, creams, and lotions
• Resins, extracts and concentrates (aka: hashish)
• Hundreds of cannabis strains with unique chemical profiles
• 100+ phytocannabinoids identified in cannabis strains from
around the globe.
Nabilone
○ Synthetic THC analogue / CB1 Receptor
Agonist
○ 0.25mg, 0.5mg, 1mg formats
RAMQ covers 0.5mg, 1.0mg
○ Approved for chemotherapy induced
nausea.
Nabiximols
○ Plant-derived oro-buccal spray approved
for treating spasticity in Multiple Sclerosis.
○ 2.7mg THC + 2.5mg CBD per spray
○ Not covered by RAMQ, or most private
insurance
Pharmaceutical Cannabinoids
Prescribing Nabilone for geriatric patients
○ Start with 0.25mg QHS for pain, sleep for 1 week
○ Move to 0.5mg BID, increase to 1mg at night as needed
RAMQ covers 0.5mg and multiples
Effects can last up to 8 hours
Cautious of sedation, dizziness, balance
Small percentage find benefit for pain despite sleep
improvements
• If not tolerated, or insufficient benefit…..
.
Pharmaceutical Cannabinoids
Cannabis formulations in the
legal framework
Dried cannabis% w/w THC : CBD
• THC-rich
• THC:CBD
• CBD-rich
Cannabis oilmg/mL (THC : CBD)
Cannabis oil capsulesmg (THC : CBD) per capsule
New Applications (topical, sprays, etc)
to come…
Research assistantReferral verification
Screening
Consent process
PhysicianMedical assessment
Cannabinoid checklist
Development plan
Cannabis Nurse-EducatorOperationalization of Tx plan
Education and support
Treatment PlanReferring physicianReferral & Supporting
documentation
Ongoing primary care
Monitoring
Safety & Efficacy
Report to MD
Ongoing
collaboration
Follow-up
1-3 months
Patient
and family
Clinical Model (Santé Cannabis)
Specialized and patient-centred
Research NurseReview of complete medical
history. Verification of
Inclusion/Excusion criteria
Goal: Continuity of Care
Warnings and Precautions
• Sensitivity to THC
• Activities requiring co-ordination• Driving, reduced mobility, vertigo, dizziness
• Possible interactions with other medications• CNS Depressants, Opioids, Sedatives, blood thinners,
SSRIs• Substance abuse potential
• Geriatrics: restrict oral administration to BID watch for renal insufficiency
• Engage with your patient to reduce harms (illegal sources, unsupervised ‘recreational use’
Contraindications
• Uncontrolled cardiac disease
• Severe liver or renal dysfunction
• Severe respiratory disease (COPD) (inhalation)
• History of psychosis, schizophrenia (THC)
• Allergy or hypersensitivity to cannabinoids
NB: Most contraindications relate only to THC, and not to
more benign cannabinoids like CBD
Need further research, including potential drug interactions
Nothing clinically significant has been identified in the
literature
Possible Side-Effects
Can often be avoided with careful titration and close followup
Occasional
• Euphoria
• Postural, orthostatic
hypotension
• Dizziness
• Vasodilation
• Headache
• Nausea, vomiting
• Tachycardia
Rare
• Panic attack
• Dysphoria, paranoia
• Hallucinations
• Depression
• Cognitive impairment
• Ataxia
• Psychosis
(under 25, predisposed)
Most Common
• Sedation
• Fatigue
• Somnolence
• Dry Mouth
CBD cannabidiol
Potential Adverse Effects of THC
Regulatory Framework
Access to Cannabis for
Medical Purposes Regulations (ACMPR)
Since 2016 in Canada, the production and sale of
medical cannabis is overseen by Health Canada
via the Access to Cannabis for Medical Purposes Regulations (ACMPR)
Licensed Producers (LPs)
• Only legal sources of medical cannabis
• Not available in the pharmacy
• Licensed Producers are strictly regulated by Health Canada
• Dried cannabis, Cannabis oils and capsules are available
• Many varieties of cannabis with specific concentrations of THC and
CBD
• Cannabis is delivered via secure courier
• Storefront sales (ie: compassion clubs) are still illegal
Guidelines are provinciallyspecific
• Dried cannabis is considered an « unrecognized treatment »
• Unrecognized treatments may only be prescribed under a
research protocol (Quebec Cannabis Registry)
• Pharmaceutical options – including pharmaceutical
cannabinoids – must be considered before prescribing dried
cannabis
• Follow up with patients at least every 3 months
Quebec Cannabis Registry currently recruited more than 2000 patients
Dx: Anorexia, attributed to major depression,
mixed dementia, stroke, coronary artery disease,
orthostatic hypotension, osteoarthritis, frailty
Symptoms: low/no appetite, weight loss 0.5-1 lb
per week, extreme fatigue, spends most days lying
in bed
Rx: Desipramine, olazapine, esomeprazole,
rosuvastin, florinef
Case Study: H.R. (90y F)
Tx Objectives: Initial visit Improve appetite, stop weight loss (weight: 85 lbs)
Tx:
• THC-rich Cannabis Oil 1mg BID,
approximately 2 hours before meals
• CBD-rich Cannabis Oil 2mg QHS (for sleep, and bedtime
anxiety)
Outcomes:
• Almost immediate appetite improvement
• Increased daily activity, Improved mood
Case Study: H.R. (90y F)
Side effects: some additional cognitive effects from baseline, ie. short-term memory loss
Case Study: H.R. (90y F)
Follow-up (1 month)
Tx:
• THC-rich Oil 1mg only QAM ~2 hrs before lunch
• CBD-rich Oil 2mg QHS
Desipramine, olazapine, esomeprazole, rosuvastin discontinued, florinef reduced
Outcomes:
• Increase appetite maintained at 1mg THC daily• Weight increasing 0.5lb per week
• Increased daily activity, reduced joint pain
• Improved mood
• Reducing to 1mg THC daily resolved the worsening cognitive
concerns (back to baseline)
Case Study: H.R. (90y F)
Follow-up (1 year)
Tx:
THC-rich Cannabis Oil 3mg QAM and 1mg QPM
CBD-rich Oil 2mg QHS
Outcomes:
• Weight increased back to 107 lbs
• Still experiences fatigue, daily THC augments energy and
mood
• No change in cognition with increased THC (some tolerance)
• Reduced joint pain and inflammation
• Reduced caregiver burnout over spoon-feeding stress
Future Directions:
Canada as a global leader in medical cannabis research?
SAFETY AND EFFICACY OF PPP001-kit FOR IMPROVING HEALTH
RELATED QUALITY OF LIFE IN ADVANCED CANCER PATIENTS WITH
UNCONTROLLED PAIN: A RANDOMIZED, DOUBLE-BLIND, PLACEBO-
CONTROLLED, PARALLEL GROUP STUDY
Principal Investigator:
Antonio Vigano, MD, MSc
Site:
Santé Cannabis
Phase III clinical trial
Primary objective:
To evaluate the effect of a specific formulation of dried cannabis to improve
HRQoL of patients with uncontrolled cancer pain and incurable malignancy
Study duration:
6 weeks in duration including the following:
A screening period of up to 2 weeks A 4-week treatment period
Questions?
Email: [email protected]
Santé Cannabis
www.santecannabis.ca
Canadian Consortium for the Investigation of Cannabinoids
www.ccic.net
International Cannabinoid Research Society
www.icrs.co
Information for Healthcare Professionals – Medical Cannabis
(Health Canada)
http://www.hc-sc.gc.ca/dhp-mps/marihuana/med/infoprof-eng.php
Some resources
