Cannabis and Older Adults Dr. Andra Smith, PhD University of Ottawa - - PowerPoint PPT Presentation

Cannabis and Older Adults

• Dr. Andra Smith, PhD

University of Ottawa Terry-Lynne Marko, BSc Nursing, RN, P.H.N. Ottawa Public Health Welcome! The webinar will begin shortly! To hear audio for this event, please turn up your computer speakers. Please note this event will be recorded.

November 28th, 2019 12 – 1:30 p.m. (EST)

Presenters

• Dr. Andra Smith, PhD

University of Ottawa Terry-Lynne Marko, BSc Nursing, RN, P.H.N. Ottawa Public Health

uOttawa.ca

Cannabis and Older Adults

• Webinar Series: Cannabis Across the Lifespan

Presented by: Andra Smith, Ph.D. School of Psychology, November 28, 2019 asmith@uOttawa.ca

Faculté des sciences sociales | Faculty of Social Sciences

uOttawa.ca

Disclosure Statement

• I have no affiliation (financial or otherwise) with a

cannabis producer, processor, distributor or communications organization.

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Objectives

• Understand the prevalence and recent trends in

cannabis use in Ontario for older adults;

• Understand the effects of cannabis use on older adults;
• Explore evidence-based practice guidelines for older

adults who use cannabis; and

• Explore examples of public health interventions aimed

to help older adults make informed choices around cannabis use.

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Promises and Propaganda

From Cannabis.net

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Cannabis Use in Older Adults

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Global News, April 19, 2017 based on data from CAMH

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• More Canadians began to use

cannabis in the first quarter

• f 2019.
• Some new cannabis consumers

and some former users who tried cannabis again post- legalization.

• First-time users in the post-

legalization period are older.

• Half of new users were

aged 45 or older, while in the same period in 2018, this age group represented about one- third of new users.

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National Cannabis Survey

• 7% of adults over 65 use cannabis
• 25% for those aged 25-44, and 26% for those aged 15-25
• Older adults have shown the greatest increase in use since

legalization (in 2012, only 1% were using cannabis)

• Furthermore, 1/4 of older adults have reported trying cannabis for

the first time in the last 3 months

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Percentage of cannabis users reporting that they began using in the past 3 months, by age group.

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Cannabis Use in Older Adults

• Seniors are more likely to use cannabis for medical reasons

and to obtain it from legal sources.

• There is a vulnerability for older adults to effects of cannabis

due to unique physiological, psychological, social and pharmacological circumstances.

• The challenge of complex clinical presentations also exists

given co-morbidities, cognitive impairment and polysubstance use.

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Brain Development

Prenatal Teen Adulthood

 Prefrontal Cortex

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Endocannabinoid System



X X

Helps to Regulate

• Sleep
• Appetite, digestion, hunger
• Mood
• Motor coordination
• Planning/ Starting a movement
• Immune Function
• Reproduction and fertility
• Pleasure and reward
• Pain
• Memory and Learning
• Emotion Regulation
• Temperature regulation

Balance Flood

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Cannabis use disorder among adults is under studied and under identified!

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Guidelines

• Funding was provided by a grant to the CCSMH from

Health Canada’s Substance Use and Addictions Program

• Working group members:
• Working group members received an honorarium.

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• Jonathan Bertram, MD CCFP (co-

chair)

• Harold Kalant, CM, MD, PhD, FRS(C)
• Ashok Krishnamoorthy, MD,

MRCPsych, FRCPC, ABAM

• Jason Nickerson, RRT, FCSRT, PhD
• Amy Porath, PhD (co-chair)
• Dallas Seitz, MD, PhD, FRCPC (co-

chair)

• Amanjot Sidhu, MD, FRCPC
• Andra Smith, PhD
• Rand Teed, BA, BEd, ICPS, CCAC

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Canadian Coalition for Seniors’ Mental Health (CCSMH)

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The mission of the CCSMH is: To promote the mental health of older adults by connecting people, ideas, and resources.

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Guideline Methods

• Interdisciplinary guideline committee was formed including a

PWLE for each of the guidelines.

• Literature search:

– Existing guidelines, meta-analyses, literature review, and website search – Databases: Cochrane Library, EMBASE, MEDLINE, PsycInfo, PubMed

• Selected literature appraised with the intent of developing

evidence-based, clinically sound recommendations – AGREE II used to identify guidelines that are of sufficient quality to inform guideline development

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 Developed by a widely representative group of international guideline developers  Clear separation between quality of evidence and strength of recommendations  Explicit evaluation of the importance of outcomes of alternative management strategies  Explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings

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Project Overview

• Provide evidence-informed guidelines aimed at healthcare

professionals and other stakeholders across Canada that include:

• Prevention
• Clinician Education
• Patient and Family/Caregiver Education
• Screening
• Assessment
• Treatment

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Prevention

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• 1. Cannabis should generally be avoided by individuals with:

a) a history of mental health disorders, problematic substance use, or substance use disorder [GRADE: Evidence: Moderate; Strength: Strong] b) cognitive impairment, cardiovascular disease, cardiac arrhythmias, coronary artery disease, unstable blood pressure, or impaired balance [GRADE: Evidence: Moderate; Strength: Strong].

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Clinician Education

• 2. Clinicians should be aware of the following:

a) The current evidence base on the medical use of cannabis is relatively limited, and cannabis and most derivative products have not been approved as therapeutic agents by Health Canada, with the exception of two pharmaceutical grade cannabinoid

• products. Clinicians should keep informed about new evidence

regarding possible indications and contraindications for cannabis and cannabinoid use [GRADE: Evidence: High; Strength: Strong].

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Moderate Evidence

1) Reduced nausea and vomiting during chemotherapy, 2) Improved appetite in people with HIV/AIDS and 3) Reduced Muscle Spasms in Multiple Sclerosis

• Limited evidence of reduced chronic pain
• Complicated by doses and ratios of CBD:THC
• Routes of administration = smoking, vaporizing, vaping,

edibles, topicals, concentrates, oils, sprays

THC= tetrahydrocannabinol CBD= cannabidiol

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Clinician Education (cont’d)

2b) The common symptoms and signs associated with cannabis use, cannabis-induced impairment, cannabis withdrawal, cannabis use disorder, and common consequences of problematic cannabis use [GRADE: Evidence: High; Strength: Strong]. c) The potential adverse effects of cannabis use in older adults, such as changes in depth perception risking balance instability and falls, changes in appetite , cognitive impairment, cardiac arrhythmia, anxiety, panic, psychosis, and depression [GRADE:

Evidence: Moderate; Strength: Strong].

d) Mental health disorders which are commonly comorbid with cannabis use disorder such as depression, anxiety, and schizophrenia/psychosis. [GRADE: Evidence: Moderate; Strength:

Strong].

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Patient and Family/Caregiver Education

• 3. In order to support the retention of information, clinicians

should provide education and counselling with regard to cannabis and cannabinoids to older patients and their family members/caregivers both verbally and in writing [best clinical

practice].

• 4. Clinicians should counsel patients, caregivers, and families to

be aware that older adults can be more susceptible than younger adults to some dose-related adverse events associated with cannabis use [GRADE: Evidence: High; Strength: Strong].

• 5. Clinicians should advise patients, caregivers, and families

about potentially increased risks associated with higher potency THC extracts, or higher potency strains of cannabis when compared to those with lower THC content [GRADE: Evidence: Low;

Strength: Strong].

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Patient and Family/Caregiver Education

• 6. Clinicians should advise patients, caregivers, and families of

risks associated with different modes of use of cannabis and cannabis products (e.g., smoking, vaporizing, oils, sprays, etc.) and counsel patients on these risks [GRADE: Evidence: Moderate;

Strength: Strong].

• 7. Clinicians should educate patients to avoid illegal synthetic

cannabinoids (e.g., K2 and SPICE,) because of the potential to cause serious harm [GRADE: Evidence: Low; Strength: Strong].

• 8. Clinicians should educate patients on the risk of cannabis-

induced impairment especially if the patient is cannabis-naive or titrating to a new dose. It is recommended that the starting dose should be as low as possible and gradually increased over time if needed [GRADE: Evidence: High; Strength: Strong].

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Driving and Cannabis

Image reproduced with permission from Arrive Alive – Ontario Student against Impaired Driving. ‘Eggs on Weed’

• Attentional focus, information

processing, motor coordination, reaction time are all impaired.

• Driving slower, reduced

control with increased task complexity = lane weaving, slower reaction times, impaired divided attention, reduced critical tracking test performance.

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Adverse Effects of Cannabis

(most commonly THC products)

CENTRAL NERVOUS SYSTEM Dizziness, Drowsiness, Perceptual alterations, Sensory alterations, Driving impairment, Headaches, Short-term memory impairment, Attention and problem-solving impairment, Falls, Slower reaction time PSYCHIATRIC Psychoactive effects such as increased anxiety, paranoia, euphoria, depression Increased risk for psychosis RESPIRATORY Chronic bronchitis and bronchial irritation (inhaled formulation), Bronchospasm CARDIOVASCULAR Palpitations, Arrhythmias, Tachycardia, Bradycardia, Postural Hypotension GASTROINTESTINAL Changes in bowel habits, Appetite changes Dry Mouth, Nausea, Vomiting

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Treatment

• 18. The SBIRT (Screening, Brief Intervention, and Referral to

Treatment) approach should be considered for assessing and managing CUD similarly to other SUDs [GRADE: Evidence: High; Strength:

Strong].

• 19. Peer support programs should be considered for individuals with

CUD [GRADE: Evidence: Moderate; Strength: Strong].

• 20. It is recommended that a variety of psychosocial approaches be

considered for harm reduction or relapse prevention including: Cognitive Behavioral Therapy (CBT), Motivational Interviewing (MI), Mindfulness Based Relapse Prevention (MBRP), Motivational Enhancement Therapy (MET), and Contingency Management (CM)

[GRADE: Evidence: Moderate; Strength: Strong].

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Mindfulness

• When we take away a drug like cannabis, we take away the
• nly thing that has made them feel good and ‘works’ for
• them. It has to be replaced with something else…..
• Mindfulness, exercise, group activities, cooking with

grandchildren

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Treatment

• 21. There are currently no established pharmacological treatments

that have been demonstrated to be safe and effective for either cannabis withdrawal symptoms or cannabis use disorder [good clinical

practice].

• 22. Accredited residential treatment should be considered as

appropriate for treating cannabis use disorder if the individual is unable to effectively reduce or cease their cannabis use [GRADE:

Evidence: Low; Strength: Strong].

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Resources

• www.ccsa.ca
• www.drugclass.ca
• www.ottawapublichealth.ca
• www.rnao.ca/substanceuse

asmith@uottawa.ca

uOttawa.ca

Acknowledgements

 Claire Checkland: CCSMH Director  Indira Fernando: Project Coordinator  All Guideline Working Group members  Steering Committee  CCSMH & Co-chair K. Rabheru  Canadian Centre on Substance Use & Addiction  Baycrest, Bruyere, CAGP, CAMH, CGS, CMHA, NICE, Reconnect

(COPA), Fountain of Health

 Registered Nurses’ Association of Ontario  CAMH (PSSP)

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Non-Medical Cannabis & The Older Adult

Terry-Lynne Marko RN, BScN Public Health Nurse Ottawa Public Health November 28, 2019

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Learning Objectives

• 1. Understand the “edutainment” approach

to increase awareness of the health risks associated with cannabis use among

• lder adults.
• 2. Describe how to help older adults make

responsible choices about cannabis.

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Why focus on older adults?

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Cannabis & The Older Adult Project

Emerging issue among older adults revealed:

 Misinformed about cannabis health

risks

 Difficulty distinguishing credible

information sources

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Age-related changes and cannabis

• Aging brain and body
• Heart and blood conditions
• Medication/ drug

interactions

Flint, A., Merali, Z., and Vaccarino, F. (Eds.). (2018)

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

When to avoid cannabis use

• Heart or blood pressure conditions
• Balance problems
• Memory or cognitive issues
• Mental health problems
• Substance use

disorders

Lloyd, S., Striley, C. (2108) ; G. A. H. van den Elsen;

• A. I. A. Ahmed, M. Lammers, et al (2014); Briscoe,

J.; Casarett, D.(2018) ; National Academies of Sciences, Engineering and Medicine (2017)

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

• Promote awareness of health effects of

cannabis use in older adults

• Promote awareness of age-related

changes that increase risk

• Distinguish fake from real information to

make responsible decisions

Communication Objectives

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

The Edutainment approach

• Mixes education with entertainment
• Encourages learning by having fun
• Stimulates curiosity and interest

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Puzzles for learning

• Encourages active engagement
• Focuses attention
• Attracts due to nature of the game
• Stimulates creativity & recall of recently

learned information

• Tests knowledge
• Achievement when completed

Aksakal, N. (2015)

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

How to spot FAKE news!

Distinguish real from false information.

Elliot, J. et al (2016)

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Knowledge Transfer…

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Edutainment Products…

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Edutainment products…

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

Online content

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Evaluation

• Ongoing Participant evaluations
• Tracking URLs to see which resources

brings people to the Older adult webpage

• Paid Ads, Facebook posts, print materials,

councillor newsletters

Thank you!

For more information contact: Christina Walker

Ottawa Public Health

Christina.Walker@ottawa.ca

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Ottawa Public Health.ca Sante Publique Ottawa.ca 613-580-6744 TTY/ATS : 613-580-9656

References

(2018) Flint, A., Merali, Z., and Vaccarino, F. (Eds.). (2018). Substance use in Canada: improving quality of life: substance use and aging. Ottawa, Ont: Canadian Centre on Substance Use and

• Addiction. http://www.ccsa.ca/Resource%20Library/CCSA-Substance-Use-and-Aging-Report-2018-

en.pdf CCSUA (2018) Lloyd S., Striley C. Marijuana Use Among Adults 50 Years or Older in the 21st Century. Gerontology and Geriatric medicine [Internet]: Vol. 4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024284/pdf/10.1177_2333721418781668.pdf (2018) Briscoe, J.; Casarett, D. Medical Marijuana Use in Older Adults. J. Am. Geriatr. Soc. 66, 859– 863. (2017) Mahvan, T.D., Hilaire, M.L., Mann, A., Brown, A., Linn, B., Gardner, T., Lai, B. Marijuana Use in the Elderly: Implications and Considerations. The Journal of American (2017) National Academies of Sciences, Engineering and Medicine. The Health effects of Cannabis and Cannabinoids: The current State of Evidence and recommendations for research. The National Academics Press. Washington, D.C. (2016) Elliot, J. et al. Engaging Older adults in Health Care decision-making: A realist synthesis. The Patient 9 (5): 383-393 (2015) Aksakal, N. Theoretical view to the approach of The Edutainment. Procedia-Social and Behavioral Sciences 186, 1232-1239 (2014) G. A. H. van den Elsen; A. I. A. Ahmed; M. Lammers; C. Kramers; R. J. Verkes; M. A. van der Marck; M. G. M. O. Rikkert. Efficacy and safety of medical cannabinoids in older subjects: a systematic

• review. Ageing research reviews. Vol 14 56-64

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To learn about upcoming events visit:

• EENet

http://eenet.ca/

• RNAO Mental Health & Addiction Initiative

http://rnao.ca/bpg/initiatives/mhai