Facts, Myths, & Misconceptions of Medical Marijuana

Announcer:
You’re listening to Conference Coverage on ReachMD, captured on location at the American Society of Consultant Pharmacists Annual Meeting and Exhibition in National Harbor, Maryland. Your host is Mario Nacinovich.

Mr. Nacinovich:
Coming to you from the American Society of Consultant Pharmacists Annual Meeting in National Harbor, Maryland, this is ReachMD.  I’m Mario Nacinovich, and joining me to discuss The Facts, Myths and Misconceptions of Medical Marijuana is Zachary Palace, M.D., C.M.D., F.A.C.P., and Robert Accetta, a registered pharmacist.  Dr. Palace and Mr. Accetta, welcome to the program.

Dr. Palace:
Thank you very much.

Mr. Accetta:
Hi, nice to be here.  Thank you.

Mr. Nacinovich:
So, any opening remarks before we begin about the context in which we will be speaking about The Facts, Myths and Misperceptions of Medical Marijuana today? 

Dr. Palace:
Sure.  So, I’m the Medical Director of the Hebrew Home in Riverdale in the Bronx, New York, and we started a program a little over 2 years ago in bringing medical cannabis or allowing our patients to participate in the New York State Designated Medical Cannabis Program, so our experiences are primarily related to the indicated diagnoses for medical cannabis within the state of New York, and a lot of that can be extrapolated to other states as well.

Mr. Accetta:
Yeah, Dr. Palace and I collaborate on many projects at the Hebrew Home at Riverdale.  I’m an independent consultant pharmacist, and my practice delves into this particular area.  I’d like to make it clear that this is really something we’ve been doing in New York State, which is very particular with its laws and regulations, and also, We’re all kind of figuring things out along the way but being respectful of the federal regulations

Mr. Nacinovich:
Thank you so much.  Let’s start off with probably a very basic question for both of you with the experiences that you have, but maybe not for our listeners.  What are the differences in the current strains and varietals of legal medical marijuana?

Dr. Palace:
So, medical marijuana, when we refer to medical marijuana, we’re talking about the extract from the cannabis plant, and that’s composed of over a hundred different cannabinoids, which are referred to as phytocannabinoids, plant-based cannabinoids from the cannabis plant.  The 2 most active cannabinoids in the cannabis plant are delta-9-THC, delta-9-tetrahydrocannabinol, and cannabidiol, or referred to often as CBD.  Now, while delta-9-THC is a phytocannabinoid that has significant psychoactive properties, cannabidiol, or CBD as we refer to it, does not have any psychoactive properties.  So, in our elderly population, we find that the use of CBD is much more effective.  There are several different strains that contain varying concentrations of THC, and within the geriatric population, we favor those strains that have very little THC and are primarily CBD, or the CBD-dominant strains. 

Mr. Accetta:
In New York State, the state has approved the use of different products and different concentration combinations, so yes, relative to the THC and the CBD concentrations, they have some guidance on how these products should be formulated by the providers.  And so usually there is a very low concentration of THC in one product.  There’s a 50/50 concentration of THC with CBD, and then there’s also a higher concentration of CBD to THC, so we have that variance.  And again, all of the different companies that have been registered as registered organizations in New York State have to provide the specifics of which products they will produce based on those concentration standards or guidelines. 

Mr. Nacinovich:
Tell us a little about the current or best and healthiest methods of consuming legal medical marijuana for the patient population that you are currently treating.

Dr. Palace:
So, typically speaking, the formulations that are most common, or the formulations that are approved in New York State, would be either the vaporized form, the capsules or the tincture under the tongue.  As a nursing facility, we have a no-smoking policy, which would include forms similar to electronic cigarettes or vaporized forms of medical cannabis, so we’re primarily using the tinctures under the tongue or the capsules.  In terms of what we find to be most effective tends to be the tinctures that are placed under the tongue, and that’s largely because it gets absorbed quicker into the bloodstream and you avoid the first pass effect of part of the med getting metabolized through the liver.  Generally, we’ve been recommending the tinctures under the tongue of the CBD.

Mr. Accetta:
We’ve had a lot of success with our nursing home residents with the tincture, as Dr. Palace has mentioned.  There are also products that the State has given approval for, which include topicals such as oils or patches, transdermal patches, and there’s also an opportunity for a plant-based product which is a crushed version of that plant.  But again, in our setting, we have found—to be cognizant of the regulations regarding controlled substances and so forth—we prefer to use those dosage forms in our setting that Dr. Palace has outlined.

Mr. Nacinovich:
So, let’s talk a little bit about the current pros and cons of medical marijuana tinctures.  And do you currently use any of the sublingual sprays as well?

Dr. Palace:
So, we’re using the sublingual sprays as well as the sublingual tincture, and we find that, for the most part, patients are tolerating that very well.  Some complain about a little bit of a bitter taste to it, but that’s not really much of a major issue. 

Mr. Nacinovich:
In terms of your experience with the transdermal patches or the topicals, or potentially even some of your patients ingesting some of the crushed or raw plant, can you tell us a little bit about the pros and cons and experience with that?

Mr. Accetta:
So, presently, in our practice and in New York State, the edible products are not legal, and so therefore, we would not be involved with the edible products.  As far as the topical products, again, the Health Department has given permission to use those products.  We particularly have not chosen to recommend that the patient use those products.  However, anecdotally, I know that there are products available for purchase through, let’s say, alternate sources, such as the net, and some residents have kind of pulled me to the side who are participating in the program, kind of give me the wink and say, “Hey, look at this one.  This one seems to be helping.  It’s a cream.  I’ve been putting in on my wrist and it’s really great.”  So, essentially, we’re kind of sticking to that process and a formulary that we’ve developed from the get-go.

Mr. Nacinovich:
Shifting gears a little bit away from current practice with these older patients in the long-term-care setting, can you tell us a little bit more broadly about some of the more common myths and misconceptions about medical marijuana, its use in long-term-care facilities, or its use in general?

Dr. Palace:
Sure.  I think many people associate medical marijuana with recreational marijuana, and as such, the older generation tends to shy away from it.  I think there’s a very significant stigma associated with medical marijuana, and it’s very important, now more than ever, that physicians should be educated on what medical marijuana is and what it isn’t because patients need to understand that.  And in order to dispel the myths, we need to be able to educate our patients on what medical marijuana is.  Essentially, medical marijuana is the use of the cannabis plant for therapeutic purposes.  It has been used for the last 3,000 to 4,000 years.  It has been documented to have been used in ancient Greece, in China, and throughout Asia.  And what’s fascinating to me is that the very same indications for which it has been documented to have extreme efficacy over the millennia are the very indications for which we’re recommending it today, such as spasticity, relief of pain, relief of nausea, relief of stiffness.  These are the very same indications...  The anti-inflammatory effect of cannabis has been documented over centuries, and these are the very same indications for which we are recommending it, so that while we may not have as many robust clinically-controlled trials as many of the other pharmaceutical agents, we need to reframe how we think about medical cannabis and view it more as a therapeutic modality.

Mr. Accetta:
Also, I think, to Dr. Palace’s point, we really need to have the medical profession embrace this as an alternate form of palliative therapy and appropriate therapy, especially in cases where patients or residents are using medications that we know are toxic medications.  And obviously, the number one concern nowadays, I believe, would be the opioid crisis and how this particular therapeutic regimen might be an alternate to help wean people off and de-prescribe opioids.  Really, there is a lot of literature coming aboard that has shown this is a viable option.  New York State actually just recently added a couple of approved indications.  One of them was opioid, for any type of opioid use, essentially.  So, it’s really a useful tool for practitioners to have available and to consider.

Dr. Palace:
And another myth that one needs to dispel is the concept of the use of CBD, cannabidiol—while it’s very effective as an anti-inflammatory and very effective as an antispasmodic, and certainly as an analgesic—it is not habit-forming.  Because it is not psychoactive, there is no concern with the use of CBD that a patient will become addicted to it.  I think that’s one of the major stigmas associated with medical marijuana use.  “Will I become addicted to it?”

Mr. Nacinovich:
For those of you just joining us on this program, this is Mario Nacinovich on ReachMD.  I’m speaking today with Dr. Zachary Palace and Mr. Robert Accetta, a registered pharmacist, about The Facts, Myths and Misperceptions of Medical Marijuana.  We spoke a bit earlier about some of the basics of legal medical cannabis and explored together some of the myths and misperceptions, but now let’s shift over to some more of the practice-specific legal and more practical concerns.  Mr. Accetta, can you discuss the process for implementing medical marijuana into a practice setting?

Mr. Accetta:
Well, for our setting, especially in the long-term-care facility, before you can do anything, you really have to have buy-in by the leadership team of the facility, so it really starts at the top—for instance, at the Hebrew Home in Riverdale, our executive team, our chief executive officer, Mr. Dan Reingold, was really the initiative for us to get involved with the program once New York State had given the go-ahead to provide this type of care for residents and starting with the leadership there and filtering down through the decision-makers, people such as the chief operating officers and chief information officers.  In our setting, of course, it would involve nursing to be aware, a pharmacist consultant also to be involved as far as preparing the facility for any regulatory concerns.  All of us together sit at a table, and we all hash out the details, no pun intended, and we come up with a solution for our particular need.  And so that goes back to what I kind of mentioned earlier in the interview, which is there’s no one right way to do it.  It’s kind of everybody’s decision-making process to get the project rolling and then to proceed with it.

Mr. Nacinovich:
As medical cannabis is still considered a Schedule I here in the U.S., what can doctors and pharmacists do currently?

Mr. Accetta:
So, again, the concern is the federal regulation which lists marijuana as a Schedule I product, and because it’s a Schedule I, people are very concerned about having anything to do with it.  And so, again, New York State allows residents of New York State to participate in using the product, so as such, we in a facility will respect the law that it is a Schedule I substance, and we’ve, again, crafted policies and procedures that allow residents to participate in the program, and we essentially have mirrored whatever concerns we have for safety, security and so-on based upon the regulations for storage of controlled substances from Schedule II to V in New York State, which is really all the controlled substances.

Mr. Nacinovich: 
We spoke earlier about some drug-to-drug interactions.  What are you most concerned about, specifically in your setting, with these older patients?

Mr. Accetta:
Well, I can talk to the concern about adding on a product and having residents… Usually, most nursing home residents can be on up to 9 medications, and so we’re really ripe for all types of adverse effects and side effects from adding on any product, excluding the fact that this is a cannabis product.  So, yeah, the number one concern would be anything to do with the risk for hypotension or hypertension which might also then cause the adverse effect of increasing the risk of falls.  Sedation can be possible, although we, again, try to avoid using any of the products that cause sedation.  Dr. Palace would probably give you a little more insight into some of those cases that he’s handled recently.

Dr. Palace:
Yeah, my concern with the formulations that have higher concentrations of THC are the effects on cognition in the elderly as well as impaired balance, impaired gait and increased risk for falls, which is always a major concern with any medication in the elderly.

Mr. Nacinovich:
Shifting gears, we’ve spoken quite a bit about the differences between New York State and certainly existing laws across the nation.  Any additional thoughts that you’d like to share or pearls regarding mitigation regarding these programs?

Mr. Accetta:
Yeah, so in the nursing facility, really, we train our nursing staff from the point of entry into the facility building all the way through to the administration of a medication to a resident/patient, to have very strict processes in place for the chain of custody, if you will, of a drug—so if you’re thinking of a scheduled drug that’s not a cannabis product—and so essentially with these products, because of the concern about handling a product that is a Schedule I federally, we do not have the nursing staff involved in handling the product.  Essentially, it’s the private property of the resident.  And we do provide a storage solution, which is a double-locked container, which kind of mirrors our practice for what we do with the regular scheduled controlled drugs.  So, I think, again, it’s just kind of using your best practices for any type of mitigation prevention, and we’ve been very successful in that regard.

Mr. Nacinovich:
So, we talked a little bit about the drug security and certainly the storage and this being the personal property of the residents.  Any thoughts about residents’ rights in the skilled nursing facilities and potential diversion and acquisition?

Mr. Accetta:
Occasionally, the issue that arises would be a person may wish to participate in a program, and I think this speaks to the availability of use of medical cannabis.  The medical cannabis—again, because it’s a Schedule I substance—would not be covered under any insurance program, and so this may become a barrier for someone who could benefit from the cannabis product, so that’s one concern.  Another concern might be that a family member or resident may wish to participate with the program and there may be some, again, resistance on the part of a family member or some reluctance to participate, so this is… Again, part of our concern is breaking down those barriers so that people may participate in the program.

Mr. Nacinovich: 
When we think about the perfect case scenario of a medical director and a pharmacist, consultant pharmacist in the case of a long-term-care facility working collaboratively, this may be a best-case scenario that we’re seeing here from New York State.  Given your experiences over the last several years together, how do you recommend medical personnel and pharmacists should be working collaboratively together to help residents access medical marijuana?

Dr. Palace:
So, I would say that it’s most important to always put the patient into focus and put the patient in the center of the equation, and we have to look at what’s best for the patient.  Obviously, concerns are always related to polypharmacy and trying to find the lowest effective dose for a patient and trying to avoid polypharmacy, trying to find one medication that will address all the concerns that’s as clean as possible from a side effect profile.  Medical cannabis is one of those treatment modalities which from a… Medical cannabis is one of those treatment modalities which, from the perspective of a side effect profile, really has minimal side effects, minimal drug-drug interactions, and should be considered in the clinician’s armamentarium of treatment options for patients who need symptom management, complaining of severe pain, spasticity and inflammation and are looking for another option.  And this is something which patients should feel comfortable talking to their physicians about, and physicians and pharmacists should be educated on the topic and be able to collaborate meaningfully in simplifying medication regimens for patients.

Mr. Accetta:
I think all of those points are excellent, and I would add for the consultant pharmacist’s role that the education component can’t be stated enough, because we have to provide education.  Obviously, the internet has a lot of available information.  However, we have to narrow it down to provide both clinical and practical information to facilities and to staff, and we have to help dispel the myths that we should never touch this product.  And we should also work very closely with the powers at the facility, the clinical practice guidelines for pain management, and our medical team will really help us move forward with this newest innovative product that’s available to help residents in need.

Mr. Nacinovich:
I think that’s a great way to round out our discussion on this very fascinating…  I think that’s a great way to round out our discussion on this very fascinating and sometimes very misunderstood and incredibly complex subject.  I want to thank my guests, Dr. Zachary Palace and Mr. Robert Accetta, for joining me to discuss The Facts, the Myths and Misconceptions of Medical Marijuana.  Dr. Palace and Mr. Accetta, it was great having you on the program.

Mr. Accetta:
Yeah, thank you so much for inviting us.

Dr. Palace:
Yeah, thank you very much.

Mr. Nacinovich:
I’m Mario Nacinovich.  To access this episode and others about legal medical cannabis, visit ReachMD.com where you can Be Part of the Knowledge.  Thanks for listening.

Announcer:
You’ve been listening to Conference Coverage on ReachMD. For more highlights from this and other meetings around the world, visit ReachMD.com.  ReachMD: Be Part of the Knowledge.