The Journey of Prescribing Medicinal Cannabis in Aged Care
Article Written by Dr Jagdeesh Singh Dhaliwal
As a General Practitioner with a special interest in aged care, I have had the privilege of treating many elderly patients over the years. A significant portion of my practice involves managing chronic pain, which is often interwoven with the physical frailty, life regrets, and familial estrangement that many elderly individuals face.
About five years ago, I began exploring the potential of medicinal cannabis as an alternative to traditional analgesics, particularly opioids. While effective in the short term, opioids can have detrimental effects on cognition and increase the risk of falls in the elderly.
This article recounts my experiences and insights into prescribing medicinal cannabis and its impact on my patients' lives.
The Limitations of Traditional Analgesics
Chronic pain is a common issue among older adults, significantly impacting their quality of life. Traditional analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, have long been the mainstay of pain management.
However, as readers will be well aware, these medications come with a host of side effects that can be particularly severe in older adults. NSAIDs can cause gastrointestinal bleeding and cardiovascular issues, while opioids, despite their efficacy, often lead to cognitive impairment, increased fall risk, and potential dependency.
These limitations sparked my initial interest in medicinal cannabis.
I was searching for a safer, more effective way to manage chronic pain in my elderly patients, many of whom were grappling with the adverse effects of long-term opioid use. The potential of cannabis to provide pain relief without the severe side effects of traditional medications made it an appealing option.
The Shift to Medicinal Cannabis
Five years ago, I began integrating medicinal cannabis into my practice, initially with some trepidation- the responsibility is so much higher when considering vulnerable patients.
The products I chiefly prescribed were LGP Classic 10:10 and Adaya 10:10, both Category 3 balanced medicinal cannabis preparations containing less than 60% CBD and at least 40% THC. This formulation is particularly advantageous as it provides a balanced therapeutic effect, harnessing the potential analgesic properties of both cannabinoids. Additionally, the product's liquid form is easy for my patients to take and for their nurses to administer, ensuring consistent and accurate dosing.
Patient Profiles and Responses
My patients are approximately 60% female and 40% male, and their ages range typically from 78 to 95. This reflects the gender and age distribution in aged care.
To date, I have found that approximately 90% of my patients benefit from medicinal cannabis. Many experience noticeable improvements within a couple of weeks, while others exhibit a 'slow burn' response, with effects becoming apparent after about a month.
One of the most encouraging signs of improvement is when families and carers observe their loved ones smiling more and ceasing to mention their pain. In addition to pain relief, patients commonly report improvements in other symptoms, such as a sense of calm and more alertness. The latter is particularly noticeable when we are able to wean any opiates that have previously been prescribed for pain management.
However, the journey is not always straightforward. Some patients initially have a strong negative reaction to medicinal cannabis, feeling generally unwell.
Interestingly, this reaction often indicates that they are strong reactors to the medication. In such cases, we pause medicinal cannabis for a week and then recommence at half the usual dose. This approach has proven effective, allowing patients to acclimate to the medication and eventually experience its benefits gradually.
Reducing Opioid Dependency
One of the most rewarding aspects of prescribing medicinal cannabis is witnessing the reduction in opioid dependency among my patients. Once they start feeling the beneficial effects of cannabis, we work together to taper and eventually cease their opioid use gradually.
In cases where medicinal cannabis works - which I would estimate at 85% of my patients - we are always able to either taper and cease or at least significantly reduce the dose of opiates.
This transition not only alleviates their pain but also mitigates the cognitive impairment and fall risk associated with opioids.
Emotional and Cognitive Benefits
Beyond the physical relief, medicinal cannabis has had a profound impact on my patients' emotional and cognitive well-being. Around 85% of my patients report feeling more cognitively alert and emotionally uplifted. This improvement in well-being applies equally to both genders, and the only relationship to age appears to be that my older patients require smaller doses.
Their families often remark on the restoration of their mental clarity and overall mood and express their gratitude in heartfelt terms. One of the highest accolades I have received is when families thank me, saying, "Thank you, doctor: we feel we've got Mum back."
Case Studies
Case Study 1: Mrs A
Mrs A, an 82-year-old woman with chronic schizophrenia and a history of opioid overuse, was one of my more challenging cases. She experienced pain from chronic pancreatitis, osteoarthritis, and frequent tension headaches.
When I started seeing her, she was angry and upset, constantly experiencing pain despite taking methadone, being on a fentanyl 25mcg patch, and frequently requesting PRN oxycodone for breakthrough pain. Initially, she disliked the CBD (<60%) and THC (≥40%) liquid, but through shared decision-making, listening, and talking, she became more comfortable with it. We commenced with 0.25ml BD and gradually increased it to 1ml BD.
The aged care nursing home team noted how she became far sunnier and quite humorous and convivial in her mood. This change in her disposition allowed us to agree on a gradual withdrawal of her opiates.
The mental health team, who had been attending every month, were impressed with her progress and have been able to discharge her to full GP care. Mrs A no longer requests oxycodone. She has repaired her relationship with her ex-husband, and they now enjoy taking trips out to the shops together.
Case Study 2: Mr B
Mr. B, an 87-year-old retired senior engineer, suffered from chronic pain due to osteoarthritis and severe ischaemic heart disease, which significantly limited his mobility. Despite taking oxycodone/naloxone 20/10mg BD with PRN oxycodone, he never felt pain-free.
His family described visits to him as feeling 'agonising' due to his unhappiness with his physical health. We commenced CBD (<60%) and THC (≥40%) liquid, starting at 0.25mls, and were able to increase it to 0.75ml BD.
Being a highly analytical man, Mr. B gave one of the best patient explanations I've ever heard:
"I am aware that the pain is still present, but I am not troubled by it. It's as if I am here and the pain is there, doctor. I can wave at the pain and let it be as it is not doing anything to me. I can carry on with the rest of my life."
His improved quality of life was tremendous: he was smiling and joking, and his family all said how happy they felt to "have our Dad back." Mr B died peacefully six months ago. It was heartwarming to see the improvement in his quality of life and the transformed mood of happiness when his family visited.
Challenges and Considerations
Despite the positive outcomes, there are challenges and considerations when prescribing medicinal cannabis. The initial negative reactions some patients experience require careful management and a tailored approach.
The most common negative reaction is an overall feeling of non-specific malaise. For these patients, I cease the medication for three days and then restart at half the original dose. Often, these patients go on to experience the most gains.
For around 15% of my patients, medicinal cannabis seems to have no beneficial impact. I find that often, there are other underlying factors - frequently relating to deep-seated trauma, that lie at the heart of their pain.
Educating patients and their families about the potential benefits and side effects of medicinal cannabis is crucial to ensure concordance and manage expectations.
Lastly, the regulatory landscape for medicinal cannabis is continually evolving, necessitating that practitioners stay informed about the latest guidelines and best practices. This dynamic environment can pose challenges in terms of consistency and medication accessibility.
Final Reflections
The journey of integrating medicinal cannabis into my practice has been profoundly rewarding. It has provided a safer, more effective alternative for managing chronic pain in elderly patients, allowing them to reduce their reliance on opioids and improve their overall quality of life.
The emotional and cognitive benefits observed have been particularly heart-warming, reinforcing the positive impact of this treatment.
As a General Practitioner, the most gratifying moments come from seeing my patients' lives transformed and receiving heartfelt thanks from their families. Medicinal cannabis has not only alleviated pain but also restored joy and mental clarity to many elderly individuals in my care.
This experience underscores the importance of exploring innovative treatments and remaining open to the potential of alternative therapies in improving patient outcomes, particularly in aged care, where novel and effective treatments are few and far between.
Dr. Jagdeesh Singh ("Jag'') Dhaliwal
Dr. Jagdeesh Singh "Jag" Dhaliwal is a distinguished GP and Medical Director with extensive international experience in healthcare leadership and technology implementation. Renowned for his clinical and corporate management, governance, and strategy expertise, Dr. Dhaliwal bridges the gap between technology innovators and healthcare practitioners. His engaging leadership style and multilingual skills (fluent in Spanish and Punjabi, advanced French) enable him to connect with diverse professionals across cultures and sectors. A recipient of the Royal College of GP's Education Excellence Award, Dr. Dhaliwal is also a respected author and speaker in health services management. His career spans public health services, corporate, and education sectors, where he consistently demonstrates a talent for fostering innovation, improving healthcare delivery, and developing effective leaders in the medical field.
Disclaimer: This information is shared with a global readership for educational purposes only and does not constitute medical or business advice. All patient-related information has been de-identified OR fictional to protect privacy. Nothing in this article is intended to promote the use or supply of medical cannabis to members of the public.
