Use of Marijuana in Nursing Homes

Resolution and Position Statements
November 7, 2019

▪ AMDA reminds clinicians and facilities that marijuana remains a Schedule I drug and, as such, federal regulations prohibit its sale, distribution, growth and use with very narrow exception. This is a particularly important concern for nursing facilities that must attest they are compliant with all applicable federal regulations.

▪ AMDA cautions against widespread routine use of marijuana in the post- acute and long-term care (PALTC) population, due to the absence of clear evidence-based guidance on appropriate use.

▪ AMDA encourages investment by the research community and pharmaceutical industry in the evaluation of marijuana and its derivatives in the PALTC population, with an emphasis on appropriate therapeutic indications, establishment of risks, drug interactions and conditionspecific dosing to guide safe prescribing and informed decision making.

▪ AMDA encourages more inclusive research of particular importance, to residents in the PALTC setting related to the impact on cognitive, psychiatric, respiratory, cardiovascular, and renal function.

▪ AMDA supports patient-centered decision making. If there is consensus from the clinician and resident that marijuana has substantial clinical benefits that justify the risks, the facility administration must have established policies and procedures in place that address the following: 

      ▪ State laws regarding the use of marijuana

      ▪ Processes to which prescribers must adhere to for the recommendation of marijuana

      ▪ Storage, disposal, and destruction of marijuana

      ▪ Dispensing of marijuana by a state-approved caregiver

      ▪ Documentation for use of marijuana

      ▪ Prevention of diversion of marijuana

      ▪ Monitoring for therapeutic benefit and adverse events from marijuana with the understanding that varied forms and doses of marijuana may result in unknown or uncontrollable adverse  events including psychosis.

      ▪ Clinicians and staff caring for residents receiving marijuana in PALTC settings should have training and education in the administration, monitoring and use of marijuana.

      ▪ Employee/Agent of the employer who may be using marijuana recommended by a prescriber for an approved condition.

      ▪ Medical Director or designee involvement in any disciplinary action or dismissal of an employee/agent for inappropriate use of marijuana.

      ▪ process to address issues including but not limited to the use, safety and quality concerns regarding marijuana in the facility.

Informed consent obtained from the Surrogate/Agent/Guardian of a patient who is using marijuana for an approved condition who is either temporarily or permanently mentally or The Society for Post-Acute and Long-Term Care Medicine (AMDA) adopts the following Policy Statements: Use of Marijuana in Nursing Homes Page 2 of 2 physically incapacitated and unable to make independent decisions regarding their health and treatment.

*There is substantial confusion about what substances constitute “marijuana”.  AMDA will use the definition from the National Institute on Drug Abuse: “marijuana refers to the dried leaves, flowers, stems and seeds from the Cannabis sativa or Cannabis indica plant”. This also includes food or extraction that is made using these ingredients. The terms “cannabis” and “marijuana” are often used interchangeably. FDA-approved medications derived from cannabinoid chemicals are included in this policy statement ("FDA Regulation," 2019).

There are more than eighty biologically active chemical compounds that have been identified in the Cannabis plant, all of which are subject to the Controlled Substances Act (CSA) (“NIDA”, 2019). Cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) are two of these compounds. Several of these chemical substances may be exploited for medicinal uses, each with a unique set of indications and risk/benefit profiles. These indications and risk/benefit profiles have not been established through well designed clinical trials. Psychoactive effects can range from a pleasant euphoria and sense of relaxation to heightened sensory perception or acute psychosis (including hallucinations or delusions). There is a presumption that topically applied derivatives have less risk than oral ingestion or inhalation forms, based on general principles of pharmacodynamics, but there is a paucity of data.

AMDA is committed to collaboration with national organizations, including but not limited to the Centers for Medicare & Medicaid Services, the Drug Enforcement Agency and the Centers for Disease Control & Prevention, to address medical marijuana use and misuse.

References:

Pollio A. (2016). The name of cannabis: a short guide for nonbotanists. Cannabis and Cannabinoid Research, 1(1), 234–238. doi:10.1089/can.2016.0027

NIDA. (2019, April 5). Marijuana. Retrieved from https://www.drugabuse.gov/publications/researchreports/marijuana on 2019, May 3

NIDA. (2019, April 5). Marijuana. Retrieved from https://www.drugabuse.gov/publications/drugfacts/marijuana on 2019, May 3

Bridgeman, M. B., & Abazia, D. T. (2017). Medicinal cannabis: history, pharmacology, and implications for the acute care setting. P & T : A peer-reviewed journal for formulary management, 42(3), 180-188.

Fife, T. D., Moawad, H., Moschonas, C., Shepard, K., & Hammond, N. (2015). Clinical perspectives on medical marijuana (cannabis) for neurologic disorders. Neurology. Clinical Practice, 5(4), 344-351.

Drug Scheduling. (n.d). Retrieved March 3, 2019 from https://www.dea.gov/drug-scheduling

State Medical Marijuana Laws. (n.d.). Retrieved from http://www.ncsl.org/research/health/state-medicalmarijuana-laws.aspx#2

Lloyd, S. L., & Striley, C. W. (2018). Marijuana use among adults 50 years or older in the 21st century. Gerontology & Geriatric Medicine, 4, 2333721418781668. doi:10.1177/2333721418781668

Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. (2014). Adverse health effects of marijuana use. The New England Journal of Medicine, 370(23), 2219-27.

FDA Regulation of Cannabis and Cannabis-Derived Products: Questions and Answers. (2019, April 2). Retrieved February 26, 2019 from https://www.fda.gov/news-events/public-health-focus/fda-regulation-canna...