Reducing opioid, antidepressant and antipsychotic use among geriatric patients in Canada’s long-term care homes

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von Blake Pearson, M.D. Chief Medical Advisor, Greenly Health Limited

Reducing opioid, antidepressant and antipsychotic use amonggeriatric patients in Canada’s long-term care homes

Over the last few years, reducing opioid prescribing has become a public health priority across Canada and indeed, many countries around the world. As medical experts look to address the ongoing opioid epidemic among various subsectors of the population, there is one patient group that is somewhat overlooked.

According to a recent report published by the Canadian Institute for Health Information, senior citizens living in long-term care in Canada are twice as likely to be prescribed opioids and three times as likely to be on antidepressants than others their age living in the general population.

On average, Canadian longterm care residents are on 9.9 different classes of medications (compared to 6.7 in the general community) and research has clearly established a strong correlation between polypharmacy and increased risk of negative health outcomes, falls, adverse drug events, and higher health costs.

In fact, the number of drugs being prescribed to seniors was the factor most responsible for hospitalizations related to adverse drug reactions (ADRs): Seniors on 10-14 drug classes were more than five times more likely to be hospitalized for an ADR than seniors taking between one and four drug classes.

This data speaks for itself and was a primary driver behind my interest in exploring safe, effective, alternative therapies for seniors living in longterm care. I see a number of senior citizens in my medical clinic every day and eventually some of these patients transitioned into long-term care. It was during a follow-up visit with one patient that I realized there was a real opportunity to use cannabinoid therapies to improve long-term care patients’ quality of life and endof-life care.

In my experience, cannabinoid medicine is a reasonable option for seniors because it is a multimodal treatment. It can be used to treat several different conditions at once, allowing doctors to reduce polypharmacy. As outlined above, this is a critical issue in long-term care.

Early data supports what we have been seeing clinically and demonstrates the need for further investigation. Earlier this year, I developed a case series exploring cannabis use as an alternative for opioids, antipsychotics and antidepressants among geriatric patients in a longterm care setting.

I presented this case series to colleagues at the 2018 CannX International Conference in Tel Aviv, Israel, and at two of Ontario, Canada’s leading health industry conferences: Health Quality Ontario’s Transformation Conference and the Ontario Long Term Care Association 2018 Conference – both in Toronto. Below is a summary of the methods and observations.

1) a reduction in polypharmacy and/or 2) trialing an alternative therapy due to poor response to current treatment or negative side effects. Families and patients

were heavily embedded in the follow-up process and six patients self-selected to trial cannabinoid therapy. Indications for treatment were chronic pain or responsive behaviors secondary to dementia. Patients were monitored every eight hours over a period of two months.

One hundred and fifty-two patient medical records were reviewed at one nursing home to identify which residents would benefit from:

Six patients (all female, average age: 87) were selected. All patients were prescribed a high CBD cannabis oil with a concentration of 5 mg THC and 20 mg CBD per 1 mL. Patients were started at a dose of 0.125 mL QID with dose adjustments occurring every four days based on symptoms. Maximum dose did not exceed 1 mL. All four patients

on an antidepressant (trazodone) were able to discontinue use. Three out of four patients on opioids (Fentanyl, Percocet, Dilaudid) discontinued use. Three out of three patients on an antipsychotic (Seroquel) discontinued use. No increase in gait disturbances or falls were observed.

CONCLUSIONS:

All patients started on the cannabinoid protocol experienced a large reduction in their opioid, antidepressant, and antipsychotic doses. Additionally, residents, family and staff reported: less sedation from narcotics and antipsychotics, enhanced appetite, more regular bowel movements, enhanced sleep durations, pain levels consistent with effective pain management, and improved persistent responsive behaviors. Indeed, some behaviors have completely resolved.

From a practical standpoint, cannabis, as a multi-modal medication, has also improved time efficiencies for team members and led to fewer medications and possible interactions for residents.

“Resident outcomes have been remarkable in terms of quality of life and pain management,” says Kim Van Dam, Administrator at Trillium Villa, a Steeves & Rozema nursing home in Ontario, Canada and the first Home in which I introduced cannabinoid therapy.

“Medical cannabis can be of great benefit to seniors. That’s why it’s so important that we address barriers to access, such as integrating the process for ordering, storing and administering medical cannabis with our existing medication management processes. The fact that it is not covered by the Ontario Drug Benefit program is another barrier that urgently needs to be addressed,” adds Van Dam.

The improvements we have seen in these patients have been extremely promising and patient and family demand has led to the development of a cannabinoid medicine program that is now offered in all Steeves & Rozema long-term care homes across Ontario.

While the clinical evidence is compelling, the next step is developing clinical trials to test these effects amongst the greater geriatric population.

ABOUT DR. PEARSON:

Blake Pearson, M.D. is a member of the College of Physicians and Surgeons of Ontario and a board-certified family physician in the U.S. He is a practicing family physician who has focused his practice on cannabinoid medicine.