Thursday, December 6, 2012

Marijuana in nursing homes

We had a discussion in CNA Class last night about the use of Marijuan a in nursing homes in states where it has been legalized. I found quite a few articles on the Internet. Interesting issue and I think it's going to become more of an issue as people age.

Cannabis Use in Nursing Homes – An Emerging Issue

13 December 2011
If you live long enough, the adverse symptoms of aging are hard to avoid.  While many people are healthy and active into their late 90s, many more will face typical aging related health issues like insomnia, reduced apetite, etc.  Others will deal with symptoms so degenerative, they will require too much care to continue living independently, and these seniors may have to graduate to assisted living facilities or hospitals.
While we consider it very fortunate to have a long life, the ailments associated with aging have not been easy to treat with conventional medicine, and the drugs typically provided can cause health implications of their own.  I have years of personal experience working with seniors in a nursing home environment where I found the limited options offered to those residents who were agitated, uncomfortable, or in pain, questionable and disappointing.  Basically, more and more pills were prescribed, rounds of them in the morning, afternoon and evening.
Some of these drugs had bad side effects of their own like seizures, nausea and caused emotional problems like uncontrollable crying (this was especially true for some of the sleeping pills).  They needed to be prescribed more drugs to deal with the side effects of the initial prescription.  I worried that some residents were overly sedated with powerful pain killers and anti-psychotics when I knew it was possible there was less toxic way these patients could be treated ~ using cannabis.
One great inefficacy of Prop 215 is not being able to provide sufficient access to or information about cannabis, for folks at the end of life.  If you look at the things cannabis is most effective for, it reads like a list of ailments afflicting seniors: insomnia, reduced apetite, pain associated with inflammation of joints & stiffness of limbs and reduced energy which in turn, has an effect on one’s mood.  Other problems facing seniors could include mental confusion, or agitation stemming from a degenerative, dementia related disease.  This is a population that could benefit tremendously from medical cannabis, yet their access is limited, if at all.
For this article I would like to discuss the use of medical cannabis by the elderly, especially the use of cannabis in a residential care facility. It’s a worrying thought for all medical cannabis patients. What will happen if and when I need more assistance?  Institutional care?  Will my medicine be allowed?  Let’s start by looking at our current legal/political situation and how it affects access.
In California on October 7th, Attorney Melinda Haag held a press conference with three other federal prosecutors and declared war on medical cannabis.  Haag’s actions have led to the closure of three permitted dispensaries in San Francisco.  Hundreds, in fact, have closed statewide, while cities and counties have stopped issuing permits for new dispensaries.  In short, the medical marijuana industry is under siege again.
Fifteen years after Proposition 215 enshrined in the California Constitution a medical right to cannabis for the sick and dying, the sick and dying have the hardest time getting it.  In fact, seniors and the sick had a difficult time getting access to medical cannabis even before the federal crackdown, back when many California patients had little trouble buying it, and the difficulty only increased as they progressed from independent living to assisted living, nursing homes, hospitals, and in many instances, hospice.
Seniors themselves are often the first to resist using medical cannabis because of societal concerns about using a drug that the federal government deems illegal.  If they do want to use medical pot, they often don’t know where to go, or how to get it.  Many cities ban cannabis clubs, and seniors in assisted living facilities, nursing homes, or hospitals often find access impossible.
Some patients are resistant to trying cannabis even when their lives are in jeopardy.  A patient named Jim explained he was resistant to smoking cannabis even though he was beginning to waste away because the nausea from chemotherapy was overwhelming and he couldn’t eat. “I got to the point where I couldn’t even stand the smell of food; it would make me throw up — just the smell,” Jim said. “It got to the point where I was ready to have a feeding tube put in. I said, ‘No, I’m really not interested.’ I just thought they were just, like, hippies and I really wasn’t into that whole scene. It’s just a totally different scene than I was used to.”
Real postcard distributed by The Inter-State Narcotic Association
This reaction to being offered or recommended to try medical cannabis is very common from a person who has been told by the government for their entire adult lives that cannabis is for losers who want to get high and that the risks associated with cannabis use outweigh the benefits.  After all, this is the propaganda the government has been feeding people for decades.
Then came the harsh reality of eating through a feeding tube. “I said ‘Okay.’ I smoked it,” Jim said of the cannabis that was offered to him.  Jim said his quality of life changed quickly. “I was able to stand the smell of food.  Then I was able to handle small plates of food.  So the feeding tube was canceled.”
Many seniors, who suffer from all types of ailments, don’t realize that medical cannabis can make the final years of their lives better and more manageable.  Not enough information has been provided to this generation about the various ways to use cannabis other than smoking ~  be it a topical creme for sore knees, for example, or as an under the tongue tincture that could be used as needed for stress, or sleeping, especially safe under the supervision of nurses and caregivers.  This year NORML (The National Organization for the Reform of Marijuana Laws) organized their Silver Toura project of the nascent NORML Senior Alliance.  The basic mission of the Silver Tour is to speak on the topic of medical cannabis in venues where senior citizens meet in large  numbers – notably at senior living communities, retirement homes, religious centers and hospice.
Valerie Leveroni Corral is head of Women’s Alliance for Medical Marijuana in Santa Cruz, an eighteen-year-old dispensary that specializes in outreach to women, seniors, and the sick and dying.  After working all over the state, she said the landscape is still very bleak for seniors in assisted living and beyond.
Fights for access result in temporary gains, then the facility is bought and policy changes, she said. “There’s been a huge shift in assisted care facilities, consolidation that I’m not sure who’s behind. These facilities leave people in pain.”
When seniors progress beyond independent living and into state-licensed assisted living they cross the Reefer Rubicon, as it were, and often enter into the cannabis-free world of nursing homes.  Such “skilled nursing facilities” take federal funds and cannot by law allow a Schedule 1 controlled substance like cannabis on the premises.  Same goes for seniors’ next destinations — hospitals and hospice care facilities.
According to the son of one assisted care patient, “They’ll just say, ‘It’s impossible,’” he said, referring to how medical staff at these facilities respond to the idea of bringing in medical cannabis for patients. “Family members can’t even bring in BenGay for their patient unless they bring it to staff first and then they have to run it by the doctor. That’s the context. That’s how controlled it can be.”
Yet in nursing homes, there are plenty of patients whose lives would be better if they had access to medical cannabis.  It was frustrating to know there wasn’t a way to even try to see whether or not these patients would even benefit from cannabis.
But there are people secreting pot to the sick and dying, sometimes under the nose of administrators, sometimes with their tacit permission.  An Oakland social worker the East Bay Express has called Gladys said nursing home seniors in two facilities she knows of use cannabis for pain and anxiety, and in a dementia group “for hunger. Getting them to eat. They forget to eat. They don’t want to eat. Food is not on their radar. … and for sleep.”
“A few have medical cannabis cards, but … they can’t show [them],” Gladys continued. “No controlled substances. Period. Not even if you have a medical marijuana card.”
“In fact,” she said, medical cannabis bans enacted in cities throughout California have had the most significant impact in terms of shutting off access for most seniors — even more than the crackdown. “The biggest factor in determining whether or not people who need access the most have access to it is whether or not your local jurisdiction has laws that permit and regulate access or ban access outright.”
When dispensaries close, “seniors are the ones that are affected the most,” she added.
I’m aware of some patients visiting PCC who live in nursing home facilities.  Their transport is organized to and from, but I’m not sure by whom.  If this nursing home was located in a city where a ban has been enacted, like Concord, for example, these patients may not be able to travel the distance to a city that allows for dispensaries.  I’m pleased some senior facilities in our area have allowed for this.
Estimates show 213,000 people could die in California this year, many from complications related to cancer.  Meanwhile, dispensaries are closing in San Francisco, making it harder for this growing number to get medical cannabis.
Neither of the state’s two hospice associations has staked out a public position on medical marijuana. California Hospice and Palliative Care Association President Susan Negreen said the issue has come up but the board declined to take a position.  Vitas — a mega-hospice corporation in California — declined to comment.
Although this article specifically highlights the need to for more access to medical cannabis for seniors, this situation mirrors itself in every facility where state or federal funding is involved – teen care homes, homeless shelters, mental institutions, etc.  The most vulnerable and needy often get left out when it comes to access to cannabis medicine.
This is not only an issue of state laws conflicting with federal law; even within states that permit medical cannabis, the rules about it’s use in the institutional setting may be hazy.  These facilities and their staff will have to walk the precarious line between providing what is best for their patients at a very difficult time in their lives, and not incurring the loss of federal funding or loss of licenses, by turning a blind eye, or quietly supervising medical cannabis use.  There are unanswered questions as to whether health care providers can legally provide or administer any forms of medical cannabis to residents.

The conflict of providing good healthcare and breaking the law has wrapped itself around nearly every tier of the health care industry.  It seems wrong not to allow nursing home patients to use cannabis which relieves many ailments and much suffering -just because the facility receives federal funding.  It would be great to see a nursing home organization pass a formal resolution recognizing this potential problem and asking the federal government to allow patients the option to use this medicine as they would any other medicine.

Experts are predicting the number of older cannabis users to increase drastically over the coming years as the baby boomers get closer to nursing home age.  This issue is only going to become more pertinent.

Medical-marijuana policies in Colorado nursing homes are cloudy

Medical-marijuana policy in long-term-care facilities across Colorado is hazy at best.
From state law and patients' rights to federal law and liabilities, regulations on how marijuana may be used by nursing-home residents who suffer from eight specific medical conditions — set out in a 2000 state constitutional amendment legalizing the use of medical pot — run the gamut.
For every facility that would discuss the matter, about a half-dozen declined, saying the topic was too controversial. The push and pull among federal, state and local regulation — possession of pot and distribution of it are crimes under federal law — has some long-term-care facilities playing it safe.
QP Health Care Services, which operates 25 facilities in Colorado, does not allow medicinal marijuana because of feared consequences.
"We follow federal law on that because these are Title 19 homes, which are Medicare-certified," QP Health Care spokeswoman Nancy Schwalm said.
Policy could change
Times, however, are changing dramatically, and should more potential clients request to use the medication, policy could change, she said. "The senior population is growing larger because of the baby boomers, so we would be open to the idea."
North Star Rehabilitation and Care Community in Denver has taken a zero-tolerance stance, and because the topic has come up with potential residents, the community advises on the issue during the admissions process.
The marijuana would have to be administered by nurses, said North Star help-information manager Kathy Szabo. "It is a liability issue, so we decided against allowing it."
Less than 7 miles away, Sunrise at Cherry Creek permits medical marijuana and handles it like any medication. The only stipulation is that medical marijuana has to be ingested in a pill form or, in some cases, baked into food, said senior executive director Reema Chugh.
As with other controlled substances, nurses at the facility distribute medical marijuana.
"It is treated like any other narcotic," Chugh said.
Emeritus Senior Living — which has 478 communities nationwide, including five in Colorado — has a systemwide policy that follows state laws governing the use of medical marijuana, spokeswoman Karen Lucas said.
Residents must self-administer the drug, and only in their rooms, Lucas said.
"The key word is resident's choice," Lucas said. "We will support whatever that may be."
Sonny Smith, 59, a Boulder nursing-home resident, is grateful he can use medical marijuana where he lives. "It meant that I didn't have to lie or leave the premises to use it. It is a huge inconvenience to leave, especially to take your own medicine."
For various aliments, Smith takes numerous medications, which make him sick to his stomach unless he is able to smoke, he said.
Smith's nursing home has a patio area where residents may smoke either cigarettes or medical marijuana. "I come out and take a few puffs when it is needed," he said. "I am mindful of others and find an area to myself."
Attorney Fred Miles has represented local and national long-term-care facilities concerning the issue and regularly gives a presentation titled "Are Nursing Homes Going to Pot?"
Until more clarity comes from the federal level on the matter, Miles said, most organizations will base policy on their use of Medicare and Medicaid funding.
"When I advise facilities, I share with them the 'don't ask, don't tell' policy," Miles said.
While some have taken a stand on the issue, others said they will address the topic when it finally comes up at their location.
Following state law
Parkplace Denver is one of those facilities, which, when time comes for a decision, will follow state law, said director Paul Chinchilla. "If a doctor prescribes it, we would protect the patient's rights."
Sheryl Thompson, president of Assured Assisted Living, said the Colorado Department of Public Health and Environment gave an advisory committee meeting on medical marijuana four years ago.
"All assisted-living locations were told there were no regulations against it, as long as it was no more than an ounce in possession and from a physician's prescription," she said.
Hospices, too, varied on what was allowed for those undergoing pain management.
The Denver Hospice allows patients to administer medical marijuana to themselves.
"If it's part of the patient's medical regimen as ordered by the patient's own physician, the patient may continue to self-administer medical marijuana," said spokeswoman Lynn Bronikowski. "Our staff does not provide nor administer medical marijuana in any form."
Melody Stanton, administrator for Family Hospice of Boulder, said the organization has no specific policy on the issue. "We neither condone nor condemn the usage of it."
Colorado Dispensary Services general manager Jill Lamoureux was not surprised many facilities were mum. She said they are in a tough spot, balancing their feelings with the law.
"Nursing homes have a conflict of conscience," she said. "On the one hand, they want to help those in pain, but on the other hand, they fear what the government might do."
Denver Drug Enforcement Administration spokesman Robert Turner said long-term-care facilities are not necessarily part of the the federal agency's "bigger picture."
"We do not target sick people," Turner said. "Never have and, as far as I can say, never will, unless they were involved with major trafficking."


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