Title Slide: Introduces the speaker, Dr. Terel Newton, and the talk on medical cannabis and polypharmacy. Sets the stage for clinical and policy discussions.
Disclosures: Dr. Newton is an interventional pain physician with research interests in cannabis, without remuneration for this presentation. Notes cannabis is federally Schedule I and state laws vary.
Learning Goals: Goals include defining polypharmacy, exploring cannabis as therapy, and reviewing implementation and evidence. Includes both clinical and legal contexts in Florida and Georgia.
Agenda: Outlines the 30-minute session: polypharmacy, cannabis intervention, legal navigation, research, and summary. Each section is time-boxed for clarity.
What is Polypharmacy?: Defined as concurrent use of multiple medications, problematic when risk outweighs benefit. Deprescribing aims to optimize medication regimens.
Scope and Risks: Nearly 60% of older adults experience polypharmacy; 22% experience hyperpolypharmacy. Risks include ADEs, drug interactions, falls, cognitive impairment, and reduced QoL.
Polypharmacy & Frailty: Strongly linked—59% of frail elderly are on multiple meds. Polypharmacy may not just correlate with frailty but contribute to it.
Deprescribing: A supervised, patient-centered method to stop inappropriate meds. Aims to reduce harm and improve quality of life.
Growing Patient Interest: Over 900,000 Florida patients as of 2025. Patients seek cannabis due to dissatisfaction with traditional meds and view it as safer/natural.
Endocannabinoid System: Comprised of CB1/CB2 receptors, endocannabinoids, and enzymes. Regulates mood, pain, appetite, inflammation, and more.
THC & CBD: THC is psychoactive; CBD is not. Together, they may have synergistic effects (entourage effect).
ECS Timeline: Historical milestones in cannabinoid science from 1964 to 1999. Includes discovery of THC, receptors, and endogenous ligands.
Opioid Reduction – Biology: Cannabis and opioids modulate pain through distinct but complementary systems. THC may lower required opioid doses.
Opioid Reduction – Observational Data: Studies report 64–79% opioid dose reduction in cannabis users. Some studies show up to 78% MME reduction.
Opioid Reduction – Caveats: Most data is observational—bias and lack of RCTs limit causal claims. Evidence rated low to very low.
Benzodiazepine (BZD) Reduction: Cannabis may aid in reducing BZDs due to its anti-anxiety and sleep-promoting effects. Retrospective data shows ~45% discontinuation at 6 months.
Retrospective BZD Analysis: 146 Canadian patients using cannabis showed progressive BZD discontinuation. Rates improved over 2, 4, and 6 months.
BZD Reduction – Concerns: One weak retrospective study; no control group. Risk of dependence substitution and masked withdrawal symptoms.
Anticonvulsant Reduction – RCTs: Epidiolex (CBD) is approved for specific epilepsies. Shows seizure reduction in high-quality trials.
AED Reduction – Non-Rx CBD: Weak evidence from surveys and case reports. Risks include inconsistent CBD products and drug interactions (e.g., with clobazam).
Antidepressant Reduction: Minimal evidence exists for cannabis aiding antidepressant tapering. CYP enzyme inhibition raises risk of toxicity.
QoL Improvements: Patients report improved quality of life from cannabis. Observational studies show QoL boosts in pain, mood, and function.
Florida Cannabis Program: Large registry with >900,000 patients and broad conditions list. Encourages clinician familiarity and cautious, guided use.
FL Qualifying Conditions: Includes cancer, epilepsy, PTSD, chronic pain, etc. "Same kind/class" provision broadens clinical applicability.
FL Same Class Examples: Anxiety, depression, migraines, arthritis, and more can mirror listed conditions. Justifies broader eligibility under existing law.
Georgia – Program Overview: Low-THC Oil program is restrictive (≤5% THC). Allows oils and topicals but not flower or full-spectrum edibles.
GA Qualifying Conditions: Includes cancer, MS, ALS, PTSD, autism, and more. Often requires “severe or end-stage” designation.
GA Access Process: ~28,000 patients in 2025. Physician certification, registry entry, and pickup at licensed dispensaries required.
Patient Motivations: Driven by dissatisfaction with current meds, stigma, and desire for natural solutions. Barriers include stigma, cost, and limited provider guidance.
Practical Regimens: Products vary in type and cannabinoid ratios. Dosing follows "start low, go slow" approach for safety.
Administration Routes: Onset and duration vary by route—smoking (fast), oral (slow), sublingual (moderate), topical (local). Tailored to patient needs.
Evidence Summary: Observational data suggest opioid and BZD reductions, with strong RCTs only for Epidiolex. QoL often improves, but causality not confirmed.
Evidence Limitations: Data often lacks RCT rigor; many confounders exist. Need for trials designed for med tapering with cannabis.
Adverse Effects: Common effects include fatigue, dry mouth, dizziness. High THC may cause anxiety or impair driving and memory.
Summary – Polypharmacy Risks: Highly prevalent and dangerous in older adults. Tied to frailty, ADEs, and reduced function.
Summary – Deprescribing Value: Deprescribing can reduce risk and improve outcomes. Cannabis may be a strategic alternative in select cases.
Key Studies on Polypharmacy: Reviews support deprescribing to reduce harm. Polypharmacy strongly linked to frailty and adverse outcomes.
Study 1: U.S. review highlights risks of ≥5 meds. Suggests deprescribing can reduce ADEs and cost.
Study 2: Systematic review shows clear link between frailty and polypharmacy. Reducing meds may prevent or lessen frailty.
Study 3: Literature review from U.S., Italy, and Canada shows widespread unnecessary prescriptions in elderly. Polypharmacy is a global concern.