February 2019

Bringing Medical Cannabis Into Skilled Nursing Facilities

By Nicole Wetsman 

When New York state legalized medical cannabis, geriatrician Zachary Palace, MD, CMD, realized that many of the conditions that qualified for the drug were those that he saw regularly in the elderly—like  chronic or neuropathic pain, Parkinson’s disease, and multiple sclerosis.

The medications typically used in older adults with those conditions often come with a host of side effects, said Palace, the medical director of the Hebrew Home at Riverdale. In addition, the elderly often take multiple medications, which might interact with each other in the patient’s system. “Even something as benign as aspirin can cause problems in the elderly,” he said. “We’re always looking to simplify patient regimens.” Cannabis seemed like a probable solution.

Nursing facilities receive federal funding and are bound by federal laws that preclude them from storing or having staff deliver cannabis. To comply with those laws, the Hebrew Home developed a unique program1 that allowed them to offer cannabis as a treatment option. Medical staff certify patients as eligible for medical cannabis, and patients either self-administer the drug or have the drug administered by designated caregivers. The facility provided lockboxes in the patient’s possession for cannabis storage. Because of the facility’s rules around smoking, all cannabis used by Hebrew Home residents is orally administered.

When the program was implemented in 2016, the care team held informational sessions about medical cannabis with residents. “Most were not aware that it could be used medicinally,” Palace said. But after learning more, many residents were interested. Ten residents are currently participating in the facility’s medical cannabis program.

Palace said that many residents have seen significant benefits from medical cannabis. He described one patient, for example, who was in severe pain and had lost interest in any hobbies or social activities. “She was always looking at the clock to see when the next pain pill would be,” he said. Since starting on medical cannabis, though, her mood has been better, and she’s started participating in art programs. “There are significant improvements, even outside of addressing their pain,” Palace said.

Hebrew Home physicians manage and monitor the dose of cannabis taken by each patient. “We view it like we would any other therapeutic intervention,” Palace said. Patients start on one standard dose of cannabis per day and move up in dosage or frequency as needed. One patient, for example, takes a high dose of cannabis, which allowed her to halve her use of oxycodone. “For her, that’s the sweet spot,” he said.

Barriers to wider use of cannabis in the Hebrew Home include cost, because cannabis is not covered by Medicare, and the rules stipulating that facility employees cannot administer it. One patient in the Hebrew Home, for example, has a seizure disorder and advanced dementia. That patient is a good candidate for cannabis, said Palace—however, the patient does not have an external caregiver who would be able to deliver the drug. Any changes to the federal scheduling of cannabis (it’s currently schedule I) would likely loosen those restrictions and might allow nurses to administer the drug to patients who aren’t able to do so themselves, he said.

Despite the challenges, cannabis has been beneficial to Hebrew Home patients. Palace said that the facility has been contacted by other organizations looking to offer cannabis to residents. “I think the program we’ve put into place is really a model program that is easily replicable at other facilities,” he said.

Palace ZJ, Reingold DA. Medical Cannabis in the Skilled Nursing Facility: A Novel Approach to Improving Symptom Management and Quality of Life. J Am Med Dir Assoc. 2019; 20:94-98

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