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276 Substance Use in Older Adults
dence-based psychotherapeutic interventions, including cognitivebehavioral therapy (CBT), motivational enhancement therapy, and contingency management. There is no evidence to support the use of pharmacotherapy for cannabis
use disorder.
EPIDEMIOLOGY
The use of cannabis by older adults has increased dramatically. In the
United States, the prevalence of past-year cannabis use among older
adults increased from 0.4% in 2006 and 2.4% in 2015 to 4.2% in 2018
(Han and Palamar 2020). The trend is international: for example, in
Canada, ~7% of older adults report using cannabis; more than a quarter
are new users, primarily for medicinal purposes (Vacaflor et al. 2020).
Increasing use may be due to the availability of medical marijuana and
the legalization of recreational marijuana in many areas, changing attitudes regarding the use of cannabis among older adults in the Baby
Boom
generation, and older adults seeking alternatives to current treat-
ments for a variety of conditions.
Among older adults who use cannabis, 6.9% meet criteria for canna-
bis use disorder (Han et al. 2017). Older adults who use cannabis have
rates of past-year and lifetime psychiatric disorders, past-year
higher
suicidal ideation, and lifetime suicide attempts than those who do not
use cannabis (Vacaflor et al. 2020). Comorbidity with at-risk use and
substance use disorders is high, especially tobacco use disorder (58%–
62% of those with cannabis use), at-risk alcohol use (42%–48%), and alcohol use disorder (29%) (Vacaflor et al. 2020). Older adults who drink
al
cohol are more likely to also use cannabis (6.3%) than older adults in
general (4.2%); simultaneous use of alcohol and cannabis has increased
over time among those age ≥50, which is concerning given the drugs’ additive cognitive and psychomotor effects (Han and Palamar 2020; Subbaraman
with increased use of illicit substances (e.g., cocaine, hallucinogens), misuse of prescription opioids, and opioid use disorder (Wolfe et al. 2023).
bis use: first use in late life, “stop-out” use (early-life use, no use between
ag
es 31 and 64, then return to use in late life), or chronic/consistent use
(Arora et al. 2021). About 50%–60% of older adults who use cannabis
started using in late life, most often for medicinal purposes (Arora et al.
2021; Yang et al. 2021). Older adults report using cannabis for the treatment of pain, insomnia, anxiety, depression, and Parkinson disease (Solomon et al. 2021). Among older adults who used cannabis, 12% did so
and Kerr 2020). Cannabis use in older adults is also associated
Older adults appear to follow one of three temporal patterns of canna-
Cannabinoid Use and Use Disorder Among Older Adults 277
weekly and 31% daily (Reynolds et al. 2018). The most common routes of
administration were lotion (35%), tinctures (35%), smoking (30%), edibles
(26%), vaping concentrate (13%), and pills (10%) (sums to more than 100%
because people use more than one route) (Yang et al. 2021).
Older adults who use cannabis generally do not view their use as risky:
79% perceived little or no risk from using once or twice a week and 85%
perceived little or no risk from using monthly (Han et al. 2021). A survey
of older adults who use cannabis found that only 16% self-reported side effects that they attributed to cannabis (Reynolds et al. 2018).
Many countries and U.S. states have legalized medical marijuana,
creational marijuana, or both. As of January 2024, medical marijuana
re
is legal in 41 U.S. states and the District of Columbia; CBD oil, but not
THC, is legal in 4 states; both are illegal in 5 states (World Population
Review 2024a). Medical marijuana has also been legalized in 13 countries, including Canada, Australia, Germany, Italy, Poland, Greece, and
Israel (W
ational marijuana is legal in 22 states and the District of Columbia, although what exactly is permitted (e.g., how much one can legally
possess and whether one can cultivate it at home) varies; under federal
law, marijuana remains illegal (World Population Review 2024b).
bis, prevalence of cannabis use disorder, and odds of driving under the
fluence of cannabis (Hasin and Walsh 2021). It appears that recre-
in
ational marijuana laws are associated with increased use and cannabis
use d
Neither of these findings is specific to older adults (Reynolds et al. 2018).
In a survey of older adults in Colorado (which allows both medical and
recreational marijuana), two-thirds of respondents obtained recreational
marijuana without a prescription.
orld Population Review 2024a). As of January 2024, recre-
Medical marijuana laws are associated with increased use of canna-
isorder, although data are not plentiful (Hasin and Walsh 2021).
MEDICAL USE OF CANNABINOIDS IN
OLDER ADULTS
Cannabinoid Preparations and Their
Physiological Effects
Marijuana consists of at least a hundred cannabinoids, including Δ-9-
tetrahydrocannabinol (THC) and cannabidiol (CBD). THC’s psychoactive properties arise from its agonism of cannabinoid type 1 (CB
receptors, which are found primarily in the brain, including the hippo-
)
1
278 Substance Use in Older Adults
campus, basal ganglia, cerebellum, and suprachiasmatic nucleus
(Sahlem et al. 2021). THC’s effects on the hippocampus likely account
for the memory loss associated with cannabis use. THC also stimulates
the sympathetic nervous system and inhibits the parasympathetic nervous system, resulting in tachycardia and other cardiovascular effects
(Page et al. 2020). CBD has low affinity for CB
receptors but may be an
1
antagonist at low doses (Sahlem et al. 2021). CBD may reduce heart rate
and blood pressure and improve vasodilation (Page et al. 2020).
Dronabinol is an FDA-approved commercial preparation of THC. Synthetic cannabinoids include nabilone (an FDA-approved THC analog)
and illega
l preparations such as K2 and spice.
The use of Δ8 THC, marketed as “legal hemp,” has been rising. Consumers may consider it a safer alternative, but Δ8 THC is nearly as active at CB
receptors as Δ9 THC—it too has psychoactive properties and
1
has led to medical complications and emergencies (Babalonis et al.
2021). In the United States, the legal status of Δ8 THC is somewhat unclear. Proponents argue that it is derived from hemp, which in 2018 the
U.S. Co
ngress excluded from the Schedule I definition of cannabis;
however, Δ8 THC is typically synthesized from CBD and then added to
products
at concentrations much higher than naturally found in hemp
(Babalonis et al. 2021). More recently, Δ10 THC and other cannabinoids
have a
lso entered the market.
There is concern about the composition of commercially available
TH
C and CBD preparations. A variety of contaminants have been
found in THC and CBD, including pesticides, metal particles, synthetic
cannabinoids, aflatoxins, molds, bacteria, and residua of toxic solvents
used during the THC/CBD extraction procedure (Hazekamp 2018). An
analysis of Dutch cannabis oil samples found significant variance of actual THC or CBD content from labeled content, for example, 0.1% actual
THC in
a product labeled as 17% THC and 0% actual CBD in a product
labeled as 25% CBD; one sample contained 57.5% THC (Hazekamp
2018). Users of these preparations may be getting much more or less
THC than expected, much less CBD than expected, and contaminants.
Cannabinoids can be ingested through various routes. Dried cannabis
r may be smoked (combustion) via cigarettes, pipes, or bongs, lead-
flowe
ing to rapid onset and peak effect (Kansagara et al. 2019). Concentrated
extract (resin or
oil) may be vaporized (heated without combustion), resulting in a similarly rapid onset and peak effect, with less exposure to
to
xins (Kansagara et al. 2019). Edibles have a delayed onset and peak but
may have greater psychoactive effects because of hepatic metabolism of
THC to 11-hydroxy-THC, which more readily crosses the blood–brain
barrier—this may be of particular concern in older adults, who tend to
Cannabinoid Use and Use Disorder Among Older Adults 279
have a more permeable blood–brain barrier (Solomon et al. 2021). Many
topical forms (creams, ointments, patches, poultices, oils) are available,
but little is known about systemic absorption (Kansagara et al. 2019).
FDA-Approved Uses of Cannabinoids
The FDA has approved three cannabinoids for use in the United States:
cannabidiol (Epidiolex oral solution) for the treatment of seizures due
to Lennox-Gastaut syndrome and Dravet syndrome; dronabinol (Marinol capsule, Syndros oral solution) for anorexia associated with weight
loss in people with AIDS and nausea/vomiting associated with cancer
chemotherapy; and nabilone (Cesamet capsule) for the treatment of
nausea associated with cancer chemotherapy (Solomon et al. 2021). In
addition, European regulatory agencies have approved the use of
nabiximols (Sativex), an oromucosal spray consisting of a 1:1 ratio of
THC to CBD, for the treatment of moderate to severe multiple sclerosis
spasticity that has not responded to other treatments (Kansagara et al.
2019).
Very little is known about the safety of these agents in older adults.
cal trials of Epidiolex did not include anyone older than 55 (Green-
Clini
wich Biosciences 2018); given the very specific indication, this medication is unlikely to be relevant to older adults. Older adults, especially
those with dementia, who are prescribed dronabinol may be more sensitive to or at increased risk for somnolence, dizziness, orthostatic hypotension, and falls;
(AbbVie 2017; Briscoe and Casarett 2018). Older adults prescribed nabilone may be more sensitive to its psychoactive properties (drowsiness,
dysphoria, confusion, psychosis) and more likely to develop orthostatic
hypotension; other common side effects include dizziness and dry
mouth (Briscoe and Casarett 2018; Valeant Pharmaceuticals International 2006).
When prescribing dronabinol or nabilone, I recommend to “start
low and
should screen for cognitive impairment before prescribing and warn
patients about the risks of cognitive impairment, including effects on
driving safety (Briscoe and Casarett 2018). It is best to avoid coadministration with other central nervous system agents.
go slow,” as we generally do in geriatric practice. Clinicians
other risks include paranoia and confusion
Other Possible Medical Uses of Cannabinoids
Very few randomized controlled trials of medical marijuana in older
adults have been conducted; in one estimate, the total number of older
adults studied is <250 (Levy et al. 2020). There are not enough data to
280 Substance Use in Older Adults
draw any conclusions about subgroups of older adults (e.g., by gender,
race, or ethnicity) or about route of marijuana ingestion (Wolfe et al.
2023). There is mixed evidence for the efficacy of medical marijuana for
cancer-related cachexia, nausea, and vomiting (Levy et al. 2020). Medical marijuana may be helpful for pain, including cancer pain, neuropathic pain, and noncancer chronic pain (Briscoe and Casarett 2018;
Levy et al. 2020). The evidence is strongest for neuropathic pain, supported by two meta-analyses (Levy et al. 2020). However, for chronic
noncancer pain, two of three meta-analyses did not find medical marijuana to be better than placebo (Levy et al. 2020). The evidence of benefit in cancer pain is also scant, with concern about adverse effects
potentially offsetting any benefit (Wolfe et al. 2023). Based on data that
Medicare claims for prescription opioids decreased in U.S. states that
had approved medical marijuana, it has been suggested that marijuana
use might allow people to decrease their doses of opioids (Levy et al.
2020).
Cannabinoids do not have any benefit for cognition in people with
dementi
mentia; indeed, they may worsen cognition (Bosnjak Kuharic et al.
2021; W
logical symptoms of dementia (BPSD), the results of six small randomized controlled trials have been mixed. One study of nabilone found
benefi
(N=15) older study of dronabinol showed benefit for agitation; the
other st
fects, especially problems with balance (Wolfe et al. 2023). I do not recommend treating BPSD with cannabinoids and I would caution people
with dementia who use cannabinoids to watch for worsening cognitive
impairment, sedation, and falls.
cannabinoids for Parkinson disease, chronic obstructive pulmonary
disease, glaucoma (in fact, CBD may increase intraocular pressure), or
any psychiatric disorder (Briscoe and Casarett 2018; Wolfe et al. 2023).
a due to Alzheimer disease, vascular dementia, or mixed de-
olfe et al. 2023). With respect to treating behavioral and psycho-
t for agitation, but sedation was common (45%); a very small
udies did not demonstrate efficacy or had significant side ef-
Randomized controlled trials have not demonstrated efficacy of
Safety Concerns With Medical Use of
Cannabinoids
Older adults have greater adiposity than younger adults, which in theory could create a larger depot for cannabinoids, thus lengthening their
half-life (Briscoe and
noids are metabolized by CYP2C9 and CYP3A4 enzymes; older adults
Casarett 2018). Dronabinol and other cannabi-
Cannabinoid Use and Use Disorder Among Older Adults 281
taking medications that inhibit or induce those enzymes would thus
have higher or lower levels of cannabinoids, respectively (Briscoe and
Casarett 2018). THC may inhibit CYP3A4, CYP2C9/19, and CYP2D6
and may induce CYP21A2; CBD may inhibit CYP3A4, CYP2C19,
CYP2D6, and CYP1A2 (Page et al. 2020). THC can increase levels of
warfarin, resulting in increased international normalized ratio (INR)
and risk of bleeding (Solomon et al. 2021). Clinicians should also be
mindful of interactions with antidepressants, antipsychotics, antiarrhythmics, and statins (Page et al. 2020).
In studies of medical marijuana (THC or THC/CBD) in older adults
with cance
disease, the most common neuropsychiatric side effects were somnolence/drowsiness/sleepiness (≤52%), confusion (≤ 25%), subjective
worsening of memory (17%), hallucinations (≤ 17%), anxiety (14%), dizziness (≤13%), and paranoia (6%) (Vacaflor et al. 2020). Other side effects of note included dry mouth, nausea, and euphoria (Briscoe and
Casarett 2018). Negative effects on quality of life have been detected in
studies of cannabinoids in people with cancer (Wolfe et al. 2023). These
may be underestimates when medical marijuana is used by the general
population of older adults, since some studies excluded people with
psychiatric illness, cognitive impairment, or substance use disorder,
and some studies selected participants based on prior use and tolerability of marijuana (Vacaflor et al. 2020). Study participants receiving cannabinoid
receiving placebo (Levy et al. 2020).
Other concerns include cough and bronchitis (when smoking marijuana), increased risk of myocardial infarction (in those with preexisting
iac disease), perhaps an increased risk of stroke, and the develop-
card
ment of CHS, described in detail later in this chapter (Briscoe and Casarett
2018). There is an association between smoking marijuana and
testicular cancer, although it is not clear if this is relevant in older men
(Briscoe and Casarett 2018).
r, Parkinson disease, or chronic obstructive pulmonary
s were more likely to withdraw from studies than those
CLINICAL PRESENTATION OF CANNABIS
USE AND USE DISORDER
Intoxication
Acute use of and intoxication with cannabis can present with a variety
of psychiatric (e.g., anxiety, paranoia), cardiovascular (e.g., tachycardia,
282 Substance Use in Older Adults
hypotension), pulmonary (e.g., bronchitis, respiratory suppression),
and psychomotor effects (DSM-5-TR [American Psychiatric Association
2022]; Page et al. 2020). Older adults may be more susceptible to the
psychiatric effects and may have a higher risk related to cardiovascular
effects such as myocardial infarction (especially in those with cardiovascular disease or risk factors) (Page et al. 2020). As noted earlier, using
an edible formulation (as opposed to inhaled) may result in delayed onset of symptoms but possibly more severe symptoms.
Cannabis use and intoxication can lead to emergency department
(ED) vi
acute psychiatric symptoms, exacerbation of cardiovascular or pulmonary disease, or CHS (described later). ED visits related to cannabis use
among older adults increased from 20.7 per 100,000 ED visits in 2005 to
395.0 in 2019 (Han et al. 2023). Increases were higher among older men
and those with more medical comorbidities (Han et al. 2023). About
one-third of ED visits for cannabis intoxication (in patients of all ages)
are for mental health reasons, primarily severe anxiety, sometimes comorbid with panic attack, confusion, aggression, or paranoia (Keung et
al. 2023). The most common symptoms of cannabis intoxication in the
ED are anxiety (27.5% of people of all ages presenting to the ED with recent cannabis use), vomiting (23.7%), agitation (22.5%), palpitations
(14.3%), and reduced consciousness (13.0%). All older adults presenting
to an ED or who have an acute change in mental state should be
screened for cannabis use.
ory, judgment, executive function, and psychomotor functioning
(Sahlem et al. 2021
ready have cognitive impairment, or those at risk of cognitive impairment (e.g., due to cerebrovascular disease). As noted earlier in
“Epidemiology,” older adults who use cannabis are more likely to use
other substances. Cannabis can increase the sedative effects of alcohol,
benzodiazepines, and opioids, thus resulting in greater cognitive impairment (Kuerbis et al. 2014).
impaired driving and a doubling of the
hicle accidents; recreational use also affects driving ability in those who
are not in
report driving under the influence of alcohol or other substances in the
past year; older adults who used cannabis in the past year were four
times more likely to drive under the influence of alcohol (Choi et al.
2016; Solomon et al. 2021).
sits. Causes include injuries (falls, motor vehicle accidents),
Of course, cannabis intoxication can have profound effects on mem-
). This is especially true in older adults, those who al-
In adults of any age, intoxication with cannabis is associated with
risk of serious or fatal motor ve-
toxicated (Solomon et al. 2021). About 6% of older adults self-
Cannabinoid Use and Use Disorder Among Older Adults 283
Withdrawal
Cannabis withdrawal occurs in about half of regular cannabis users
with abrupt cessation or marked reduction in use of THC (but not CBD)
(Connor et al. 2022). In animal models, chronic THC administration results in downregulation of CB
mechanism for tolerance to and withdrawal from cannabis (Brezing et
al. 2021). Symptoms of cannabis withdrawal include anger, irritability,
aggression, anxiety, dysphoria, restlessness, decreased appetite, weight
loss, insomnia, and disturbed dreaming (Brezing and Levin 2016).
Symptoms of withdrawal typically start around 24–48 hours after cessation, peak around days 2–6, and in those with heavy use of cannabis
may last 2–3
carboxylic acid (THC-COOH) may predict severity of withdrawal
(Claus et al. 2020).
The endocannabinoid system plays a role in sleep-wake regulation;
although the effe
complicated, it is clear that withdrawal from cannabis can result in substantial sleep disruption (Sahlem et al. 2021). Sleep disruption during
withdrawal can
cannabis (Sahlem et al. 2021).
Because older adults using cannabis are more likely to use other
substances as well, clinicians should be mindful of a complicated clinical picture that includes symptoms of two or more withdrawal syndromes (Connor et al. 2022). Use of other substances (e.g., tobacco) may
also worsen symptoms of cannabis withdrawal (Connor et al. 2022). Inpatient admission may be necessary in such cases, especially if patients
have comor
Treatment of cannabis withdrawal syndrome is discussed later in this
chapter (“Management”).
weeks or more (Connor et al. 2022). Urine levels of THC
cts of cannabis on sleep quality and architecture are
be long-lasting and can increase the risk of relapse on
bid psychiatric or physical conditions (Connor et al. 2022).
receptors, suggesting a physiological
1
Cannabis Hyperemesis Syndrome
Although the cannabinoids dronabinol and nabilone have been approved by the FDA for the treatment of nausea due to cancer chemotherapy, chronic use of cannabis may result in a cyclic syndrome of
severe
nausea and vomiting called cannabis hyperemesis syndrome (CHS,
ned earlier). It is not clear how CHS arises, although it is possible
as defi
that activation of CB
resulting in nausea and vomiting and overriding the antiemetic effects
of CB
activation in the chemotactic zone in the brain stem (Senderovich
1
et al. 2022).
receptors in the gut may slow gastric emptying,
1
284 Substance Use in Older Adults
Table 10–1. Cannabis-related syndromes in older adults
Syndrome Features Concerns in older adults
Cannabis
intoxication
Impaired motor
coordination
Impaired short-term
memory
Sedation, lethargy
Anxiety, panic, dysphoria
Perceptual disturbances
(hallucinations)
Sensation of slowed time
Impaired judgment
Social withdrawal
Tachycardia
Increased appetite
Dry mouth
Older adults may be more
suscepti
ble to cognitive effects,
psychiatric effects, and
respiratory suppression.
Tachycardia may be more
problema
tic in older adults,
especially those with cardiac
disease (e.g., increased risk of
myocardial infarction, heart
failure, and mortality).
Edible form may have more
cognitiv
e and psychiatric
effects because of THC
metabolite that more easily
crosses the blood–brain barrier.
Cannabis
withdrawal
syndro
Irritability, anger, or
aggression
me
Anxiety, restlessness
Insomnia may arise or worsen
due to tolerance of and
withdrawal from cannabis.
Insomnia, disturbing
dreams
Fatigue, yawning
Decreased appetite,
weight loss
Dysphoria
Abdominal pain
Tremor, sweating, fever,
chills, headac
he
Difficulty concentrating
CHS Recurrent episodes of
nausea an
d vomiting for
hours, days, or weeks
Associated with ingesting
high amounts of cannabis
for 6 or more months
Decreased oral intake,
malnutr
ition, weight loss,
dehydration
Relieved by cessation of
cannabis
CHS= cannabis hyperemesis syndrome.
Source. DSM-5-TR [American Psychiatric Association 2022]; Page et al. 2020;
Send
erovich et al. 2022.
Medical comorbidities may
exacerbate the syndrome or
complicate its detection.
Need to monitor carefully for
ration, renal failure, and
dehyd
electrolyte disturbances.
Older adults may not tolerate
interventions that have some
evidence of efficacy in CHS
(droperidol, haloperidol,
clonazepam).
Cannabinoid Use and Use Disorder Among Older Adults 285
CHS typically arises after ≥ 6 months of cannabis use. Presenting
symptoms include nausea, vomiting, and abdominal pain that may be
relieved by long, hot showers (Kansagara et al. 2019). CHS improves
with cessation of cannabis use (Senderovich et al. 2022). Other interventions that may be effective include topical capsaicin, droperidol, haloperidol, and clonazepam (Senderovich et al. 2022).
See Table 10–1 for a summary of cannabis intoxication, cannabis
withdrawal syndrome, and CHS.
SCREENING AND ASSESSMENT
In one survey of older adults using cannabis, only 41% reported that
their health care providers knew about their use (Yang et al. 2021). Thus
all older adults should be regularly screened for the use of cannabis in
any form, including recreational marijuana (smoked, vaporized, and
edibles), medical marijuana, or prescription cannabinoids. This could
be done as part of a broader screening for the use of alcohol or other
substances (see Table 2–3 in Chapter 2, page 32, for a list of screening
. To specifically screen for problematic cannabis use, I would rec-
tools)
ommend a modification of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool, as shown in Table 10–2. A
score of 1 suggests that the patient has problematic use of cannabis. A
score of 2 or 3 should raise concern for a diagnosis of cannabis use disorder. Those with problematic use are at risk of developing cannabis
use disorder. See Box 10–1 for DSM-5-TR diagnostic criteria for cannabis use disorder.
Box 10–1. Cannabis Use Disorder
Diagnostic Criteria
A. A problematic pattern of cannabis use leading to clinically significant
impairment or distress, as manifested by at least two of the following,
occurring within a 12-month period:
1. Cannabis is often taken in larger amounts or over a longer period
than was in
2. There is a persistent desire or unsuccessful efforts to cut down or
control cannab
3. A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or recover from its effects.
4. Craving, or a strong desire or urge to use cannabis.
tended.
is use.
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