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286 Substance Use in Older Adults
Table 10–2. Screening for cannabis use
Question Response Action
In the past 12 months, how
often have
juana?
In the past 3 months, did
you use marijuana?
In the past 3 months, have
you had a stro
urge to use marijuana at
least once a week or more
often?
If the past 3 months, has
anyone expressed concern
about your use of
marijuana?
Note. Note that the relevant study included some older adults, but these results are for
all ages (≥18). At cutoff of 1, sensitivity and specificity for problem use of cannabis are
82% and 93%, r
order are 71% and 94%, respectively. Those with a score of 2 or 3 should be administered
the CUDIT-R (see
Source. McNeely et al. 2016.
you used mari-
ng desire or
espectively. At cutoff of 2, sensitivity and specificity for cannabis use dis-
Table 10–3).
Daily or almost daily,
weekly, monthly,
less than monthly,
never
Y
es or no 1 point if yes and
Yes or no 1 point if yes
Yes or no 1 point if yes
For any answer other
than “never,” continue
with next
continue with next
two questions
question
5. Recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects
of cannabis.
7. Impo
rtant social, occupational, or recreational activities are given
up or reduced because o
f cannabis use.
8. Recurrent cannabis use in situations in which it is physically hazardous.
9. Cannabis use is continued despite knowledge of having a persistent
or recurrent physical or psychological problem that is likely to have
been caused or exacerbated by cannabis.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of cannabis to achieve
intoxication or d
esired effect.
b. Markedly diminished effect with continued use of the same
amount of
cannabis.
Cannabinoid Use and Use Disorder Among Older Adults 287
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for cannabis (refer to
Criteria A and B of the criteria set for cannabis withdrawal).
b. Cannabis (or a closely related substance) is taken to relieve or
avoid wi
Specify if:
In early remission: After full criteria for cannabis use disorder were
previously met, none o
met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use cannabis,” may be met).
In sustained remission: After full criteria for cannabis use disorder
were prev
been met at any time during a period of 12 months or longer (with the
exception that Criterion A4, “Craving, or a strong desire or urge to use
cannabis,” may be present).
Specify if:
In a controlled environment: This additional specifier is used if the in-
dividual is in an environment where access to cannabis is restricted.
Specify current severity:
Mild: Presence of 2–3 symptoms.
Moderate: Presence of 4–5 symptoms.
Severe: Presence of 6 or more symptoms.
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders, 5th Edition, Text Revision. Washington, DC, American Psychiatric Asso-
ciation, 2022. Copyright © 2022 American Psychiatric Association. Used with permission.
thdrawal symptoms.
f the criteria for cannabis use disorder have been
iously met, none of the criteria for cannabis use disorder have
The Cannabis Use Disorder Identification Test–Revised (CUDIT-R)
offers more in-depth screening, although it has not been validated in
older adults (Adamson et al. 2010). A score of ≥12 detects cannabis use
der with a sensitivity of 91% and specificity of 90%. See Table 10–
disor
3 for further details.
Clinicians should screen for the use of alcohol and other substances
and for comorbid psychiatric issues. Urine drug testing could be considered to identify recent or current use of cannabis or other substances.
MANAGEMENT
The intensity of the intervention will depend on the severity of cannabis
use, ranging from problem use of cannabis to meeting criteria for cannabis use disorder. All older adults with problem use or cannabis use
disor
der should be counseled to reduce or end use of cannabis. Clini-
Table 10–3. Cannabis Use Disorder Identification Test–Revised (CUDIT-R)
Question Response and score
Have you used any cannabis in the past 6 months? (Yes/No)
If YES, please answer the following questions in relation to your
cannabis use over the past month.
1. How often do you use cannabis? Never=0 Monthly or
less=1
2. How many hours were you stoned on a typical day when you
had been using cannabis?
3. How often during the past 6 months did you find that you were
not able to stop using cannabis once you had started?
4. How often during the past 6 months did you fail to do what was
normally expected from you because of using cannabis?
5. How often in the past 6 months have you devoted a great deal of
your time to getting, using, o
6. How often in the past 6 months have you had a problem with
your memory or concentration after using cannabis?
7. How often do you use cannabis when physically hazardous, such
as dr
iving, operating machinery, or caring for children?
8. Have you ever thought about cutting down or stopping your use
of cannabis?
Note. A score of ≥12 detects cannabis use disorder with a sensitivity of 91% and specificity of 90%.
Source. Adamson et al. 2010.
r recovering from cannabis?
Less than
1=0
Never= 0 Less than
Never= 0 Less than
Never= 0 Less than
Never= 0 Less than
Never, 0 Less than
ver, 0 Yes, but not
Ne
1 or 2=1 3 or 4=2 5 or 6=3 7+ =4
monthly=1
monthly=1
monthly=1
monthly=1
monthly, 1
in the past 6
months, 2
2–4 times a
month=2
Monthly= 2 Weekly =3 Daily/ almost
Monthly= 2 Weekly =3 Daily/ almost
Monthly= 2 Weekly =3 Daily/ almost
Monthly= 2 Weekly =3 Daily/ almost
Monthly= 2 Weekly =3 Daily/ almost
Yes, d uring
the past 6
months, 4
2–3 times a
week=3
4+ times a
week=4
daily=4
daily=4
daily=4
daily=4
daily=4
288 Substance Use in Older Adults
Cannabinoid Use and Use Disorder Among Older Adults 289
cians should use motivational interviewing techniques (as described in
Chapter 3, “Psychosocial Interventions,” page 65, and Table 3–3, page
61) to educate patients, help them determine their treatment goals, and
engage them to meet
about the risks of combining cannabis with alcohol and other drugs and
should advise patients not to use cannabis and drive. Consider engaging family members and caregivers in these discussions. Harm-reduction strategies include using products with lower THC content,
itching to legal or regulated THC products, refraining from daily or
sw
near-daily use, and not bingeing on THC (Connor et al. 2022).
For those meeting criteria for cannabis use disorder, psychosocial interventions are the gold standard. Motivational enhancement therapy
(MET), CBT, and
treatment of cannabis use disorder (National Institute on Drug Abuse
2019). The combination of MET and CBT is more effective than either
one alone, and contingency management may enhance the effects of
MET and CBT (Brezing et al. 2021). All three modalities may be delivered electronically (Brezing et al. 2021). A large trial of an internet-based
self
-help intervention found it to be effective for reducing days of can-
nabis use and severity of cannabis use disorder (Baumgartner et al.
2021). None of these interventions have been specifically studied in
older adults. Nevertheless, I would strongly recommend them, given
the overall evidence of efficacy and likely tolerability and acceptability
by older adults.
There are no medications approved for the treatment of cannabis
thdrawal syndrome, although there is some evidence to support the
wi
use of gabapentin, quetiapine, dronabinol, and nabiximols, as well as
zolpidem for insomnia (Connor et al. 2022). In older adults, the risks
and benefits of medications to address withdrawal symptoms need to
be carefully weighed.
With respect to maintenance treatment of cannabis use disorder, a
number of pharmacological interventions have been found to be either
ineffective or intolerable, including SSRIs, bupropion, atomoxetine,
venlafaxine, mirtazapine, buspirone, lithium, valproate, baclofen,
dronabinol, rimonabant, and topiramate (Bahji et al. 2021; Brezing et al.
2021). Nabilone or gabapentin might be helpful, but more study is
needed (Bahji et al. 2021; Brezing et al. 2021). I do not recommend the
use of a medication for the treatment of cannabis use disorder in older
adults.
From a public health perspective, ways to address the unintended
effects of legalization and greater acceptability of cannabis use among
older adults would be to regularly screen older patients for cannabis
their goals. Clinicians should educate patients
contingency management are recommended for the
290 Substance Use in Older Adults
use and associated harms, educate older adults and their families about
the risks of cannabis use, and ensure that older adults have access to
substance use treatment (Hasin and Walsh 2021).
SUMMARY
Although there is promise that cannabinoids might provide relief for
some symptoms in older adults, such as neuropathic pain and chemotherapy-related nausea and vomiting, older adults are also more susceptible to neuropsychiatric symptoms and other adverse effects.
Especially concerning is the risk of CHS, which could be quite dangerous in older adults. Older adults are also at risk for drug–drug interactions and synergistic negative effects on cognition, balance, and driving
fety. The proliferation of various cannabinoids such as Δ8 THC and
sa
Δ10 THC is outpacing our understanding of their safety and efficacy,
potentially putti
cians can help by educating their older adult patients about the risks of
cannabinoids and counseling cautio
problematic use of cannabis should be advised to cut back or stop cannabis use, and those meeting criteria for cannabis use disorder should
eferred for specialty treatment.
be r
ng older adults at risk for further complications. Clini-
n about their use. Older adults with
KEY POINTS
• More older adults are using cannabis, and many of them are using
it frequently and in a variety of forms: smoked, vaped, eaten, or
applied topically.
• Older adults are more susceptible than younger adults to the cog-
nitive, psychiatric, and cardiovascular effects of cannabis use.
• Various cannabinoid preparations have been approved in the
United States and Europe for nausea and vomiting due
chemotherapy, cachexia associated with AIDS, and muscle spasticity in people with multiple sclerosis. These medications should be
used with caution in older adults, given the possibility of neuropsychiatric and cardiovascular side effects. Start low, go slow, and
avoid coadministration with other central nervous system depressants.
• Some evidence supports the use of medical marijuana for neuro-
pathic
pain and mixed evidence for noncancer chronic pain. No
evidence supports its use for dementia.
to cancer
Cannabinoid Use and Use Disorder Among Older Adults 291
• Any older adult with a new or sudden change in cognitive or psychiatric state should be assessed for cannabis use or intoxication.
• About half of regular users of cannabis develop withdrawal with
upt cessation or marked reduction of use. Insomnia can be es-
abr
pecially prominent and long-lasting, making abstinence difficult.
• Cannabis hyperemesis syndrome includes recurrent episodes of
nausea and vomiting
adults, given the risks of dehydration, renal failure, and electrolyte
disturbances. Maintaining a high index of suspicion is essential.
• Screen older adults for cannabis use at initial contact, periodically
af
terward, or with any significant change in medical or psychiatric
status. Use the CUDIT-R scale to rate the severity of cannabis use
disorder.
• Older adults with problematic use of cannabis should be advised
cut down or stop. Psychotherapy (motivational enhancement
to
therapy, CBT, contingency management, or a combination) is the
gold-standard treatment for cannabis use disorder.
. It may be particularly concerning for older
RESOURCES FOR PATIENTS, FAMILIES,
AND CAREGIVERS
National Institute on Drug Abuse
Cannabis (Marijuana) DrugFacts: The NIDA provides this reference
on cannabis, including physical, cognitive, and mental health
effects (https://nida.nih.gov/publications/drugfacts/cannabismarijuana). Also available in Spanish.
Drugged Driving DrugFacts: NIDA provides this resource on the
da
ngers of driving while impaired by marijuana or other drugs
(https://nida.nih.gov/publications/drugfacts/drugged-driving).
Also available in
Centers for Disease Control and Prevention
Marijuana and Public Health (www.cdc.gov/marijuana/in-
dex.htm): This CDC website covers the health effects of marijuana, data and statistics related to marijuana use, and answers to
freq
uently asked questions about marijuana and health. Also
available in Spanish.
Spanish.
292 Substance Use in Older Adults
RESOURCES FOR CLINICIANS
American Psychiatric Association
Cannabis: The APA has collected various resources on motivational
interviewing, comorbidity of marijuana and mental health, medical
cannabis, and links to other organizations’ online materials
(www.psychiatry.org/psychiatrists/practice/professionalinterests/addiction-psychiatry/cannabis).
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CHAPTER 11
Cultural, Structural, and
Ethical Considerations in
the Care of Older Adults
With Substance
Use Disorders
Noelle Martinez, M.D., M.P.H.
Susan Lehmann, M.D.
Michael Fingerhood, M.D.
In this chapter, we examine the ways culture and identity influence
care of an older adult with a substance use disorder. We also explore
disparities in treatment access and outcomes among patients belonging
to racial and ethnic minorities, including the structural determinants of
such outcomes. We highlight the impact of unique care settings such as
295
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