The Blunt Truth about Medical Cannabis: Implications for Hospice

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The Blunt Truth about Medical Cannabis: Implications for Hospice Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE Terri Maxwell, PhD, APRN Ryan Costantino, PharmD, BCPS, BCGP Presenters Mary Lynn

1 The Blunt Truth about Medical Cannabis: Implications for Hospice Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE Terri Maxwell, PhD, APRN Ryan Costantino, PharmD, BCPS, BCGP Presenters Mary Lynn McPherson, PharmD, MA, MDE, BCPS, CPE Professor and Executive Director, Advanced Post Graduate Education in Palliative Care & Program Director, Online Master of Science in Palliative Care, University of Maryland School of Pharmacy Terri Maxwell, PhD, APRN Chief Clinical Officer, Turn Key Health keyhealth.com Ryan Costantino, PharmD, BCPS, BCGP PGY 2 Pain/Palliative Care Pharmacy Resident, University of Maryland School of Pharmacy rcostantino@rx.maryland.edu 1

Disclosure All presenters have nothing to disclose Learning Objectives 1. Describe the clinical role in hospice care of FDA approved cannabinoid products. 2.

2 Disclosure All presenters have nothing to disclose Learning Objectives 1. Describe the clinical role in hospice care of FDA approved cannabinoid products. 2. Describe the clinical role in hospice care of cannabis products from dispensaries. 3. Summarize legal and regulatory issues including "related" and "coverage" status of cannabis in hospice. 4. Describe results of a nationwide survey of how hospice programs are dealing with cannabis use by patients. 5. Review components of a medical cannabis protocol for hospices. 2

3 What is Medical Marijuana? Legal definition: the use of cannabis or marijuana, including constituents like THC and other cannabinoids, as a physicianrecommended form of medicine or herbal therapy Marijuana Cannabis plant Comes in various forms from buds, oils, tinctures, pills or topicals marijuana/ Introduction Marijuana has been used for thousands of years, by cultures all over the world, for both medicinal and religious purposes In 2008 a 2,700 year old grave in the Gobi Desert was identified as the world's oldest marijuana stash 2 primary strains: sa va ( THC) and indica ( CBD) Cannabis contains: >400 chemical compounds >100 separate cannabinoids The female buds of the plant are smoked once dried 3

The picture can't be displayed. 10/18/2018 THC vs.

Sleep inducing Appetite stimulant CBD (cannabidiol) Low euphoria Modulates

com/differences cbd thc/ Formulations of Marijuana Buds Ointment/ Cream/

4 The picture can't be displayed. 10/18/2018 THC vs. CBD THC (tetrahydrocannabinol) Euphoric high effect Confusion, paranoia Sleep inducing Appetite stimulant CBD (cannabidiol) Low euphoria Modulates effects of THC Many clinical uses cbd thc/ Formulations of Marijuana Buds Ointment/ Cream/ Lotion Transdermal Patch Concentrates: hash, budder, shatter, dabs, wax, oil Wine/ Beer Oral tincture Edibles 4

5 Routes of Administration Route Onset Duration Inhaled smoked or vaporized Rapid 2 3 Hours Oral ingestion min 5 6 hours Oral Transmucosal min 5 6 hours Rectal min 2 8 hours Topical?? Transdermal 1 2 hours 8 24 hours Huestis MA. Human Cannabinoid Pharmacokinetics. Chem Biodivers. 2007; 4(8): Stott CG et al. Euro Journ of Clin Pharm. 2013; 69(4): Which Breed Should a Patient Buy? And what data supports which combo? THC CBD 5

6 Adverse Effects Anxiety: Not seen as commonly with CBD vs. THC Psychosis: Hallucinations, paranoid delusions Caution in patients with pre existing risk factors such as family history, previous mental illness, or childhood abuse Lung Damage? Cardiac Hyperemesis syndrome a.k.a. Greenout syndrome Note: no receptors in brain stem so cannot overdose Pletcher M, et al. Association between marijuana exposure and pulmonary function over 20 years. JAMA 307, no. 2 (2012): marijuana exposure and pulmonary function over 20 years. JAMA 307, no. 2 (2012): Drug Interactions CNS depressants: Additive drowsiness, fall risk Opioids, benzodiazepines, alcohol Medications that cause tachycardia: Psychostimulants, anticholinergics, theophylline CYP450 liver enzyme inducers and inhibitors 6

7 Indications Hospice and Cannabis Main clinical uses: Seizures Adjuvant analgesic treatment Sleep disturbance Nausea Dyspnea Anorexia QOL/well being 7

$Seizures Treatment of refractory seizures is an active area of research Many documented anecdotal accounts in the literature Most research done on Dravet syndrome in children Data suggests CBD vs.$

8 Seizures Treatment of refractory seizures is an active area of research Many documented anecdotal accounts in the literature Most research done on Dravet syndrome in children Data suggests CBD vs. THC is preferred Devinsky O, Cross JH, Laux L, et al. Trial of cannabidiol for drug resistant seizures in the Dravet syndrome. N Engl J Med. 2017; 376: Pain Many clinical trials conducted to evaluate effect on pain CBD may be more effective than THC More effective for neuropathic pain (treatment resistant) vs. other types of pain Adjuvant effect for pain control in conjunction with opioids Treatments are well tolerated and preferred by patients Wilsey B, Marcotte T, Deutsch R, et al. Low dose vaporized cannabis significantly improves neuropathic pain. J Pain Feb;14(2): Abrams DI, Couey P, Shade SB, et al. Cannabinoid opioid interaction in chronic pain. Clin Pharmacol Ther Dec;90(6): Ware MA, et al. Smoked cannabis for chronic neuropathic pain: A randomized controlled trial. Canadian Medical Association Journal 182, no. 14 (2010): E

9 Nausea Meta analysis demonstrating efficacy, particularly in chemotherapy induced nausea Studies with patients using whole plant marijuana or natural cannabinoids like CBD are lacking Several studies showed smoked marijuana did not alleviate nausea better than standard treatment (ex: ondansetron), but was more preferred by patients Machado Rocha FC, et al. (2008), Therapeutic use of Cannabis sativa on chemotherapy induced nausea and vomiting among cancer patients: systematic review and meta analysis. European Journal of Cancer Care, 17: Söderpalm H, et al(2001). Antiemetic efficacy of smoked marijuana: subjective and behavioral effects on nausea induced by syrup of ipecac. Pharmacology, biochemistry, and behavior Cachexia/Anorexia Evidence for promoting weight gain inconclusive The munchies are real, based upon patient feedback Cannabis did increase appetite, +/ weight gain in several studies Some studies did not show benefit over traditional therapies Possibly helpful in patients for whom it s important to eat Haney et al. Dronabinol and Marijuana in HIV Positive Marijuana Smokers Caloric Intake, Mood, and Sleep. J Acquir Immune Defic Syndr (5): Cannabis In Cachexia Study, J Clin Oncol (21): p Foltin, R et al. Effects of smoked marijuana on food intake and body weight of humans living in a residential laboratory Appetite

10 Dyspnea Studies dating back to the 1970 s demonstrated improvements in lung function immediately after smoking Marijuana inhaler studied but never made it to market In patients with lung disease, consider alternatives to the inhaled route If the inhaled route is necessary, vaporization may be preferred Tashkin DP, Shapiro BJ, Lee YE, Harper CE. Effects of smoked marijuana in experimentally induced asthma. Am Rev Respir Dis Sep;112(3): Williams SJ, et al. Bronchodilator effect of delta tetrahydrocannabinol administered by aerosol of asthmatic patients. Thorax 31 no 6 (1976): Insomnia Few randomized, controlled trials available Drowsiness/ sleepiness often listed as a side effect in trials evaluating marijuana for other conditions Doses should be used in moderation to prevent anxiety THC more effective than CBD Russo, Ethan B., Guy, Geoffrey W. and Robson, Philip J. (2007), Cannabis, Pain, and Sleep: Lessons from Therapeutic Clinical Trials of Sativex, a Cannabis Based Medicine. Chemistry & Biodiversity, 4:

11 Dementia & Parkinson s Several studies with cannabis in patients with dementia and Parkinson s Results are inconclusive Zach Klein Film: Prescribed Grass Documentary filmmaker, certified marijuana instructor Anecdotal results: Patients calmer, more relaxed, able to write better, possibly able to discontinue other medications Geke A.H et al. Tetrahydrocannabinol for neuropsychiatric symptoms in dementia Neurology May 2015, Lotan et al. Cannabis (Medical Marijuana) Treatment for Motor and Non Motor Symptoms of Parkinson Disease: An Open Label Observational Study. Clinical Neuropharmacology: March/April ( 2) Prescribed Glass. A documentary by Zach Klein. Society of Cannabis Clinicians. Accessed 2017 Jul. Available from: grass/ Quality of Life (QOL) Improvement Study in March 2018 evaluating safety and efficacy of medical cannabis in population of 2736 elderly patients 564 patient died within 6 months of treatment After 6 months of treatment, 94% reported improvement in QOL and pain level was reduced from a median of 8 down to 4 on a scale of 0 10 Most common adverse events: dizziness (9%) & dry mouth (7%) After 6 months, 18% stopped using opioid analgesics or reduced their dose Abuhasira R, et al. Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. European Journal of Internal Medicine 49 (2018)

Non Opioids: Acetaminophen, NSAIDs (Ibuprofen) Adjuvants:

Based Products Dronabinol (Marinol ) Dronabinol (Syndros) Nabilone

12 Non Opioids: Acetaminophen, NSAIDs (Ibuprofen) Adjuvants: Antidepressants, Anticonvulsants, Corticosteroids, Anesthetics, World Health Organization. Commercially Available Cannabinoid Based Products Dronabinol (Marinol ) Dronabinol (Syndros) Nabilone (Cesamet ) Nabiximols (Sativex ) * Cannabidiol (Epidiolex ) U.S. Food and Drug Administration. * Not available in the U.S. 12

13 Cannabis.new kid on the block? Not likely has a long history as a medicinal plant (dating back more than two millennia) In 1985 pharmaceutical companies received approval to begin developing THC preparations (dronabinol and nabilone) for therapeutic use Now cannabinoid based preparations are being evaluated for epilepsy and schizophrenia Nabiximols oromucosal spray of a whole cannabis plant extract (1:1 THC to CBD) approved for use in Europe, UK, Canada for pain and spasticity associated with multiple sclerosis Dronabinol (Marinol) $200 1,000/month; $150 million market THC analogue Indication Anorexia in AIDS patients; chemo induced NV Small effect at increasing appetite; trend toward improved body weight, improved mood, less nausea AE asthenia, palpitations, tachycardia, vasodilation/flushing, dizziness, euphoria, paranoia, somnolence, abnormal thinking 18% of patients feel high after using 13

Dronabinol (Syndros) New oral solution formulation Same

2 kg GAIN No weight gain noted in cancer patients; reduced

Nabilone (Cesamet) 01 Chemo induced NV in patients who do

14 Dronabinol (Syndros) New oral solution formulation Same indications Weight gain ranged from 2 kg LOSS to 3.2 kg GAIN No weight gain noted in cancer patients; reduced rate of weight loss $2,000/month $400 million/year market Nabilone (Cesamet) 01 Chemo induced NV in patients who do not respond to more conventional antiemetic therapy 02 Limited effectiveness 14

Epidiolex just approved by FDA (June 2018) Epidiolex (cannabidiol) [CBD] oral solution for the treatment of seizures associated with two rare and

15 Nabiximol (Sativex) A THC CBD (1:1) oromucosal spray used as add on therapy for patients with moderate to severe treatment resistant spasticity 37% treated patients had response vs. 26% placebo Cannabis.new kid on the block? Epidiolex just approved by FDA (June 2018) Epidiolex (cannabidiol) [CBD] oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox Gastaut syndrome and Dravet syndrome, in patients two years of age and older. This is the first FDA approved drug that contains a purified drug substance derived from marijuana. 15

Cannabidiol (Epidiolex) Drop seizures frequency per 28 days 41.9% on 20 mg/kg/day 37.2% on 10 mg/kg/day 17.2% placebo FDA Briefing Document, 4 19 18 Adverse Events of Cannabinoid vs.

16 Cannabidiol (Epidiolex) Drop seizures frequency per 28 days 41.9% on 20 mg/kg/day 37.2% on 10 mg/kg/day 17.2% placebo FDA Briefing Document, Adverse Events of Cannabinoid vs. Placebo Cannabinoid (vs. Placebo) Odds Ratio More Adverse Effects with Cannabinoid Dronabinol 3.01 Nabiximols 3.41 Nabilone 3.63 Levonantradol 4.84 THC capsules 3.16 THC oromucosal spray 2.0 THC/Cannabidiol capsules 3.03 Whiting PF, et al. Cannabinoids for medical use: a systematic review and meta analysis. JAMA 2015;313(24):

17 Commercially Available Cannabinoid Based Products Dronabinol (Marinol ) Dronabinol (Syndros) Nabilone (Cesamet ) Nabiximols (Sativex ) * Cannabidiol (Epidiolex ) U.S. Food and Drug Administration. * Not available in the U.S. 17

18 Summary Marijuana has many active compounds CBD seems to have more medical benefit than THC Marijuana appears to be relatively safe and effective for a variety of conditions New, commercially available products are entering the marketplace More studies are needed to better understand its role in hospice and palliative care Regulations 18

Federal Regulations Cannabis is listed in Schedule Iof the federal Controlled Substances Act No medical value and high potential for abuse No large scale clinical trials to prove its use, but

19 Federal Regulations Cannabis is listed in Schedule Iof the federal Controlled Substances Act No medical value and high potential for abuse No large scale clinical trials to prove its use, but restrictions make doing trials difficult Justice Dept. advised that states and local gov t can authorize cannabis use (2013) Not FDA approved (ingredients vary) Cannot be prescribed but can be recommended State Regulations 19

General Requirements Registration and training requirements for health care practitioners Written recommendation from a licensed physician Qualifying conditions

20 General Requirements Registration and training requirements for health care practitioners Written recommendation from a licensed physician Qualifying conditions Register for a medical marijuana ID card Approved dispensaries Proxy/caregiver rules Transporting Possession/cultivation limits Rules vary from state to state 20

Most states allow more than one proxy/caregiver State Marijuana

21 Caregivers State dependent rules: Caregiver usually needs to be designated Must apply and register Complete a background check Most states allow more than one proxy/caregiver State Marijuana Law Resource Procon.org 21

22 Sample State Website Shout out to Pennsylvania! Challenges for Patients Mandatory registration (physician s recommendation, gov t issued ID, proof of residency) Initial cost for physician visit to get certified Registration fees (range from $0 $200) Use of registry ID cards across state lines Number of approved dispensaries Some states smoking not allowed; edibles only allowed for minors 22

Challenges for Hospices Question legitimate medical therapy Willingness to recommend medical cannabis Physician certification & training requirements Staff lack fundamental understanding (various

23 Challenges for Hospices Question legitimate medical therapy Willingness to recommend medical cannabis Physician certification & training requirements Staff lack fundamental understanding (various types, edible vs. smoked, etc.) Concern about turning off referral community Lack of policies or procedures Who Pays? Not federally approved so funds from the Medicare Hospice Benefit can NOT be used cover cost Cost should be covered out of pocket by the patient 23

24 Other Conundrums Balancing act legal in your state, but federally illegal Accommodations for those in ALFs or nursing homes? What if someone is smoking or using illegally? Where to store it? Tracking dosing (especially in nursing homes) Objection by staff or nursing home residents Dealing with smoking Assist in medicating especially for those with dementia Regulatory Summary Medical marijuana is federally illegal (Class 1) Legal in 29 states and District of Columbia Regulations vary from state to state check your state regulations Policies and procedures to guide use are needed 24

SURVEY OF HOSPICE PRACTICES WITH CANNABIS Table 1.

Average daily census where you practice 0 50 patients 51 200 patients 201 500 patients >500 patients 36 (11.6%) 7 (2.2%) 181 (58.3%) 11 (3.5%) 7 (2.

Primarily urban Primarily rural Primarily suburban Mixed urban, rural, suburban Is cannabis legal in your state?

25 SURVEY OF HOSPICE PRACTICES WITH CANNABIS Table 1. Respondent Characteristics (n=310) Hospice Role Physician Pharmacist Nurse (RN, LPN) Advanced Practice Nurse Social Worker Aide Administrator Other Average daily census where you practice 0 50 patients patients patients >500 patients 36 (11.6%) 7 (2.2%) 181 (58.3%) 11 (3.5%) 7 (2.2%) 4 (1.2%) 44 (14.1%) 20 (6.4%) 99 (31.9%) 138 (44.5%) 35 (11.3%) 38 (12.3%) Geographic setting of hospice? Primarily urban Primarily rural Primarily suburban Mixed urban, rural, suburban Is cannabis legal in your state? Legal for medical use Legal for recreational use Legal for both medical and recreational use Not legal, but decriminalized Not legal Not Sure 18 (5.8%) 74 (23.8%) 36 (11.6%) 182 (58.7%) 149 (48.0%) 0 (0.0%) 44 (14.1%) 6 (1.9%) 96 (30.9%) 15 (4.8%) Hospice profit status Not for profit For profit Government 212 (68.3%) 95 (30.6%) 3 (0.9%) 25

26 Table 2. Fear of Medical Cannabis Question How fearful are you or the following persons of using medical cannabis? (n=310), n (%) Survey Family Characteristic Patient Staff/Coworker Respondent Members Not fearful 236 (76.1%) 95 (30.6%) 66 (21.2%) 122 (39.3%) Rarely fearful 40 (12.9%) 56 (18.0%) 52 (16.7%) 71 (22.9%) Sometimes fearful 24 (7.7%) 61 (19.6%) 85 (27.4%) 66 (21.2%) Very fearful 4 (1.2%) 6 (1.9%) 11 (3.5%) 5 (1.6%) Don t know 6 (1.9%) 92 (29.6%) 96 (30.9%) 46 (14.8%) Table 3. Hospice Processes Characteristic If a patient is using medical cannabis, where is it documented? (Select all that apply) (Responses=448, n=310), Responses (%) Medication profile Within progress notes On a face or cover sheet Within admission notes It is not documented Other Do you alert the dispensing pharmacist/medication reviewer when a patient is using medical cannabis? (n=310), n (%) Always Often Sometimes Rarely Never Value 114 (26.6%) 127 (29.6%) 3 (0.7%) 79 (18.4%) 34 (7.9%) 71 (16.5%) 129 (41.6%) 41 (13.2%) 31 (10.0%) 33 (10.6%) 76 (24.5%) 26

27 27

28 Discussion Regardless of legal status, hospice staff were overwhelmingly in agreement that it is appropriate for patients to have access to medical cannabis There are various barriers to use Discordant legal status between state and federal governments Concerns about clinical efficacy and safety, and other societal factors Many expressed knowledge deficits and regulatory related concerns Underutilization Lack of access Barriers to procurement Cost Clinical Consideration Quotes I would love to see it used in Hospice/end of life. I feel more dying patients would have a more comfortable experience. I see the great benefits it offers my patients. One drug is able to replace many used for end of life needs. Our medical director has said he would prefer marijuana as a treatment for symptoms above other options but he doesn't prescribe it because he is not licensed to. As with patients, I discuss marijuana only with those who have chosen to use it. These families often state that nothing else is as effective for every symptom they have as marijuana. 28

29 Qualitative Concerns Patients/Families "I don't want to get high. To be classified as a pothead The cost is prohibitive for many of our patients, so it not used very often. Respondent/Staff Some patients will attempt to smoke while clinicians are present, which can be a very uncomfortable situation. They do not want to go into a house that reeks of the smell and then come out smelling of marijuana. It is a sticky topic, most of the time the patient who do use the medical or not medical marijuana never bother to disclose to hospice staff, often it is discovered rather than disclosed." Conclusions Our findings highlight important opportunities to support hospice providers and their patients through education and the development of policies around medical cannabis. 29

30 Hospice Policies & Procedures Poll 1. Does your hospice have a policy/procedure for medical marijuana? Yes No 2. Does your hospice offer training to your staff about medical marijuana? Yes No 30

31 Procolizing Medical Cannabis 1. Hospice clinicians are offered education on medicinal marijuana with an emphasis on possible side effects and drug interactions. 2. The nurse will ask the patient and/or caregiver if the patient is using medical marijuana and document in the designated section in the nurse visit note of the EMR. 3. If the patient is using medical marijuana, the nurse will educate the patient on the potential for side effects and drug interactions. 4. The nurse will inform the hospice s pharmacist/med reviewer/pharmacy vendor when a patient is using medical marijuana during medication profiling, so they can check for drug interactions. Seasons Hospice & Palliative Care Protocol (Used with permission) Procolizing Medical Cannabis 5. The nurse will inform the medical director/hospice physician and entire IDG when a patient is using medical marijuana. 6. Hospice clinicians will not participate in any aspect of recommending, administering, or providing medical cannabis (marijuana). 7. A physician may discuss medical marijuana with the patient and caregiver at his/her discretion. 8. If the attending physician is also a Hospice employee and practices in a state where medical marijuana is legal, it is at his/her discretion to participate in the recommending or ordering process. Seasons Hospice & Palliative Care Protocol (Used with permission) 31

32 Questions? References Casarett, D. J. (2015). Stoned: A doctor's case for medical marijuana. Abuhasira R, et al. Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. European Journal of Internal Medicine. March (49): Aggarwal SK, Blinderman CD. The Palliative Care Network of Wisconsin (PCNOW) Fast Fact #279: Cannabis for Symptom Control. [cited 2017 Jun 10]. Available at: Huesti MA. Human Cannabinoid Pharmacokinetics. Chem Biodivers. 2007; 4(8): Berkovic SF. Cannabinoids for Epilepsy Real Data, at Last. N Engl J Med May 25;376(21): Pletcher M, et al. Association between marijuana exposure and pulmonary function over 20 years. JAMA 307, no. 2 (2012): marijuana exposure and pulmonary function over 20 years. JAMA 307, no. 2 (2012): Karschner EL, et al. Plasma Cannabinoid Pharmacokinetics following Controlled Oral 9 Tetrahydrocannabinol and Oromucosal Cannabis Extract Administration. Clin Chem. 2011; 57(1): Melton SD. Stirring the Pot: Potential Drug Interactions With Marijuana. Medscape article June 8. Ware MA, et al. Smoked cannabis for chronic neuropathic pain: A randomized controlled trial. Canadian Medical Association Journal 182, no. 14 (2010): E Haney et al. Dronabinol and Marijuana in HIV Positive Marijuana Smokers Caloric Intake, Mood, and Sleep. J Acquir Immune Defic Syndr (5): Cannabis In Cachexia Study, J Clin Oncol (21): p Abuhasira R, et al. Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. European Journal of Internal Medicine 49 (2018) Crane M. Doctors legal risks with medical marijuana Jun 4. Medscape News & Perspective. Available from: FsGPYa%2BToEoLjuhFnUEHw%3D%3D 32

33 References Wilsey B, Marcotte T, Deutsch R, et al. Low dose vaporized cannabis significantly improves neuropathic pain. J Pain Feb;14(2): Devinsky O, Cross JH, Laux L, et al. Trial of cannabidiol for drug resistant seizures in the Dravet syndrome. N Engl J Med. 2017; 376: Wilsey B, Marcotte T, Deutsch R, et al. Low dose vaporized cannabis significantly improves neuropathic pain. J Pain Feb;14(2): Abrams DI, Couey P, Shade SB, et al. Cannabinoid opioid interaction in chronic pain. Clin Pharmacol Ther Dec;90(6): Cannabis In Cachexia Study. Comparison of orally administered cannabis extract and delta 9 tetrahydrocannabinol in treating patients with cancer related anorexia cachexia syndrome: a multicenter, phase III, randomized, double blind, placebo controlled clinical trial from the Cannabis In Cachexia Study Group. J Clin Oncol (21): p Tashkin DP, Shapiro BJ, Lee YE, Harper CE. Effects of smoked marijuana in experimentally induced asthma. Am Rev Respir Dis Sep;112(3): Williams SJ, Hartley JP, Graham JD. Bronchodilator effect of delta1 tetrahydrocannabinol administered by aerosol of asthmatic patients. Thorax Dec; 31(6): Machado Rocha FC, et al. (2008), Therapeutic use of Cannabis sativa on chemotherapy induced nausea and vomiting among cancer patients: systematic review and meta analysis. European Journal of Cancer Care, 17: Söderpalm H, et al(2001). Antiemetic efficacy of smoked marijuana: subjective and behavioral effects on nausea induced by syrup of ipecac. Pharmacology, biochemistry, and behavior Geke A.H et al. Tetrahydrocannabinol for neuropsychiatric symptoms in dementia Neurology May 2015, Lotan et al. Cannabis (Medical Marijuana) Treatment for Motor and Non Motor Symptoms of Parkinson Disease: An Open Label Observational Study. Clinical Neuropharmacology: March/April ( 2) State Marijuana Laws in 2017 Map. Governing: The States and Localities. Accessed 2017 Jul. Available from: marijuana laws map medical recreational.html Office of the Deputy Attorney General, US Department of Justice. August 29, Guidance to US attorneys regarding marijuana enforcement. 33

Medical Marijuana and its Use in Hospice and Palliative Care

Medical Marijuana and its Use in Hospice and Palliative Care Terri Maxwell PhD, APRN VP, Clinical Education Enclara Pharmacia Play the 2018 Conference Post to Win Game for a chance to win different prizes