A Longitudinal Observational Study of Medical Cannabis Use and Polypharmacy among Patients Presenting to Dispensaries in Pennsylvania.

BACKGROUND: Cannabis use is increasing among adults to treat a variety of health conditions. Given the potential for interactions and adverse events, it is important to assess the use of medical cannabis along with other concomitant medications when assessing for polypharmacy. METHODS: The objective of this observational, longitudinal study was to examine medical cannabis (MC) use along with concomitant medications over 12 months in patients with serious medical conditions enrolled in the Pennsylvania (PA) Department of Health's (DOH) Medical Marijuana Program and to collect and catalog which forms of MC patients are taking along with their concomitant medications. RESULTS: There were 213 participants who completed the baseline surveys in full, and 201, 187, and 175 who completed the 1, 6, and 12-month follow-up surveys. The mean age of the participants was 41.3 years, and 54.5% were female. The mean number of MC products taken at baseline was 3.41 and 3.47 at the 12-month survey. Participants took an average of 3.76 (SD 3.15) medications at baseline and 3.65 (SD 3.4) at 12 months. Most commonly used concomitant medications at baseline included vitamins (42.3%), antidepressants (29.1%), analgesics (22.1%), herbal products (19.7%), and anxiolytics (17.8%). CONCLUSION: Participants used multiple medical cannabis products to treat a number of medication conditions in conjunction with multiple medications.

Clinician Attitudes, Training, and Beliefs About Cannabis: An Interprofessional Assessment.

Background: Medical use of cannabis is growing in popularity across the United States, but medical education and clinician comfort discussing cannabis use for medical purposes have not kept pace. Materials and Methods: A total of 344 clinicians in the state of Pennsylvania (response rate 14%) completed a brief online survey about their attitudes, training, and experiences regarding medical cannabis and certifying patients to use medical cannabis. Results: Only 51% of clinicians reported completing any formal training on medical cannabis. Compared with noncertifying clinicians (pharmacists, nurse practitioners, and physician assistants), physicians were significantly more comfortable with patient use of medical cannabis, saw fewer risks, more benefits, and felt better prepared to discuss its use with vulnerable populations. All clinicians noted significant limitations to their understanding of how medical cannabis can affect patients, and many indicated a desire for more research and training to fill in gaps in their knowledge. Conclusions: Insufficient medical curricula on the medical uses of cannabis are available to interprofessional clinicians across their disciplines, and clinicians report significant deficits in their knowledge base about its effects. Additionally, these data suggest an urgent need to expand training opportunities to the full spectrum of clinicians as all are involved in caring for patients who use medical cannabis.

Characterizing anxiety, pain, sleep, and quality of life among patients in a state Medical Marijuana Program.

BACKGROUND: Cannabis is increasingly used for symptom management, but its effects on health-related quality of life (QoL) have been inconclusive. OBJECTIVES: The goal of the present study was to characterize self-reported symptoms and QoL among patients certified to use medical cannabis. METHODS: These data are from the baseline assessment of a 12-month longitudinal study. The survey assessed certifying conditions, current medications, symptoms and symptom severity. QoL was assessed using the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) which includes Physical Well-Being (PWB), Social/Family Well-Being (SWB), Emotional Well-Being (EWB), Functional Well-Being (FWB), and the Palliative Care subscale. Higher scores indicated better QoL. RESULTS: Overall, 210 patients (114 female, 92 male, 3 non-binary, 1 refused) completed the survey. The most common certifying conditions were pain (48.6%), anxiety (36.7%), and PTSD (15.7%) and the most common symptoms were anxiety (65.2%), pain (56.7%), sleep disturbance (38.6%), and depression (31.4%). Compared to normative data, this sample reported lower QoL, specifically EWB and SWB scores (i.e., T-Scores<45). Opioid/benzodiazepine/sedative-hypnotic use was associated with lower QoL on all subscales (except SWB and FWB) (ps < 0.05). Greater number of self-reported symptoms and medical conditions were associated with lower QoL (ps < 0.01). CONCLUSION: Despite mixed evidence regarding cannabis' efficacy for anxiety, 36.7% of the current sample were certified by a physician for anxiety. Lower QoL was associated with more self-reported comorbid medical conditions, higher total symptom count, and reported use of an opioid and/or benzodiazepine. Future longitudinal data will provide critical information regarding the trajectory of these symptoms and QoL.

Cannabis Use in Patients With Cancer: A Clinical Review.

Cannabis use and interest continues to increase among patients with cancer and caregivers. High-quality research remains scant in many areas, causing hesitancy or discomfort among most clinical providers. Although we have limitations on hard outcomes, we can provide some guidance and more proactively engage in conversations with patients and family about cannabis. Several studies support the efficacy of cannabis for various cancer and treatment-related symptoms, such as chemotherapy-induced nausea and cancer pain. Although formulations and dosing guidelines for clinicians do not formally exist at present, attention to tetrahydrocannabinol concentration and understanding of risks with inhalation can reduce risk. Conflicting information exists on the interaction between cannabis and immunotherapy as well as estrogen receptor interactions. Motivational interviewing can help engage in more productive, less stigmatized conversations.

A Failure to Guide: Patient Experiences within a State-Run Cannabis Program in Pennsylvania, United States.

INTRODUCTION: Medical cannabis has been available for purchase in dispensaries in Pennsylvania, United States since April 2018. Patients wanting to access medical cannabis must receive certification from physicians for a limited number of physical and psychological conditions. Despite increasing numbers of patients using cannabis in the United States, little is known about the patient experience during certification and entry into state-regulated cannabis programs and how and if they are guided by health care professionals and dispensary staff. Through focus group discussions, we sought to capture patient perspectives of certification, cannabis acquisition and cannabis use. METHODS: Twenty-seven Pennsylvania participants took part in 7 virtual focus groups from June to July 2020. Participants were recruited statewide from the community, medical settings, and dispensaries. RESULTS: Focus group results indicate that while the medical cannabis program is functional, policymakers and the medical community have failed to meaningfully integrate cannabis into the health care system. Participants expressed frustration around two central themes: there was no overarching education about medical use of cannabis and there was little consistency and availability for people once they found a suitable product, resulting in inadequate symptom relief and exorbitant out of pocket costs to pursue cannabis use as an adjuvant therapeutic. Participants noted a siloed experience between the certification process, accessing dispensaries, and receiving ongoing medical care. The lack of integrated care required high levels of self-reliance and experimentation with medical cannabis for participants. CONCLUSION: We recommend that cannabis be better integrated into medical care for patients with qualifying conditions.

Polypharmacy in the Geriatric Oncology Population.

PURPOSE OF REVIEW: This review explores the multiple definitions, epidemiology, and impact of polypharmacy in geriatric oncology patients. Risk factors and clinical implications of polypharmacy are delineated and potential clinical approaches to reduce polypharmacy are reviewed. RECENT FINDINGS: Most sources currently define polypharmacy as the administration of multiple medications that are non-essential, unnecessary, duplicative, or ineffective. Possible risk factors associated with polypharmacy in geriatric cancer patients include comorbid conditions, prescribing cascades, and hospitalization. Consequences of polypharmacy in this population include adverse drug events, drug-drug interactions, reduced adherence, frailty, and increased morbidity. Clinical approaches to the reduction of polypharmacy include thorough medication histories and an interprofessional team approach to care. Polypharmacy is common and has a direct clinical impact on geriatric oncology patients. There is a clear deficit in our understanding of the scope and impact of polypharmacy in this population and only limited evaluation of various interventions exist. The paucity of information is at least partially linked to the consistent exclusion of older adults in cancer studies and the complex interaction between polypharmacy and potential morbidities/mortality.

Deprescribing: A simple method for reducing polypharmacy.

Polypharmacy brings with it increased risks for adverse drug events and reduced functional capacity. This 4-step plan will help you safely deprescribe in older adults.

Implementing a pharmacist-led, individualized medication assessment and planning (iMAP) intervention to reduce medication related problems among older adults with cancer.

OBJECTIVES: Medication-related problems (MRP) affecting older adults are a significant healthcare concern and account for billions in medication-related morbidity. Cancer therapies can increase the prevalence of MRP. The objective of this study was to test the feasibility and effectiveness of implementing a pharmacist-led individualized medication assessment and planning (iMAP) intervention on the number and prevalence of MRP. MATERIALS AND METHODS: This prospective pilot study enrolled oncology outpatients aged ≥65years. Intervention feasibility encompassed recommendation acceptance rate and intervention delivery time. The intervention was facilitated by pharmacists where patients received comprehensive medication management at baseline and at the 30- and 60-day follow-up. RESULTS: Forty-eight eligible patients enrolled and 41 patients (85.4%) were included in the analysis. Mean age was 79.1years [range 65-101]; 66% women, 83% Caucasian, mean comorbidity count was 7.76. Forty-six percent of the pharmacist recommendations were accepted and the prevalence of MRP at baseline versus 60-day follow-up decreased by 20.5%. The average time to conduct the initial session was 22min versus 15min for the follow-up sessions. Resources needed included a tracking system for scheduling follow-up calls and a database for tracking acceptance of recommendations. A total of 123 MRP were identified in 95% of patients (N=39) with a mean of 3 MRP per patient. The mean reduction in number of MRP (3 at baseline versus 1.6 at 60-day follow-up) was 45.5%. CONCLUSIONS: The pharmacist-led iMAP intervention was feasible and effective at reducing MRP. Additional inter-professional medication safety based interventions measuring patient-reported outcomes are still needed.

Sequencing of Simulation and Clinic Experiences in an Introductory Pharmacy Practice Experience.

Objective. To examine how the intrasemester sequencing of a simulation component, delivered during an ambulatory care introductory pharmacy practice experience (IPPE), affects student performance on a series of 3 assessments delivered during the second professional (P2) year. Design. At the Jefferson College of Pharmacy (JCP), P2 student pharmacists were randomly assigned to 6 weeks of simulation activities, followed by 6 weeks on site at an ambulatory care clinic or vice versa during either the fall or spring semesters. At the end of each semester, these students completed 3 skills-based assessments: answering a series of drug information (DI) questions; conducting medication adherence counseling; and conducting a medication history. The 2 groups' raw scores on assessment rubrics were compared. Assessment. During academic years 2011-2012 and 2012-2013, 180 P2 student pharmacists participated in the required ambulatory care IPPE. Ninety experienced simulation first, while the other 90 experienced the clinic first. Students assessed over a 2-year time span performed similarly on each of 3 skills-based assessments, regardless of how simulation experiences were sequenced within the IPPE. Conclusion. The lack of significant difference in student performance suggests that schools of pharmacy may have flexibility with regard to how they choose to incorporate simulation into clinical ambulatory care IPPEs.

A pharmacist-led medication assessment used to determine a more precise estimation of the prevalence of complementary and alternative medication (CAM) use among ambulatory senior adults with cancer.

OBJECTIVES: The prevalence of complementary and alternative medication (CAM) use in senior adult oncology (SAO) patients is widely variable and little is known about whether polypharmacy (PP) and potentially inappropriate medication (PIM) use influences CAM use given the increased number of comorbidities and polypharmacy. One approach to optimize medication management is through utilization of pharmacists as part of a team-based, healthcare model. MATERIALS AND METHODS: Prevalence of CAM and factors influencing CAM use was examined in a secondary analysis of 248 patients who received an initial comprehensive geriatric oncology assessment between January 2011 and June 2013. Data was collected from electronic medical records. CAM was defined as herbal medications, minerals, or other dietary supplements, excluding vitamins. Patient characteristics influencing CAM use (e.g. comorbidities, PP and PIM use) were analyzed. RESULTS: Only 234 patients (evaluated by pharmacists) were included in the final analysis. Mean age was 79.9 years [range 61-98]; 64% women, 74% Caucasian, 87% with a solid tumor, mean comorbidities, 7.69. CAM prevalence was 26.5% (n=62) and median CAM use was 0 (range 0-10). The proportion of CAM use (1, 2, and 3) was 19.2%, 6.4%, and 0.4%, respectively. Associations with CAM use (versus no-CAM) were polypharmacy (P=0.045), vision impairment (P=0.048) and urologic comorbidities (P=0.021). CONCLUSIONS: A pharmacist-led comprehensive medication assessment demonstrated a more precise estimation of CAM prevalence in the ambulatory SAO population. CAM use was associated with polypharmacy, ophthalmic and urologic medical conditions. Integrating pharmacists into team-based (geriatric and oncology) care models is an underutilized yet viable solution to optimize medication use.

Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer.

PURPOSE: The use of multiple and/or inappropriate medications in seniors is a significant public health problem, and cancer treatment escalates its prevalence and complexity. Existing studies are limited by patient self-report and medical record extraction compared with a pharmacist-led comprehensive medication assessment. PATIENTS AND METHODS: We retrospectively examined medication use in ambulatory senior adults with cancer to determine the prevalence of polypharmacy (PP) and potentially inappropriate medication (PIM) use and associated factors. PP was defined as concurrent use of five or more and less than 10 medications, and excessive polypharmacy (EPP) was defined as 10 or more medications. PIMs were categorized by 2012 Beers Criteria, Screening Tool of Older Person's Prescriptions (STOPP), and the Healthcare Effectiveness Data and Information Set (HEDIS). RESULTS: A total of 248 patients received a geriatric oncology assessment between January 2011 and June 2013 (mean age was 79.9 years, 64% were women, 74% were white, and 87% had solid tumors). Only 234 patients (evaluated by pharmacists) were included in the final analysis. Mean number of medications used was 9.23. The prevalence of PP, EPP, and PIM use was 41% (n = 96), 43% (n = 101), and 51% (n = 119), respectively. 2012 Beers, STOPP, and HEDIS criteria classified 173 occurrences of PIMs, which were present in 40%, 38%, and 21% of patients, respectively. Associations with PIM use were PP (P < .001) and increased comorbidities (P = .005). CONCLUSION: A pharmacist-led comprehensive medication assessment demonstrated a high prevalence of PP, EPP, and PIM use. Medication assessments that integrate both 2012 Beers and STOPP criteria and consider cancer diagnosis, prognosis, and cancer-related therapy are needed to optimize medication use in this population.

Clinical consequences of polypharmacy in elderly.

INTRODUCTION: Polypharmacy, defined as the use of multiple drugs or more than are medically necessary, is a growing concern for older adults. MEDLINE and EMBASE databases were searched from January 1, 1986 to June 30, 2013) to identify relevant articles in people aged > 65 years. AREAS COVERED: We present information about: i) prevalence of polypharmacy and unnecessary medication use; ii) negative consequences of polypharmacy; and iii) interventions to improve polypharmacy. EXPERT OPINION: International research shows that polypharmacy is common in older adults with the highest number of drugs taken by those residing in nursing homes. Nearly 50% of older adults take one or more medications that are not medically necessary. Research has clearly established a strong relationship between polypharmacy and negative clinical consequences. Moreover, well-designed interprofessional (often including clinical pharmacist) intervention studies that focus on enrolling high-risk older patients with polypharmacy have shown that they can be effective in reducing aspects of unnecessary prescribing with mixed results on distal health outcomes.

Polypharmacy, adverse drug reactions, and geriatric syndromes.

The elderly are at risk for polypharmacy, which is associated with significant consequences such as adverse effects, medication nonadherence, drug-drug and drug-disease interactions, and increased risk of geriatric syndromes. Providers should evaluate all existing medications at each patient visit for appropriateness and weigh the risks and benefits of starting new medications to minimize polypharmacy.

Polypharmacy and health beliefs in older outpatients.

BACKGROUND: Polypharmacy is a significant problem among older adults. Patient-related characteristics and beliefs have not been the focus of prior research in this area, which has primarily evaluated the effects of patients' health status and health care system factors. OBJECTIVE: The goal of this research was to determine the prevalence and predictors of unnecessary drug use in older veteran outpatients, with a focus on patient-related factors and health beliefs. METHODS: Community-dwelling veterans aged > or =60 years, with > or =5 self-administered medications per day, not cognitively impaired, able to speak and/or write English, and receiving primary care and medications from a large urban Veterans Affairs Medical Center were eligible for study. Assessment of unnecessary drug use was determined by clinical pharmacists applying the criteria of the Medication Appropriateness Index to each regularly scheduled medication. Those drugs that received an inappropriate rating for indication, effectiveness, or therapeutic duplication were defined as unnecessary. Health beliefs regarding medication use were assessed with decisional balance, self-efficacy, and health locus of control scales. RESULTS: A total of 128 veterans (mean [SD] age, 72.0 [8.9] years; 93.0% white; 93.0% male) were enrolled. Analysis showed that 58.6% of patients had > or =1 unnecessary prescribed drug; the most common reason for a medication being considered inappropriate was lack of effectiveness (41.4%). The most commonly prescribed unnecessary drug classes were central nervous system (19.5%), gastrointestinal (18.0%), and vitamins (16.4%). Factors with tendency for association (P < 0.20) with any unnecessary drug use included race (white), income (<$30,000/year), number of prescription medications (mean [SD], 6.8 [2.8]), and lack of belief in a "powerful other" for their health locus of control. CONCLUSIONS: We found a very high prevalence of unnecessary drug use in this older veteran outpatient population. Race, income, and polypharmacy, as well as health-related beliefs, were central factors associated with unnecessary drug use.

Polypharmacy in elderly patients.

BACKGROUND: Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly. OBJECTIVE: The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults. METHODS: Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy. RESULTS: The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy. CONCLUSIONS: Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

Clinically important drug-disease interactions and their prevalence in older adults.

BACKGROUND: Older adults may have decreased homeostatic reserve, have multiple chronic diseases, and take multiple medications. Therefore, they are at risk for adverse outcomes after receiving a drug that exacerbates a chronic disease. OBJECTIVES: The aims of this study were to compile a list of clinically important drug-disease interactions in older adults, obtain the consensus of a multidisciplinary panel of geriatric health care professionals on these interactions, and determine the prevalence of these interactions in a sample of outpatients. METHODS: This analysis included a 2-round modified Delphi survey and cross-sectional study. Possible drug-disease interactions in patients aged > or =65 years were identified through a search of the English-language literature indexed on MEDLINE and International Pharmaceutical Abstracts (1966-July 2004) using terms that included drug-disease interaction, medication errors, and inappropriate prescribing. Nine health care professionals with expertise in geriatrics (2 geriatricians, 7 geriatric clinical pharmacist specialists) were selected based on specialty training and continuing clinical work in geriatrics, academic appointments, and geographic location. The panel rated the importance of the potential drug-disease interactions using a 5-point Likert scale (from 1 = definitely not serious to 5 = definitely serious). Consensus on a drug-disease interaction was defined as a lower bound of the 95% CI > or =4.0. The prevalence of drug-disease interactions was determined by applying the consensus criteria to a convenience sample of frail older veterans at hospital discharge who were enrolled in a health services intervention trial. RESULTS: The panel reached consensus on 28 individual drug-disease interactions involving 14 diseases or conditions. Overall, 205 (15.3%) of the 1340 veterans in the sample had > or =1 drug-disease interaction. The 2 most common drug-disease interactions were use of first-generation calcium channel blockers in patients with congestive heart failure and use of aspirin in patients with peptic ulcer disease (both, 3.7%). CONCLUSIONS: A survey of multidisciplinary geriatric health care professionals resulted in a concise consensus list of clinically important drug-disease interactions in older adults. Further research is needed to examine the impact of these drug-disease interactions on health outcomes and their applicability as national measures for the prevention of drug-related problems.

Incidence and predictors of all and preventable adverse drug reactions in frail elderly persons after hospital stay.

BACKGROUND: Adverse drug reactions (ADR) negatively impact life quality and are sometimes fatal. This study examines the incidence and predictors of all and preventable ADRs in frail elderly persons after hospital discharge, a highly vulnerable but rarely studied population. METHODS: The design was a prospective cohort study involving 808 frail elderly persons who were discharged from 11 Veteran Affairs hospitals to outpatient care. The main outcome measure was number of ADRs per patient as determined by blinded geriatrician and geropharmacist pairs using Naranjo's ADR algorithm. For all ADRs (possible, probable, or definite), preventability was assessed. Discordances were resolved by consensus conferences. RESULTS: Overall, 33% of patients had one or more ADRs for a rate of 1.92 per 1000 person-days of follow-up. The rate for preventable ADRs was 0.71 per 1000 person-days of follow-up. Independent risk factors for all ADRs were number of medications (adjusted [Adj.] hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.05-1.10 per medication), use of warfarin (Adj. HR, 1.51; 95% CI, 1.22-1.87), and (marginally) the use of benzodiazepines (Adj. HR, 1.23; 95% CI, 0.95-1.58). Counterintuitively, use of sedatives and/or hypnotics was inversely related to ADR risk (Adj. HR, 0.14; 95% CI, 0.04-0.57). Similar trends were seen for number of medications and warfarin use as predictors of preventable ADRs. CONCLUSIONS: ADRs are very common in frail elderly persons after hospital stay, and polypharmacy and warfarin use consistently increase the risk of ADRs.

Unnecessary drug use in frail older people at hospital discharge.

OBJECTIVES: To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients. DESIGN: Cross-sectional. SETTING: Eleven Veterans Affairs Medical Centers. PARTICIPANTS: Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study. MEASUREMENTS: Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary. RESULTS: Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38-0.96), multiple prescribers (AOR=3.35, 95% CI=1.16-9.68), and nine or more medications (AOR=2.24, 95% CI=1.25-3.99). CONCLUSION: A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem.