Pubdate: Sat, 13 Jul 2019 Source: Wall Street Journal (US) Copyright: 2019 Dow Jones & Company, Inc. Contact: http://www.wsj.com/ Details: http://www.mapinc.org/media/487 Author: Amanda Chicago Lewis HELPING SENIORS FIND THE RIGHT POT RX The waiting room at NiaMedic Healthcare & Research Services looked just like every other doctor's office at the Saddleback Medical Center in California's Laguna Hills: unflattering overhead lighting, landscape paintings and a smiling person in scrubs behind the reception desk. It was the ideal location to attract NiaMedic's target demographic: seniors. Saddleback is nestled in the rolling hills of a region surrounded by at least 15 retirement communities, including the over 18,000-resident Laguna Woods Village. But the patients who come through NiaMedic's doors generally start with the same question: Can marijuana help? "The short answer is yes," said Alon Blatt, NiaMedic's director of business development. "The constant pain, the arthritis, the fatigue, the trouble sleeping, the anxiety-we see cannabis help with all of these." As legalization of cannabis has spread across the country, the stigma and suspicions around using marijuana for therapeutic purposes have begun to fade-even among older people. Eleven states allow anyone over 21 to purchase pot and another 22 permit medical use with a physician's recommendation. Between 2006 and 2013, the percentage of those over 65 reporting cannabis use in the past year rose nationally to 3% from 0.4%, according to a study published in 2017 in the journal Addiction, while the rates among people aged 50 to 64 rose to 9% from 2.8%. Although marijuana use is still much more common among millennials, older folks represent a growing portion of consumers, a trend that cannabis investors hope will continue as more baby boomers retire. According to BDS Analytics, a market research firm for the cannabis industry, 18% of marijuana users nationwide are baby boomers; in states with legal, adult-use markets, 21% of boomers have consumed cannabis in the past six months. But in the quasi-legal, for-profit medical weed industry, where peer-reviewed clinical studies are scarce and federal prohibition has prevented the Food and Drug Administration from providing much oversight, there are no clear guidelines on how many milligrams and which mix of cannabis compounds might work best for any given ailment. Most research involves mice instead of humans. Medical students rarely get taught about the potential benefits of cannabis. Many doctors are reluctant to suggest marijuana to their patients. Those who do risk losing federal research funding or the license to study and prescribe other controlled substances. Filling the void is a cottage industry of cannabis-friendly doctors, ready to give patients with a qualifying condition the go-ahead to enter a pot store. At dispensaries, salespeople often take on the task of advising sick people on what and how much to take. Businesses must avoid making claims about weed's ability to cure or treat a disease, rendering the whole process a confusing dance for the patient, supported by little solid information and requiring trial and error. That's where NiaMedic comes in. Their clinics aim to offer something unusual and particularly appealing to seniors and their caregivers: an evidence-based bridge between the scientists doing marijuana research and the consumers buying legal marijuana. The company does not sell its own marijuana or have a financial interest in the businesses that do. Instead, NiaMedic offers customized cannabis treatment plans based on the few clinical trials that have been done on cannabis as well as the company's own internal data from over 10,000 patients, going back nearly a decade. Founded outside Tel Aviv in 2016, NiaMedic now has about a dozen medical staff members at three clinics worldwide-two in Israel and one in Beverly Hills. (The Laguna Woods location's lease expired but it's set to reopen in a nearby town.) NiaMedic expects to open several more U.S. clinics in the next year, including on the East Coast, and has begun to offer video consultations. "Within five to 10 years, we're going to see cannabis in every ambulance: for stroke, for heart attack, for all kinds of things," Mr. Blatt said. "Right now, we're sitting on a jet engine, but we're still on the runway going 10 miles an hour." At the U.S. clinics, doctors see six to 10 patients a day. They try to help people manage an array of diseases, medications and complaints while avoiding a disorienting "high." Doctors and nurses test patients' balance. They ask about diet. They talk about the patient's home, and suggest getting rid of carpets and rugs, because older people tend to drag their feet, and carpets can lead to falls. If someone has a history of certain severe cardiac or psychiatric issues, NiaMedic's doctors won't recommend cannabis. NiaMedic said an internal study covering just over 100 elderly cases shows that 93.8% of patients "reported improvement in their condition," and more than half stopped using opioids or other painkillers. "I never wanted to try any of this stuff. I was very skeptical,'" said Mary Perini, 58, who was referred to NiaMedic in December by a doctor at Los Angeles's Cedars-Sinai medical center, for severe chronic pain from two car accidents. "Since getting on NiaMedic, I've been able to walk with my walker down the block and back, and I haven't been able to do that for years," she said. Dr. Benjamin Han, a geriatrician and assistant professor at the NYU School of Medicine, said he began hearing questions from his patients about medical marijuana about five years ago. "The two main things are pain and sleep," Dr. Han said. "The problem is that we really don't have much research in this area." For decades, marijuana's illegality has made doing clinical trials on the plant's medical benefits nearly impossible. The little research that exists about cannabis and its compounds-such as tetrahydrocannabinol (THC), which gets you high, or the non-intoxicating cannabidiol (CBD)-has mostly been done in animals or overseas. Much of the medical advice about marijuana, from dosage to strain to delivery method, is not based on rigorous studies in humans. While prescription drugs must be approved by the FDA, the federal prohibition against pot means the cannabis industry operates in a grey area, and is therefore harder to hold to any medical standards. Some states have tightly regulated medical marijuana markets, but there are also marijuana oils that claim to cure cancer and dispensary workers known as "budtenders" who could suggest something that results in a two-day high. NiaMedic says it is one of only a handful of organizations and businesses that have amassed enough private data to provide medical cannabis patients with detailed recommendations. The company's co-founder, Inbal Sikorin, began treating patients with marijuana about a decade ago, as the head nurse at a nursing home on the Kibbutz Na'an near Rehovot, Israel. (She said she was inspired by a documentary about Raphael Mechoulam, the Israel-based scientist who discovered in 1964 that THC is the cannabinoid that causes a "high.") Medical marijuana had been legal in Israel since 1994, though access only began to expand significantly in 2002. After partnering with one of Israel's licensed medical-cannabis growers, Tikun Olam, in 2010, Ms. Sikorin began tracking her patients' outcomes, collecting information that led to the system of protocols that her company uses today. "We're not claiming to cure any diseases. We're trying to manage the symptoms, to improve quality of life," said Mr. Blatt. "The bulk of the work is case management." After the initial appointment, the patient or caregiver will go to a local dispensary to purchase products with the recommended strength and mixture of ingredients. (NiaMedic keeps tabs on which local shops have what products to better advise patients about what is available, but it does not refer them to specific dispensaries.) NiaMedic's nurses then spend about a month checking in with patients over the phone and slowly toggling the dosage and delivery method of the cannabis until the patient's treatment goals are achieved. Many of the older patients are afraid of feeling stoned, so NiaMedic's recommendations typically cover relatively low doses of THC, as well as non-intoxicating cannabinoids like CBD, and the plant's many other compounds, provided they are available at dispensaries. Only 6% of their patients report feeling light-headed, or high, the company said. Access to this kind of service, and to medical cannabis in general, remains out of reach for most seniors. Consultations with NiaMedic cost $350. Patients with Medicare pay only $100 out-of-pocket for the cannabis portion of the appointment. A similar consultation with a data-oriented medical cannabis company in California called Calla Spring Wellness costs $200 or $300, depending on whether you speak with a doctor or a nurse. Marijuana products themselves might cost about $50 a month, and are not covered by insurance. In places with wealthier aging populations, some pot firms have been eager to market to older people. Trulieve, which has 29 medical marijuana shops in Florida, says its average customer is over 50. The company often holds educational events at assisted living homes and opened a call center to connect with seniors offline. "They want that human interaction, rather than just opening a laptop," says Trulieve Chief Executive Kim Rivers. To help patients better determine what to buy and how much to take, the company encourages them to consult with their doctors and to keep a diary of what products they took, how they felt and how that changes. Trulieve also created a portal where doctors who write cannabis recommendations can browse medical journal articles about marijuana's effects. NYU's Dr. Han remains apprehensive about the limited nature of existing research. Seniors around the country might be experimenting with cannabis and becoming too intoxicated, he said. "A lot of what I do as a geriatrician is taking care of old people who have many chronic diseases, probably take a lot of medicines, and are really vulnerable to the adverse effects. A common thing [for older patients trying marijuana] is they get dizzy," he said. "That makes me worried. Could this be associated with falls?" Other people who work with seniors expressed concern that in the absence of accurate dosage information, cannabis businesses have a financial incentive to recommend a patient take a higher dose than they might actually need. "One does not want to leave it to an individual or a dispensary to determine how much THC or CBD a person is taking," said Daniel Reingold, the president of Hebrew Home at Riverdale, an assisted living facility in New York City. Mr. Reingold decided to allow cannabis on premises after the state legalized medical marijuana use in 2014. Now, about a dozen of his 735 residents have obtained medical marijuana recommendations, and all have seen some benefit, he said. But it's not ideal: "Scientific data needs to be available and promulgated and disseminated so practitioners can know how to use the drug to help people," he said. Many older folks remain uncomfortable with the drug and with breaking federal law, even if weed has been legalized in their state. "People over 55 still have the largest percentage of what we'd call cannabis rejecters: they don't consume, nor are they open to it," said Jessica Lukas, vice president of consumer insights at BDS Analytics. That "rejecter" percentage is higher among African-American and Hispanic populations, said Sue Taylor, a retired Catholic-school principal turned cannabis activist for the elderly. "That's who they incarcerate first, and they don't forget it. Many of them will not touch it still because it's federally illegal." Ms. Taylor plans to open a senior-oriented pot shop and education center in Berkeley, Calif., in the next few months, across from a clinic for people over 60. Several marijuana companies are partnering with universities and researchers to make some of their information public. Dr. Han, for example, has done research using patient data from a multi-state medical marijuana company called Columbia Care. Mr. Reingold of Hebrew Home said that as more states legalize marijuana and evidence-based protocols like the ones developed by NiaMedic proliferate, medical marijuana use among seniors will become more common. "It's no longer being viewed with the same stigma," Mr. Reingold said. "This is going to be a very big part of the baby boomer experience."