Yesterday I attended a meeting put on by one of our local assisted living organizations. The topic was CBD. I was pretty stoked to attend. I have been following the explosive growth of cannabis, and more specifically the CBD industry for a while and am somewhat familiar with the industry. As an assisted living home owner, I am very interested to see how this product is used in the industry and understanding the potential benefit for our residents. Here are some of my thoughts on CBD usage by care home residents.
CBD – A Miracle Cure?
There is a tremendous amount of CBD marketing out there now that make all sorts of claims about the therapeutic benefits of CBD. I take some issue with this notion. Due to intense regulation, cannabis and CBD study has been severely limited. Thankfully, this is changing now. But I remain skeptical of some claims that are based on antidotal evidence. There are indeed studies that indicate CBD provides relief for anxiety. Epidiolex is an approved drug containing CBD which reduces seizures. But treating cancer, Alzheimer’s disease, opioid withdrawal, pain and pet anxiety, increasing women’s libido? Not so much. These claims all have drawn warnings from the FDA when stated to promote CBD products.
There is reason for optimism and hope that cannabinoids can provide great therapeutic benefit. Discussing the endocannabinoid system, full spectrum CBD, terpenes, and the entourage effect is beyond the scope of this article. But needless to say, there is a lot to learn and much more research to be done. The efficacy of CBD for many of the conditions that it is currently marketed for remains unproven.
CBD and Assisted Living Residents
CBD may very well prove to provide therapeutic benefits for our residents. But, like any other product, we need to be informed about its benefits and risks. We also need to engage the resident’s entire care team to ensure its usage is appropriate for our residents.
It remains to be seen how regulatory agencies will ultimately handle CBD in an assisted living facility. Right now it seems that they are taking a wait and see approach towards CBD and not creating any new rules or regulations to address it in care homes. This may change in the future.
Our care home residents generally have at least one, if not many diagnosed conditions that are being managed by a healthcare team. Many, if not all, require a regimen of medications. It’s very important that we understand any potential interactions between these medications and CBD before administering CBD for a therapeutic benefit.
CBD is a Potent Inhibitor of CYP3A4 and CYP2D6
The majority of prescription drugs are metabolized by the body through enzymes in the liver. These enzymes are cytochrome P450, or CYP450. CYP3A4 and CYP2D6 are both members of the cytochrome P450 family of oxidizing enzymes. These are the same enzymes that metabolize CBD. There is research that suggests that CBD is an inhibitor for these enzymes.
As CYP3A4 metabolizes about a quarter of all drugs, CBD may increase serum concentrations of macrolides, calcium channel blockers, benzodiazepines, cyclosporine, sildenafil (and other PDE5 inhibitors), antihistamines, haloperidol, antiretrovirals, and some statins (atorvastatin and simvastatin).
CYP2D6 metabolizes many antidepressants, so CBD may increase serum concentrations of SSRIs, tricyclic antidepressants, antipsychotics, beta blockers and opioids (including codeine and oxycodone)
So, what does this mean for elderly populations in assisted living?
Let’s say a resident is taking Warfarin or Coumadin to prevent blood clots. If CBD were also taken, the research suggests that the metabolism by CYP450 of the medication could be impeded and therefore lead to increased active levels of the drug in the body. The risks here are toxicity and increased possibility of dangerous bleed or hemorrhage. In addition, if your care team is trying to stabilize a resident’s INR you can see how CBD usage can be problematic.
Another common medication in the assisted living population is Xanax or Ativan. These are often prescribed for anxiety. CBD, taken in conjunction with this drug, can have the same effect. Increased amounts of the active components of these benzodiazepines can amplify the side effects including increased drowsiness and sedation.
We all know about the grape fruit rule. Harvard Medical School reports that grapefruit inhibits the same set of liver enzymes that CBD blocks. So, like grapefruit juice, CBD can boost levels of other medications in your blood.
As assisted living managers and operators, I suggest that we do our best to separate marketing hype from facts and research regarding CBD. For the average person in good health, CBD may be harmless to experiment with in order to determine if there is any therapeutic benefit. But in the assisted living world, things get a bit more complicated. There is a higher likelihood of adverse effects on existing conditions for your residents.
If you have a family member who is interested in exploring the option of CBD therapy for a resident in your home, I suggest you and the family explore the option with the primary care provider. I would also ensure that if a CBD regimen is pursued, that you obtain a prescription from the PCP and carefully document your observations in your progress notes.