The world has increasingly recognized the therapeutic benefits of cannabis. This is especially true in the U.S. among mature adults who move to it for pain relief, sleep aid and to enhance appetites after chemotherapy treatments, among other reasons. The growth of CBD dispensaries throughout the U.S. has only made access to cannabis easier than ever, allowing those in need to skirt working with physicians to secure medical cannabis prescriptions. That’s where the rub comes in. Self-medicating can have its risks, particularly for older adults who may already be taking multiple prescriptions. Thankfully, Dr. Leigh Vincor, a nationally recognized expert on medical cannabis and member of the Society of Cannabis Clinicians, spoke with WellWell recently on the mixed bag of challenges and risks older adults face as they look to cannabis for therapeutic help.
Cannabis will be a $45 billion industry by the end of 2025. How has this growth impacted the perception of cannabis?
I think that there is this perception now as acceptance and some of the stigma has gone away. When you look at other substances like alcohol and tobacco, which probably cause more deaths than cannabis, I think there is this perception that it’s completely safe. And that’s not true of any medicine or any substance. There’s always a risk-benefit. It was the 16th-century Swiss physician, Paracelsus who said, “The dose makes the poison.” So, you can take in too much water and it can kill you. I’ve seen the benefits; I take it seriously and treat it like a medication. So, there’s nothing that’s 100 percent safe.
Does the public largely understand the difference between recreational cannabis and medical cannabis?
There was a Pew Research survey that said Americans largely favor the legalization of cannabis. In fact, 57 percent said it should be legal for both medical and recreational use. But I don’t know that there is that distinction. Certainly, as a physician, I have that distinction as I recommend it to patients. And I do worry in a lot of these states that once legalization came about people might start to self-medicate and not talk to a medical professional before trying to use cannabis in that way.
Is it more difficult to monitor the impact of use because it’s so widespread? Specifically, those self-medicating?
I think if we look at Colorado, which was one of the first states to pass the legalization of cannabis in 2012, they did see a slight decrease in their medical registration because there’s a cost to medical registration and follow-up with physicians and such. Then the medication costs something, too. So, I think theirs went down from 110 to like eight hundred and 11,000 registered medical patients to 81,000. As a physician, I get to know the patients I’m seeing I used to weed them out to see if they were just trying to get a medical license because they wanted to use cannabis recreationally. Every young person who worked in one of our medical dispensaries had some kind of medical problem and somehow got a license. I was very picky about who I recommended to get a license. I mostly get referrals now from physicians and most of my patients are ill and need it. We monitor it in this state because there are registered patients and every state knows who’s medically registered, but certainly, there is a group of patients that self-medicate.
As a physician, that’s a little worrisome for me. I think there was a study that came out that said 54 percent of customers that come into dispensaries will ask the dispensary staff medical questions on selecting products and how to use them, while only 3 percent of those patients had talked to their physician and got input from medical professionals. So, I think that’s worrisome. But part of it is the onus on us as medical physicians who don’t train that much in medical cannabis. Even to this day, an older study from the American Association of Medical Colleges said only nine to 10 percent of colleges are teaching the endocannabinoid system, teaching about cannabis and two-thirds of medical students were saying they felt unprepared to deal with patients when they come out. We need to do a lot more education within the medical community so that they understand therapeutic medical cannabis science and the therapeutics they can provide.
If I need medical cannabis, how am I getting it?
Each state had its laws when they passed adult medical cannabis legislation first, which predated almost every state that has adult use now. So, there are agencies in Maryland that used to be called the Maryland Medical Cannabis Commission. Now it’s the Medical Cannabis Administration because they oversee both adult use and medical. But at the time you find a provider that’s registered. Sometimes primary care providers will recommend and certify patients if they’re familiar with it, but a lot of them will say you have to go to the website and find a provider. The Society for Cannabis Clinicians has lists in each state of providers that are doing it. And then you go and apply for a card and register. And in Maryland, we did it a little bit differently. There were already all these medical dispensaries that had been certified and under some strict stringent rules about dosing and packaging, which are critical and important if you’re going to use it therapeutically. And then when we passed and it was a referendum that the public voted on, so the public wanted it for adult use rather than scramble as some states have had.
These adult-use recreational dispensaries suddenly could sell to regular consumers for adult use. However, precedence still took for the medical patients. There were certain times when only medical patients could be served in dispensaries and different lines were set up. But as a physician too, I do worry that perhaps the products being made, especially dispensaries that have three verticals that have growing and processing and a dispensary, they’re going to start to cater more to adult use and using cannabis for recreation. I’m a firm believer that the dose makes the poison. We’re seeing higher and higher percentages of THC and cannabis and such—and not some of the other ingredients that can temporize like cannabidiol, some of the mitigates, some of the intoxicating effects and some of the other physiologic effects.
How can consumers ensure they’re getting reliable guidance on medical cannabis interactions, especially when comparing advice from dispensary staff versus pharmacists?
Maryland did have a law with all the dispensaries and there’s no distinction now between them, but the dispensaries that were approved during medical do have to have a clinical advisor on staff. Usually, that is a pharmacist who has some understanding and training in medical cannabis science and therapeutics. The University of Maryland School of Pharmacy, where I got my master’s degree, was one of the first in the country to have an actual master’s in medical cannabis science and therapeutics. So, in Maryland, I think we have a little bit more safety measures there because these are the same dispensary. So, if somebody was coming in and wanted to purchase it but hadn’t seen a doctor and been approved, they could ask to talk to the clinical advisor there and answer some of the questions for themselves. Adult use patients can’t even get as high levels of THC as perhaps medical patients can. There are some differences in the products and the amount that they can buy because medical cannabis patients who are registered might need a certain amount for the month, they can have higher quantities.
Do you see more mature adults seeking medical cannabis?
It is increasing in people 65 and older. We know that. I think there was one study that said from 2009, it had tripled from 11 percent to 32 percent by 2019. So, within that decade. And now I think the number of older Americans was maybe from 2021, 35 percent noted that with a demographic between 60 and 64, almost half reporting cannabis use. So, it has taken off. That generation might’ve been the generation who used it in college. But it is different. I like to tell people it’s not your grandmother’s cannabis, your baby boomer grandmother’s cannabis. Because we’re seeing higher levels of THC in it. People do have to be aware.
How has cannabis changed over the years? What are the practical implications for older adults who may assume it’s the same as what they remember?
A long time ago was just being grown illicitly. Now we use genetics and there’s all kinds of sophistication in growing and it is a business. Now we’re reading so much about the potential side effects and abuse and all of these things. But certainly, as the level of THC goes up in cannabis, and is bred that way, that’s when you’re going to see all of the issues. When I’m recommending it medically, I try and recommend it with more of a full spectrum that might have CBD dominant, cannabidiol dominant or certainly even maybe a one-to-one THC cannabidiol. There are certain things depending on conditions where you might like to use different ratios and obviously either a young person or anyone just using it the way they say as a drink after work is fine.
Physicians and family members should be aware of overuse and the incidence of cannabis use disorder. We will see substance use go up. Is it more dangerous than alcohol? I don’t know. I’m not a drinker. I’m a cannabis physician. It does have some great therapeutic and beneficial effects, but you really should be under the guidance of a physician and monitoring it and things like that.
Are older adults one of the fastest-growing demographics for medical cannabis use as they face more health challenges?
Yes, it is one of the fastest growing demographics as we cited, supposedly 35 percent of people over 65 were using it, turning to it for issues like chronic pain. 74 percent of older Americans complain of chronic pain. That’s probably the number one reason people look to cannabis, especially in the face of the opioid crisis and the worry about that and addiction. We were told short-term use of opiates is not addictive, but that’s not in fact true. And I would hate to see with the new types of cannabis coming out, this being led down the same road. So, we do have to be careful, but there are considerations. 70 percent of mature adults probably have at least two or more chronic illnesses. Unfortunately, we are a society of chronic illnesses. And so almost 40 percent of them sometimes are on five or more prescriptions. So that polypharmacy, that’s an issue when you add any other medication. Cannabis is like that, especially oral ingestion of cannabis, tinctures or gummies because it goes through the liver, our P450 system, and when it’s metabolized there, we only have so much enzyme at a time to metabolize. So, if you’re taking a bunch of other drugs with it, either you’re going to get subtherapeutic levels of some of those drugs or supratherapeutic above. Drug interactions are a big issue that I think mature adults need to think about. It is one of the reasons why nothing’s a hundred percent safe. The other thing that happens as we age, is that there are a lot of changes that occur in our body that are related to metabolism. For example, usually, our stomach acid level decreases so the oral absorption of any medicine is affected in that way. We lose lean body mass, which has a lot of water in it as we age, and muscle mass and that affects the distribution of any drug cannabis included in the body. We start to metabolize it differently. We have decreased blood flow to our liver and our kidneys. And what happens then is we become less efficient at metabolizing the drug and excreting it. And then, of course, any drug that has intoxicating effects as we get older. There could be over-intoxication with it.
I’m very careful when I start older. And I have to tell you, I’ve seen patients come to me in their eighties with their family members. I tell them they can only try it if someone’s going to stay in the house with them at night. So, they’re not getting up so much with somebody there if they get up because over intoxication can lead to falls and falls and trauma injury is one of the leading causes of death in people over 65. There’s this adage with medical cannabis physicians, start low, very, very low doses and then slowly increase. And it is a very individualized, personalized type of medication.
What are the reasons a mature adult would be taking medicinal cannabis? Is it sleep? Is it pain?
Pain management is probably the number one reason that people turn to it, but it also depends on the chronic illness.
Way back before 2008, I was on faculty at the University of Maryland and a colleague was showing me a paper of his that had just been published. The title of the paper is The Level of Endocannabinoids In Stressed Rats. And I was like, what, wait a minute, what were endocannabinoids? They just floored me. I said, you mean like endorphins? We have internal cannabinoids and that’s part of the problem. I never heard that word through medical school training. I’ve been practicing for almost 20 years by now and I hadn’t even been reading a lot about it. Now some of it is we didn’t discover the endocannabinoid system until the late 80s and early 90s. I had already graduated from medical school then, but I was in training.
We have this endogenous system in our body, and this is why we respond to phytocannabinoids, the ones that come from plants because we have this system called the endocannabinoid system, which is a mechanism that is so ingrained in our evolution that anything with a nervous system has this system in place to sort of dampen and maintain homeostasis within our nervous system. And it’s in our immune cells, it’s in our brain, it’s everywhere. So, we have these receptors and our own body makes these internal cannabinoids. We know in certain situations in the body after seizures, things like that, our body makes on demand these cannabinoids to help dampen the immune system. That is why we respond to external cannabinoids.
A famous, researcher, Ethan Russo, sort of coined this frame endocannabinoid deficiency syndrome. He looked at conditions that are very hard to treat and might be a dysfunction of our endocannabinoid system. Things like fibromyalgia, which is a chronic pain syndrome, and autism in children. People aren’t with these conditions, they do respond to cannabinoids. So that’s why there is this judicious therapeutic use in certain conditions. People who have MS, for example, sometimes turn to cannabis if we’re talking about different reasons, because of the spasticity and the pain, because the cannabinoids have anti-inflammatory effects. They have antioxidant effects and analgesic effects because they interact with our internal cannabinoid receptors that are all through the brain, the peripheral nervous system, our GI tract and all these things. Someone recently asked me about ulcerative colitis and cannabis, which is kind of like this autoimmune disease. It can dampen the immune response. There’s a whole host of medical problems that people turn to that we’re still don’t have a great grasp on managing.
DiMarzio is another researcher who said it helps us sleep, eat and forget. It can stimulate your appetite. That’s why people used to take cannabis and they developed a synthetic THC molecule called Marinol, which was the brand name. It’s just like an isomer, a backward molecule that they had tried to use for years to get people to eat. It’s been shown to be effective in chemotherapy, damaged nerve pain and diabetes. It’s been shown to be effective in seizures. GW Pharmaceuticals in England developed the first ever that was approved here in the U.S., it’s FDA-approved Epidiolex, which is a CBD, cannabidiol product, not a synthetic. It comes from the plant to treat resistant seizures in very specific genetic conditions. But we know cannabidiol is very effective and dampens the nervous system. So, when you have a seizure, you have just this continuous flow of the neurons firing, firing, firing. In the normal body, when things are functioning, we make endocannabinoids that go backward and dampen that nerve expression. But sometimes it doesn’t work enough. Taking something like cannabidiol also has anticonvulsant properties by dampening that constant signaling of the nerves from things like seizures.
What’s the process of moving into medicinal cannabis versus if I don’t feel well, I’m going to use recreational cannabis?
It’s important to be guided by a physician who’s knowledgeable in it. There are a lot of primary care doctors who aren’t comfortable. I think more and more are coming to believe they are, there’s more and more research out there that it is useful in certain conditions. The biggest problem with research, one, it’s federally illegal, so that’s creating a problem with research, and two, there’s no standardization anymore. When you test a certain drug from one state to the other, because it’s legal from state to state, it’s a patchwork of standardization. That makes it a problem too. I mean, there was a JAMA study that came out not long ago stating cancer patients did well with cannabis and used fewer opioids, but there was no dose recommendation. And there was no ratio of cannabinoids in there because there’s no standard to it. And that’s the biggest problem standing in the way of medicinal cannabis. And it all is because of the federal illegality of it.
There are no national standards like there are for pharmaceuticals and over-the-counter drugs. I think having somebody guide you and start with the dosing is important because it’s complicated too. I prefer tinctures because you can control the dosing better, but it requires calculations of milligrams per ml, even the way the tincture bottles come, they give the full dose of cannabis in the bottle and you have to figure out how many milligrams per ml it is. So, I do those calculations with my patients and then they try it and I tell them, look, you have to keep a log so that when we talk again, you can tell me this is how many milligrams per ml, this is how it helped or it didn’t help. Same thing with gummies. You might get a package that tells you the whole dose of THC in there, but it’s like six gummies and you have to divide them into pieces and they have to be equal. These are the things that are standing a little bit in the way and why you need a good provider who understands it if you want medicinal cannabis.
For someone considering medical cannabis—should they consult their primary care physician or seek out a specialist?
Some primary care physicians might be discouraged. I would hope that a lot of them are open to it, but they don’t feel comfortable recommending it or certifying somebody for it. So, you can start with a state agency that is controlling licensing for medical dispensaries. You can ask them if they have a list of physicians.
Does insurance come into play in all of this?
No, never. And it is expensive because of that. I’m very cognizant of that when I meet with patients. Even though I spend sometimes over an hour with my patients I don’t charge them for the time like that. I just couldn’t because I knew they were going to have to buy the medication and it’s expensive. Insurance for regular medicines is an issue. If you want to take the brand-name thyroid medicine, nobody’s going to let you have it. We know that what’s interesting is generic meds can have a 10 percent difference in efficacy, especially with things like hormones where tinkering a little bit matters, insurance companies are fighting tooth and nail to cover any meds. So, cannabis, federally illegal, is not even a question today.
What are the biggest misconceptions about medicinal cannabis that people need to keep in mind?
I don’t know a misconception or challenge for mature adults because it is a very personalized therapy. One of the biggest issues I have is that you have to have patience. You have to have someone to walk through with you to evaluate the types of products and the combination of cannabinoids. We want something maybe in the daytime that’s more CBD dominant because it has less of the intoxicating effects. And maybe at night, if sleep is an issue, you can change the ratios of the cannabinoids. It can be difficult for anyone, especially maybe mature adults. There’s no one-size pill that fits all. The way that you take a pill, this is the dose the FDA says, and this is it. So correct dosing makes it challenging. And you need a partner to go through it with you so that you can maintain consistency.
Another thing to consider is that it’s a plant, not a factory. All medicine started as plant medicine. If you think of it, Foxglove became digitalis, Willow bark was aspirin. Why did it switch to synthetics and whatever? Because there’s more standardization. You can be precise. And I have people tell me they’ll use one product, and even though it’s supposedly the same product, the next time maybe the effects are not exactly that good because these are plants. The littlest thing can change how it’s grown. Maybe something happened to one of the lights one day and the plant before they processed it didn’t have quite this mixture of cannabinoids. That makes it challenging too. Plant medicine is challenging and cannabis has over 500 different compounds. But there is this thing in cannabis we call the entourage effect where all the different cannabinoids and terpenes work synergistically to give you that more natural and satisfying effect of it medically. But it’s all those little nuances that make it a challenge as a medicine too.
About Dr. Leigh Vinocur
Dr. Leigh Vinocur, a member of the Society of Cannabis Clinicians, is a distinguished board-certified emergency physician and a nationally recognized medical expert. As a medical cannabis physician and expert, her Ananda Medical Practice and Consulting has been active since Maryland’s medical cannabis laws passed in 2016. Her practice is focused on educating often through tailor-made training programs for patients, clinicians, and industry with the most up-to-date, evidence-based medical cannabis science, safety and therapeutics.
About The Society of Cannabis Clinicians
The Society of Cannabis Clinicians is a nonprofit organization dedicated to education and research into cannabis for medical use.
To learn more, please visit drleigh.com and the Society of Cannabis Clinicians.
