Transcript Potential scope of medicinal cannabis as an alternative to chronic

Potential scope of medicinal cannabis as an alternative
to chronic pain management regimes for older
Australians living in residential aged care:
The Aged-Care Pain Australia (ACA Pain) Study:
Leah Bisiani RN1, M Health Sci
Dementia Consultant
Managing Director, CEO - GreenC Medical
Innovative Cannabis Research
Abstract:
Background: Potent opioid analgesics are widely prescribed within the aged care sector, yet
these agents are associated with the highest degree of drug-related harm.
Aim: This major research initiative examines current practices in pain management in the
Australian aged care sector, exploring the scope for a potential positive and significant impact
from the utilization of medicinal cannabis as an alternative to current pain management
regimes. The Study will be the first large-scale, comprehensive examination of pain
management examining in detail the characteristics of medication in three key domains
amongst a large cohort of older Australians. These domains include management of pain in the
palliative care context, chronic non-cancer pain, and chronic neuropathic pain. ‘Ward MM’, and
‘GreenC Medical’, are partnering to complete the subsequent implementation of research
exploring the use of medicinal cannabis as a potentially beneficial alternative to existing
approaches.
Method: The study will characterize the detailed characteristics of unmanaged pain
management in aged care, with extensive examination of medication usage characteristics in
context, identifying the extent to which dose escalation occurs, and the extent to which this
engenders potential prescribing cascades in response to treatment-emergent adverse effects.
Results: This study will illustrate potential benefits of medicinal cannabis in treating poorly
managed chronic pain. The study may additionally identify dose escalation patterns and
associated prescribing cascades occurring in response to treatment-emergent adverse effects.
Conclusion: This research aims to provide support for the use of medicinal cannabis as a
beneficial alternative approach to enhancing quality of life and maximizing comfort.
Chronic Pain in the Aged Care Setting:
The nature of the problem:

Australia has a current population of approximately 25
million people, with over 300,000 currently in RACFs

The nature of aged care has changed in recent years

Ageing in place - more people living at home for longer

Acuity in RACF has increased – people are sicker and have more
multimorbidity, disability and polypharmacy

Medication usage is extensive, creating substantial potential for
drug-related harm

Despite this, many have sub-optimal control of symptoms
Chronic Pain in Aged Care:
Pain in RACFs arises from various sources:

Acute pain – post-procedural, minor intermittent pain

Pain in the context of life-limiting illness – carcinoma, CRF, endstage illnesses - palliative care

Chronic somatic and visceral pain – e.g. OA, # with OP

Neuropathic pain - post-herpetic neuralgia, diabetic neuropathy,
phantom limb pain, trigeminal neuralgia
Chronic Pain – current options available:
Many approaches:

Non-pharmacological approaches

Simple analgesia – paracetamol/ibuprofen

Intermediate potency analgesics – codeine phosphate
tramadol

Potent opioids – morphine/oxycodone

Adjuvant agents – amitriptyline, duloxetine, pregabalin, carbamazepine
BOTTOM LINE – NO SOLUTION IS UNIVERSALLY EFFECTIVE
ALL HAVE LIMITATIONS AND PROBLEMS
MANY CAUSE AS MANY PROBLEMS AS THEY FIX
Chronic Pain in Australian Aged Care:

Chronic pain is a massive burden:
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Contributes to overall suffering/debilitating

Comes from different background etiologies

Especially difficult in context of dementia - BPSD

Opioids, NSAIDs are associated with substantial hardship and harm

Widespread in use in aged care – we could do better………….
Chronic Pain in Australian Aged Care:
Snapshot of the current state:

Partnership with Ward MM – leaders in medication management in the
Australian aged care sector/Ward data analytics

15,178 RMMR (residential medication management review) reports provided
in response to GP referrals from 2014 -2016, examining use of potent oral
analgesia

In 4474 cases (29.5%), residents who received an RMMR were treated with at
least one of three agents:

Oxycodone alone accounted for 3356 cases (22.1%)
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Morphine (n= 611, 4.0%)

Tramadol (n = 500, 3.3%).
WHO Analgesic Ladder:
Chronic Pain in Australian Aged Care:

WHO stipulates a Defined Daily Dose (DDD) for all pharmaceutical
drugs, specified as the assumed average maintenance dose per day,
for a drug used for its main indication in adults

75 mg daily for oxycodone

100 mg daily for morphine

300 mg daily for tramadol

For 2014 & 2015, each drug prescribed below the DDD in > 99% of
cases, year to date (to May 2016) showed oxycodone doses above the
DDD have increased to 9.1%

Year on year prescribing rates for morphine and tramadol have
remained stable, prescribing of oxycodone increased rapidly (738
cases in 2014, 1512 in 2015 and 1106 cases for the first five months of
2016).
Downsides of Opioids in Aged Care:
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Nausea, vomiting, constipation, potential for impaction

Sedation, respiratory depression
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Tachyphylaxis, tolerance
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Drug interactions
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Administrative burden

Security risks

Potential diversion
Chronic Pain – new options to explore:

If what you are doing now is not effective, and can
actually cause harm, why not do something differently?

Non-pharmacological approaches can be used better and more often

Consider referral for expert review for pain control

Analyse medications in context

Another solution is available – medicinal cannabis and
therapeutic cannabinoid products

Very optimistic/positive approach
Cannabinoid products for pain in RACF:
In Australia, barriers exist but can be overcome:
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Regulatory issues
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Conservative medical approaches
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Perceptions of public
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Dose standardization

Active ingredient standardization

Dose delivery

Individualisation of treatment approach
Medicinal Cannabis is a promising, exciting avenue to
explore, and the need for an effective alternative
clearly exists.
Conclusion:
“Be the change you
want to see in the
world”
“Ghandi”