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From the days of "Reefer Madness" until the timing of Proposition 19 with the "Legalization of Marijuana Initiative" on the ballot last November, the controversies swirling around not only the recreational use, but also the medical use of marijuana, particularly in frail, elderly geriatric patients with clinically significant weight loss (and cachexia), has been fraught with controversy. Even though the ballot initiative from 2010 went down in defeat on November 2, 2010, rumblings of some of the authors bringing another, more "targeted" CA initiative in 2012 are regaining momentum.

It is therefore incumbent upon long-term care (LTC) facility medical directors, practitioners and our IDT colleagues-who care for our frail elders in our states's postacute facilities-to understand the clinical, legal, and ethical ramifications of the commonly encountered medical "uses" of marijuana (including the synthetic derivative-Dronabinol).

In the summer of 2010, the California Society of Addiction Medicine (CSAM) went a long way toward assisting both clinicians and CA voters in both their understanding of the latest scientific evidence concerning CSAM's Position on the role of "Medical Marijuana" as well as the "Medical Aspects of Cannibis Legislation" prior to the November state elections re: the vote on state-wide legalization (labeled: "The Regulate, Control, & Tax Act of 2010").

Our clinical investigation should include an analysis of the scientific data to date behind the role of 9-Tetrahydrocannabinol (THC), the active ingredient in Medical Marijuana, as one of several potential orixigenic agents in the LTC setting, more and more being used to treat involuntary weight loss in frail elders. As with any other medication introduced into the rapidly growing frail, geriatric sub-population of longterm residents in this setting, medical indications need to be justified with each potential orixigenic agent and a traditional risk/benefit analysis, of course, needs to likewise be conducted in this sub-population of vulnerable patients within the LTC setting.

The specter of poor clinical outcomes in patients in the LTC setting directly related to unintentional weight loss (UIWL), defined as the loss of 5% of absolute body weight over 1 month or the loss of 10% of absolute weight loss over 6 months, looms large, particularly in the growing number of institutionalized patients over the age of 80 (with an annual incidence of involuntary weight loss of 30%-50% commonly quoted). Significant clinical sequelae commonly attributed to UIWL in the advanced elderly in LTC include: Increased post-operative complications, anemia, falls, fractures, pressure ulcers, a decline in ability to perform Activities of Daily Living (ADL's), probable Cytokine-medicated diminished host immunity (via TNF), as well as increased mortality.

It is important to point out that in the LTC setting UIWL is typically thought to be multi-factorial. For example, most advanced elderly institutionalized patients have at least one chronic co-morbidity-such as Cardiovascular (CV) Disease, Hypertension (HTN), or Chronic Kidney Disease (CKD)-resulting in a "restricted diet and/or fluid intake" which can lead to decreased oral intake. Depression, Polypharmacy, and various commonly encountered medication side-effects can cause various degrees of decreased oral intake as well; for example, medications such as ACE Inhibitors, Quinolones, and Metronidazole can cause dysgeusia; CI's and SSRI's can cause nausea, vomiting, and diarrhea; Psychoactive agents like antidepressants, anticonvulsants, antipsychotics, and Medical Marijuana can cause increased sedation at meal times and poor by mouth (PO) intake. Other causes of weight loss in the institutionalized elderly due to decreased PO intake include: Dental/periodontal problems, cognitive and functional impairments, difficulty with self-feeding, and dysphagia/gastro-esophageal dysmotility problems. Another disorder related to agerelated dysregulation of food intake includes: "physiologic anorexia/cachexia of aging," which likely represents an inter-relation between changing levels Cholecystokinin, Leptin, and probably other humeral agents.

The evaluation and treatment of UIWL in the LTC setting includes a comprehensive approach, featuring screening, assessment, and potential orixigenic medication treatments; treatment typically involves adequate supplementation and hydration, but often orixigenic agents-like Dronabinol-are administered with clear-cut risks along with very little proven long term LTC scientific benefit to fall back on.

It is important to point out that from the days of "Reefer Madness" through the passage of Proposition 215 in California in 1996-as one of the first states to legalize the use of Medical marijuana-(entitled: "The Compassionate Use Act"-allowing state-wide "medical use" of Marijuana) through the recent attempt at passage of the statewide initial legalization act of 2010, there are no long term, placebo-controlled, doubleblinded trials with significant numbers of frail, advanced elderly patients conducted in the LTC setting to date convincing practitioners to utilize any of the commonly encountered orixegenic agents-including Medical Marijuana-thus far. In fact, A Pub Med search of the literature from 1956 until present regarding five of the most commonly encountered orixegenic agents, including Dronabinol [Rudolph 2001].

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John H. Fullerton, MD, MRO, CMD, CFP, FACP, AGSF, FAAHPM is Board Certified in both Internal Medicine and in Geriatrics. He maintains active medical licenses in both California and Florida. He is also Board Certified in Hospice and Palliative Medicine and holds national certificates of added qualifications as a Certified Medical Director (CMD) at multiple levels of care locally and in Home Care (AAHCP). Dr. Fullerton specializes in comprehensive Internal Medicine, Geriatric care and consultation, Addiction Medicine, Medical Toxicology, and Hospice & Palliative Medicine.

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