The New Old Age - Caring and Coping
Medical Marijuana Raises Tough Questions for Nursing Homes
By NUSHIN RASHIDIAN AND ALYSON MARTIN


Every night before bed, Norma Winkler, 82, opens a small jar of cannabis oil and measures out a quarter-teaspoon to mix with homemade applesauce. Soon after she eats it, she drifts off to sleep.

Ms. Winkler, who lives in Rhode Island, where medical marijuana is legal, has endured chronic back pain since a car accident fractured her skull and spine at age 15. Operations haven’t helped, and other medicines don’t touch the pain that can keep her up through the night.

“It’s really been a lifesaver for me,” Ms. Winkler said of her cannabis oil. “I used to walk into the walls sometimes. I was so tired because I didn’t sleep.”

Today, she’s healthy enough to remain independent in her home and to operate the jewelry factory she owns. But she worries about what will happen if she needs institutional care. Would a long-term care facility allow her to use this particular medicine?

“I wouldn’t go if they didn’t allow me to take it,” Ms. Winkler said.

When states began embracing medical marijuana, few anticipated this inevitable scenario: patients using it would grow older, and many would need to enter assisted living and nursing homes. The prospect has just begun to raise difficult questions for administrators and state regulators.

Any patient using medical marijuana breaks federal law. Marijuana is listed as a Schedule 1 drug, which means the federal government considers it to have no medicinal value. Despite this, physicians in 14 states and the District of Columbia are allowed to recommend it. Legalization of medical marijuana is under consideration in eight additional states this year.

Though firm numbers are difficult to come by, experts say elderly patients like Ms. Winkler increasingly use medical marijuana to ease their pain. But many care facilities in which they reside, or will reside, receive federal funding through Medicare and indirectly through Medicaid.

Many facility administrators wonder how they can comply with federal law and preserve their reimbursements and at the same time permit residents to medicate with marijuana. At an American Health Care Association conference in early October, Fred Miles, a Colorado lawyer who represents health care providers, gave a presentation called “Medical Marijuana — Are Nursing Homes Going to Pot?”

The issue is badly in need of federal clarification, he said.

“What do these health care facilities do? Adopt a ‘don’t ask, don’t tell’ policy? Somebody is using medical marijuana in the residence and you just close your eyes to it? I don’t think that’s going to work very well,” Mr. Miles said in an interview.

Said Maribeth Bersani, senior vice president of public policy for the Assisted Living Federation of America: “Where do they store [marijuana]? Who assists the residents with it? Do they even want to get involved because it still is not legal federally? It’s one of those challenges that we are beginning to confront in the communities.”

Such questions prompted the American Medical Directors Association to consider a resolution last spring proposing a discussion with the federal Centers for Medicare and Medicaid Services about how to relax federal regulations with regard to medical marijuana in long-term care facilities. (The resolution did not pass.)

In most states that allow medical marijuana, laws don’t explicitly address the possibility that elderly patients in care facilities will want to use it. Alaska’s medical marijuana law explicitly states that it does not require accommodation for users of marijuana medical in any facility monitored by the state’s Department of Administration, which includes assisted-living facilities.

But Michigan, Oregon and Rhode Island do include “agitation of Alzheimer’s” as a qualifying condition for legal use of marijuana. And when Maine’s medical marijuana law changed last November to allow for the establishment of dispensaries, the state expressly permitted nursing homes and inpatient hospice workers to act as registered medical marijuana caregivers for patients.

Catherine Cobb, director of the state’s division of licensing and regulatory services, invited representatives from Maine’s nursing homes to a conference where she explained the program.

In order for a nursing home or inpatient hospice to act as a registered medical marijuana caregiver, the facility must obtain medical marijuana from a dispensary. Ms. Cobb is encouraging the state’s new dispensaries to measure and package doses to make it easier for care facilities to inventory and administer the medicine.

Dosage, in addition to federal law, is among the most common questions in care facilities wrestling with the prospect of medical marijuana.

In New Mexico, which legalized medical marijuana in 2007, the transition to allowing facility residents to use it has gone fairly smoothly, said the state’s long-term care ombudsman, Sondra Everhart. But the lack of dosing direction has caused problems.

“If the marijuana is kept at the nurses’ station, it tends to disappear,” Ms. Everhart said. “Pills in nursing homes are in what they call vacuum packs: you have to pop a pill out one at a time. They don’t do that with marijuana. It’s an amount of marijuana in a small plastic bag, so there is no way to track if someone took one or two pinches.”

Montana’s long-term care ombudsman, Kelly Moorse, said in an e-mail that in one state facility, workers took medical marijuana from a resident’s lockbox. She also said there were claims of staff members approaching a resident, seeking to “share” the patient’s marijuana.

Another problem perplexing officials: Other residents may object to the use of marijuana at a care facility. A roommate, for instance, might see a medical marijuana patient as a criminal, raising additional questions about patients’ rights.

“They have an affirmative right to complain and ask for redress and so forth if there’s smoke in the air and it’s aggravating their lungs, or they don’t like the smell of marijuana,” said Joe Greenman, legal counsel with the Oregon Health Care Association. “And there are cultural complaints, because medical marijuana has stigma attached to it.”

Valerie Corral, director and co-founder of Wo/Men’s Alliance for Medical Marijuana in Santa Cruz, Calif., said that one local long-term care facility tries to accommodate patients on both sides by designating a garden patio as a marijuana-smoking area.

“In that courtyard, people are allowed to use their medicine with one of the aides that works at the facility,” Ms. Corral said. (Smoke-free options do exist for marijuana. Some facilities report patients using vaporizers or consuming cannabis baked into desserts, according to Ms. Moorse.)

Oregon’s long-term care ombudsman, Mary Jaeger, believes the emerging controversy highlights the rights of patients to use medical marijuana, whatever the setting.

“Wouldn’t any one of us, in our own homes, feel that we have the right to live our lives by our own values and choices, to preserve our own dignity and, frankly, to live pain-free?” Ms. Jaeger asked. “Because typically, that’s why a patient gets prescribed medical marijuana.”

In January, the National Organization for the Reform of Marijuana Laws, or Norml, plans to introduce the Norml Senior Alliance, which will offer to elderly Americans information about the medical uses of marijuana, according to Allen St. Pierre, executive director of the organization.

Next week, voters in California will vote on whether to support the recreational use of marijuana. Ms. Corral said passage of the measure and the changes it would bring would be positive for those living in long-term care facilities by providing wider access to medical marijuana.

“What keeps many elders from using marijuana in the first place, medically, and relieving their suffering, is the stigma that’s attached to marijuana,” Ms. Corral said.

    * Copyright 2010 The New York Times Company