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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: Curr Addict Rep. 2023 Sep 26;10(4):837–843. doi: 10.1007/s40429-023-00519-x

Medical Cannabis Use and Its Impact on Health Among Older Adults: Recent Research Findings and Future Directions

Yan Wang 1, Kendall R Robinson 1, Hannah Fechtel 1, Alexis Hartog 2
PMCID: PMC10997349  NIHMSID: NIHMS1934465  PMID: 38586531

Abstract

Purpose of Review

With the rapidly changing landscape of state level legalization of cannabis, older adults have become one of the fastest growing populations seeking medical cannabis (MC). However, research evidence on the risks and benefits of MC use in this population remains limited. This review aims to synthesize recent literature on the impacts of MC use in older adults and identify critical knowledge gaps to be addressed in future research.

Recent Findings

Recent literature showed that older adults often face financial and/or educational barriers and stigma associated with MC access. Emerging data showed that MC may have therapeutic effects on symptoms of conditions such as chronic pain, insomnia, anxiety/depression, dementia, nausea, and vomiting. However, available evidence is inconsistent and tends to rely on self-report and uncontrolled studies. While some adverse events associated with MC use were reported, it is generally well tolerated in older adults. Neurocognitive and psychological consequences and cardiovascular risks have been reported but again only in limited studies with inconsistent findings.

Summary

There is a need for more systematic and rigorous research on MC in older adults to determine its safety and efficacy. Research on dosing procedures and product characteristics, as well as how these may impact health outcomes, is crucial. More consistent evidence is needed to inform policy changes and patient/physician education to minimize potential risks and optimize benefits among older adults seeking MC as an alternative treatment.

Keywords: Medical cannabis, Medical marijuana, Cannabinoids, Older adults

Introduction

In recent years, there has been a substantial increase in the number of older adults using medical cannabis (MC), exceeding the growth of other age groups [1, 2•, 3–5]. In 2016, a national survey found a 333% increase in cannabis use in people over the age of 65 and a 455% increase in people between the ages of 55 and 65 [1]. Older adults are beginning to make up a moderate to large portion of MC using population. Depending on the country and region, the number of older adults using MC ranges from 7% to over 33% [6]. For example, a large proportion of early adopters of MC in Florida, according to the state Medical Marijuana Use Registry, were older adults (aged 50 years and older), with one study reporting 58.6% of registrants falling within this age range [7•, 8].

The increasing trend in MC use among older adults could be attributed to more prevalent legalization of cannabis at the state level, which reduces perception of harm and increases access to cannabis in the USA [9, 10]. It may also reflect the trend of older adults seeking MC as an alternative treatment to conventional medications (e.g., opioids) for various health conditions such as chronic pain and insomnia with the expectation that MC could be similarly effective and associated with fewer side effects than some conventional medications [11]. Indeed, some recent studies investigating older adults’ perceptions of cannabis when compared to other treatments supported this hypothesis. For example, one study found that 69% of older adults in the sample believed that cannabis “definitely” or “probably” provides pain relief, while only 48% of respondents believed that traditional pain medications were more effective than MC [12•]. When asked about the risks of each treatment, 57% believed in more prevalent side effects associated with traditional medications than cannabis, and 48% believed in a higher risk of addiction using traditional medications such as opioids [12•].

Despite the increase in medical cannabis use and accepting attitudes among older adults, research on the risks and benefits of cannabis use in this population remains relatively limited [13, 14•, 15, 16]. In fact, many studies assessing MC’s safety have excluded older adults from their sample [14•, 17, 18•, 19]. A literature review by Levy et al. published in 2020 found only 8 randomized controlled trials assessing a total of fewer than 250 older adults using MC [15]. While observational and qualitative study designs can be useful for better understanding the experiences of MC users, the lack of clinical trials makes it difficult to determine dosing, MC strain, and product type recommendations, as well as, the efficacy of MC in comparison to other treatments [15]. This scarcity of research is especially problematic due to the increased risk of polypharmacy, falls, neurological deterioration, and cardiovascular events in older adults [13, 18•], while cannabis may exacerbate some of these adverse outcomes. Thus, there is an urgent need for more rigorous and systematic research to investigate the impacts of MC use in this population. This review aims to synthesize recent literature (focusing on studies in the past 3–5 years) regarding MC use and its health impacts among older adults and identify key areas for future research.

Access and Barriers to MC Use

Although MC has become a more popular alternative treatment among this population, research shows that many older adults face barriers to obtaining MC. A recent study analyzing data from the 2018 and 2019 National Survey on Drug Use and Health with a total of 17,685 individuals aged 50+ showed that even those who reported medical use of cannabis mostly obtained cannabis from private/informal sources as opposed to regulated state dispensaries [3]. This finding suggests that among older adults, even though many use cannabis for medical reasons, a considerable proportion of them are self-treating without healthcare professional consultation [20]. This discrepancy between motivation and actual practice of cannabis use could be attributed to several barriers, such as lack of knowledge/guidance, high cost, and perceived stigma regarding MC use.

Bobitt et al. (2019) conducted a qualitative study with 17 focus groups consisting of older adults and identified key barriers to MC use, including difficulty in identifying an MC physician for the medical program, the high cost associated with MC physician visits, and the need to seek an MC physician outside of their health insurance network [2]. A similar study conducted by Manning and Bouchard (2021) also found similar barriers regarding the process of getting approved for an MC card and financial concerns due to out-of-pocket costs [21•]. Although the process of obtaining MC may differ from state to state, barriers seem to exist when older adults seek MC certificate/license and try to purchase the products from MC dispensaries. These barriers may prevent older adults from safely obtaining MC products from the sources that they would prefer and force them into the recreational market or unregulated sources to obtain cannabis products. Taken together, research on these barriers suggests a need for policies to improve the process to allow easier access for those who want to use cannabis for medical purposes.

Another potential barrier to MC use is related to the separation between primary care and cannabis treatment and the lack of knowledge or confidence in primary care physicians regarding the medical use of cannabis. Currently, MC prescription and primary care tend to be separate practices, although some clinics may have both. Due to this separation in practices and perceived stigma, which is discussed in the following paragraph, many older adults are not comfortable discussing MC treatment with their providers and would like their providers to speak more openly about MC [2]. Research shows that provider discussion of MC treatment makes patients more likely to use cannabis alone or in conjunction with opioid treatments [22]. Open communication can potentially help older adults maximize the benefits and minimize risks when using it in combination with other treatments. This is especially important for older adults, as medications commonly used by this population, such as warfarin and selective serotonin reuptake inhibitors (SSRIs), may be metabolized by similar enzymes to cannabinoids and could increase risk of interactions [23•, 24]. However, providers are often hesitant to initiate discussions regarding MC treatment due to a lack of confidence in their knowledge of MC’s health impacts or safely prescribing MC use [16]. The limited studies that provide recommendations for MC prescription hardly mention specific procedures for older adults [18]. In general, there is a lack in evidence on the risk of drug-interactions and polypharmacy between cannabis and other drugs in all ages, but especially limited in older adults [24]. As such, there is often hesitancy to prescribe MC to older adults, and it has been recommended to prescribe lower doses to this population due to concerns regarding adverse events [13, 18]. With the increased prevalence of MC use among older adults, more research is needed to educate physicians and inform prescription guidelines tailored to the older adult population.

Another barrier to MC use among older adults is the stigma surrounding cannabis use, even if it’s medical use or in a state where cannabis is fully legalized. Participants in the majority of Bobitt et al.’s (2019) focus groups reported concerns about the stigma surrounding their use of MC, despite that they were in Colorado, a state quite liberal regarding cannabis use [2]. Stigma was also a main overarching theme that emerged in the interviews reported in another study [21•]. Older adults often refrained from disclosing MC use with family, friends, and even healthcare providers [2, 21•] for fear of being labeled a “pothead” [2]. As mentioned above, the lack of communication between older adults and their healthcare provider about cannabis use, due to the perceived stigma, could be problematic and place older adults using MC at higher risk for adverse outcomes given possible drug-drug interactions or side effects from cannabis use. More scientific data on MC use among older adults for various health conditions and more education among healthcare providers on this topic can potentially reduce stigma on MC use among this population.

MC Use Patterns and Dosing

Given the increasing prevalence of MC use in older adults, it is critical to understand the product characteristics (e.g., modes of consumption, THC/CBD components), frequency of use, and dosing. A recent study analyzing NSDUH data showed that compared to nonmedical users, older adults using cannabis for medical purposes were 2.6 times more likely to report high-frequency use [25]. Another study surveyed over 11,000 medical cannabis patients in New York State and found that compared to their younger counterparts, older adults were more likely to use sublingual tincture versus other consumption modes, more likely to use products with a lower THC:CBD ratio, and more likely to start MC treatment with a lower THC and higher CBD dose [5]. Another study surveyed over 9700 older adult MC users in Canada and found that 81.0% used cannabis oil, and 83.6% among these participants used oil only or mostly containing CBD [26]. However, research also showed that older adults demonstrated a similar increase in THC dosing over time similar to their younger counterparts [5].

On the other hand, since there is no established guideline on MC treatment, especially regarding the specific product and dose, there is a great need for more research on dosing, especially among older adults [12]. Bobitt et al. (2019) found that 70% of comments older adults made in the focus groups were related to the need for education on cannabis use [2]. Many older adults reported difficulty with the lack of educational support regarding how to use MC products. For example, many noted frustration around the trial and error of finding effective products to treat their specific symptoms [21]. The lack of clear dosing guidelines can be a barrier for many new MC users. Recommendations to use micro-dosing to find the right amount of product rather than having a set prescription like traditional medicine can be overwhelming for many individuals [21•]. Therefore, more research is needed to support the development of better dosing guidelines, especially for older adults with more health concerns and vulnerability.

Potential Health Benefits of MC Use

While scientific evidence is still emerging, many observational studies showed that older adults using MC experience health benefits. Chronic pain is one of the most commonly cited reasons for older adults to use MC. Multiple reviews and meta-analyses evaluating the effects of cannabis on chronic pain showed inconsistent conclusions [27, 28], but few have focused on older adults specifically. Some recent studies on older adults reported significant improvements in pain and reductions in opioid use as benefits from MC treatments [2, 6, 17]. In one study, over 70% of participants reported decreased pain, and 93.7% felt their conditions improved after 6 months of treatment [26]. When assessing the median pain levels on a 0–10 scale, scores went from a median of eight to a median of four [6]. Other studies have found that MC use can potentially lead to a 30% reduction in various types of pain [27, 29, 30]. Another study by Wang et al. (2021) using both real-time smartphone-based ecological momentary assessment (EMA) and longitudinal survey comparing pre- and post-MC treatment also found improvements in real-time pain intensity (measured on a 0–100 visual analogue), as well as improvements in chronic pain intensity, pain interference, and quality of life among middle-aged and older adults [31]. However, it should be noted that these studies are mostly observational without control groups, so more rigorous studies on older adults and pain are needed to further confirm how older adults with pain may benefit from MC treatment.

Sleep problems are another common reason for older adults to seek MC use, and recent studies have shown potential benefits of MC on improving sleep and mood. The large-scale Canadian survey study found that 64.5% of older adults in the sample reported improved sleep [26]. These findings are also supported by qualitative research where positive outcomes of MC use were reported regarding sleep improvement [2]. Another recent cross-sectional study [32] found that older adults using MC were less likely to report problems with staying asleep compared with those not using MC, independently of potential confounders such as chronic pain and sleep medication. However, these two groups did not differ in other sleep problems. This suggests that MC may help minimize awakenings during the night, but not all types of sleep problems. The same study also found that among older adults using MC, more frequent use was associated with problems staying asleep during the night and more problems falling asleep. This finding may be attributable to tolerance developed as a result of more frequent use, or alternatively, these individuals had more severe sleep problems to start with, given the cross-sectional nature of the data [32]. Wang et al.’s (2021) study described above is a prospective study and also found significant improvement in self-reported sleep hours and sleep quality among middle-aged and older adults after initiating MC use. While these results seem to be promising, more controlled studies, such as randomized trials, are still needed to further determine how beneficial MC may be for sleep problems [31].

The potential benefits of MC use on several other conditions or domains have also been explored but not extensively. For example, studies have examined the impact of MC use on mood or mental health among older adults. In the Canadian survey, approximately 53% of the older adults reported improved mood after starting MC treatment [26]. Wang et al.’s (2021) study also showed a significant reduction in real-time anxiety levels and a significant reduction of depressive symptoms after 3 months of MC treatment among middle-aged and older adults with chronic pain. Some studies suggest that MC may be beneficial for treating behavioral and psychological symptoms of dementia, such as agitation, aggression, psychosis, and mood disturbances [24], with few safety risks associated with using low-dose THC treatments for dementia-affected older adults [33]. Another condition that may benefit from MC treatment is nausea and vomiting. Multiple studies reported nausea as a common reason for use within their sample of older adults with cancer in palliative care settings [34, 35]. In particular, a review by Beedham et al. found that MC treatment may help treat nausea related to chemotherapy treatment [14]. All these potential benefits of MC on various health conditions/domains will benefit from further validation using more rigorous scientific data collected from longitudinal and/or randomized controlled studies [17, 23].

It is worth noting that a recently published scoping review on health effects of medical and nonmedical cannabis use on older adults concluded that, in general, there was inconsistent evidence on therapeutic effects on health conditions such as end-stage cancer, Parkinson’s disease, and Alzheimer’s disease/dementia [36•]. However, it should also be noted that this review may not reflect older adults who are using cannabis solely for medical purposes because it included both medical and nonmedical cannabis users, with a considerable number of studies reviewed in the paper not having a clear indication of user type. Additionally, this review included many studies examining cannabis products (e.g., nabilone, dronabinol) that were different from the state dispensary products (e.g., whole plant extraction) that many older adults use in the real world, which may have limited generalizability to the more widely available and utilized state dispensary MC products.

Potential Adverse Outcomes of MC Use

Overall, research so far suggests that MC treatment is generally well tolerated by older adults [13, 37]. MC use is generally associated with mild adverse events and side effects [15, 26, 33, 37–39], especially CBD-only use [40•]. Common side effects include dizziness, somnolence/drowsiness, fatigue, and dry mouth [15, 37]. While many of these adverse events are not severe, one study showed an association between increased hospitalizations and emergency department visits in older adults who used cannabis in the past year than those who did not use recently or never used cannabis [3]. It should be noted that many observational studies did not evaluate adverse outcomes or potential harms [36•], therefore leading to potential underestimation of negative health effects. Future studies on MC use among older adults should consistently collect data on the prevalence and severity of MC-related adverse outcomes to inform recommendations for MC use and its risk/benefit profile in this population.

In the older adult population, the potential neurocognitive and psychological adverse effects of cannabis constitute an important factor to consider. Prior studies have found reductions in the hippocampus in long-term cannabis users of all ages; however, this is especially concerning in older adults as it may suggest accelerated degeneration of the brain with aging [41]. These effects seem more prevalent when older adults use THC dominant treatments [40•]. A recent meta-analysis found a positive correlation between THC dosage and the presence of thinking or perception disorders [40•]. In addition, various studies found that cannabis use, specifically higher THC contents, is associated with the risk of psychosis [4, 18•]. The risk of neurocognitive impairment is concerning in older adults also given the increased risk of falls in this population. Commonly experienced adverse events when using cannabis include dizziness [15, 18•, 38, 42] and impairment in motor function [15, 24, 39], which can be dangerous for individuals prone to falling. Future studies collecting objective data on neurocognitive functioning and fall risks among older adults using MC would be critical to fully understand the potential consequences of MC use in this population.

Another concern regarding MC use is the risk of cardiovascular events, which again has not been well studied. Using a difference-in-difference analysis to assess changes in cardiac mortality outcomes between states with differing MC legalization and dispensing rules, one study found an association between MC legalization and an increase in cardiac-related deaths in both men and women in those states with more liberal rules for cannabis dispensing [1]. Even in younger populations, there have been associations between cannabis use and increased cardiovascular risk [18•]. These findings suggest there is likely an increased risk of these events in the older population. On the other hand, some studies showed cannabis use was associated with significantly reduced risks of shock and mortality among older adults who suffered an acute myocardial infarction. These conflicting findings highlight the urgent need for more research investigating the cardiac risks/benefits associated with MC use among older adults, given this is a high-risk population for cardiac conditions.

Inconsistent Evidence and Factors Contributing to Inconsistency

Overall, evidence on MC’s potential health benefits and harms in the older adult population remains limited and inconsistent. For example, there is conflicting evidence supporting the use of MC as a treatment option for pain. A review by Minerbi et al. (2019) suggests that while research has reported benefits, some studies also indicated psychiatric adverse effects and other side effects may decrease the overall benefit of the treatment [18•]. In particular, Minerbi et al. found that evidence of the efficacy of MC for cancer-related pain was essentially non-existent in the older adult population [18•]. Similar inconsistency in literature exists regarding the other health conditions or potential adverse outcomes mentioned above.

The wide variety of MC products available, lack of standardized dosing, and individual characteristics (e.g., biological sex, previous cannabis use, health condition prior to cannabis use) may all contribute to the inconsistent findings from different studies. Among the limited studies examining cannabis use specifically among older adults, the cannabis products used by the study participants ranged from cannabis flower obtained from unregulated sources to FDA-approved products (e.g., Marinol) or state dispensary products. Not only do the products themselves differ considerably (e.g., chemical compounds, THC:CBD ratio, route of administration), but the dosing of these products is not well-established and hard to measure. MC products such as concentrates, lotions, and vaporization cartridges make it challenging to quantify the dose used by the patients. Finally, individual differences may be an important confounding factor to consider when evaluating the health effects of MC, especially for observational studies. For example, both pre-clinical and clinical research suggests that cannabis may have sex-dependent therapeutic effects and abuse potential [43]. Also, those who started using cannabis regularly early in life may experience different health effects compared to those who started using cannabis in their later life. Lastly, those who had more severe health conditions may experience less improvement and/or more adverse events compared to their healthier counterparts. Without taking into consideration these important factors, different studies will likely reach contradictory conclusions when evaluating MC’s efficacy and safety. It should also be noted that randomized clinical trials can address many of these issues (e.g., using a single MC product and pre-determined dosing schedule, accounting for baseline confounding), but currently, it is still challenging to conduct randomized trials using dispensary MC products given the legal barriers in the USA.

Conclusions

While MC becomes a more popular alternative treatment for older adults, financial and educational barriers, as well as perceived stigma, could be important factors limiting their access to regulated MC products. There is limited and inconsistent evidence on MC’s health effects and adverse outcomes among older adults. Emerging evidence supports that MC may have therapeutic benefits for symptoms associated with chronic pain, insomnia, dementia, nausea, and vomiting. There are adverse events associated with MC use that may be concerning for the older adult population, such as the neurocognitive and psychological effects of THC and cardiovascular risks. However, the treatment appears to be well tolerated by the majority of older patients. More systematic and rigorous research on MC in older adults, such as randomized trials using real-world MC products, to determine its safety and efficacy for various health conditions is needed. Research on dosing procedures and product characteristics, as well as how these may impact health outcomes among older adults, is also crucial.

Funding

This work is supported in part by NIH/NIA R01AG071729 to YW.

Footnotes

Conflict of Interest The authors declare no competing interests.

Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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