Development and Implementation of a Medical Cannabis Clinic Within a Geriatrics Primary Care Clinic: Preliminary Data
VCU School of Pharmacy, Department of Pharmacotherapy & Outcomes Science, Richmond, Virginia, USA
VCU School of Medicine, Department of Internal Medicine, Division of Geriatric Medicine, Richmond, Virginia, USA
ABSTRACT
Background
Cannabis use is rising among adults, yet few users receive structured medical supervision. Older users face unique risks necessitating specialized oversight. Given their longitudinal relationships and detailed understanding of patients' health and goals, primary care providers are well‐positioned to guide decisions and education about medical cannabis (MC). Further, because of their expertise in managing complex considerations of aging, geriatricians in particular are uniquely qualified to offer safe, evidence‐informed guidance to older adults using MC. This led us to develop and implement a physician‐led MC clinic embedded in a geriatric primary care practice.
Methods
A monthly, physician‐led MC certification clinic was established to provide individualized evaluation, safety assessment, medication review, and counseling, with support from pharmacy and nursing. The clinic was shaped by the legal, regulatory, and clinical context. The demographic characteristics, medical and qualifying conditions, and medication profiles of patients with a MC clinic visit between Jan 1, 2022, and July 1, 2024, were evaluated retrospectively. Data was analyzed descriptively.
Results
In 30 months, 144 visits were completed. The population had a mean age of 65 years (SD 13.8), was 59.7% female, and diverse. There was high clinical complexity (mean 20.9 comorbid conditions, 14.7 medications). Pain was the predominant qualifying condition (88.9%), with anxiety (13.9%) and insomnia (11.8%) also common. Drug utilization reviews revealed a mean of 4.6 interactions per patient. Common medications included CNS depressants (66.0%), pain medications (59.0%), and psychiatric medications (56.9%).
Conclusions
This model demonstrates a feasible approach to integrating MC care into primary care for medically complex older adults. This integration prevents MC care fragmentation, provides thorough drug interaction screening, and supports informed MC risk–benefit assessment.
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Keywords: geriatrics, medical cannabis, polypharmacy, primary care, program implementation
Summary
- Key points
- ○Embedding a physician‐led medical cannabis (MC) clinic within geriatrics primary care is feasible and addresses the needs of medically complex older adults.
- ○This model leverages the expertise and continuity of geriatric and primary care teams to provide individualized evaluation, risk assessment, and medication safety monitoring.
- ○Patients served had high clinical complexity and frequent drug interactions, underscoring the importance of integrated, interdisciplinary oversight.
- Why does this paper matter?
- ○This paper describes a scalable, interprofessional model for integrating medical cannabis care into geriatric primary care for older adults, ensuring oversight and minimizing risks in a vulnerable population. As cannabis use rises among older adults, primary care–based models can improve safety, coordination, and informed decision‐making.
Article notes
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Revised 2025 Nov 5; Received 2025 Jul 18; Accepted 2025 Nov 9; Issue date 2026 Mar.
1.Introduction
Cannabis use has risen significantly over the past decade, with over 22% of American adults reportedly using cannabis in the past year. Although cannabis use is more prevalent among younger users, 12.4% of older adults reported use in the past year [1, 2]. Despite medical cannabis (MC) programs in 42 US states, greater than 84% of cannabis use is purely recreational, with few users receiving oversight through structured MC programs [3]. Participation in MC programs can support safe use, tailored treatment, professional supervision, legal protections, and continuity of care. Despite this, few patients participate in MC programs. For example, in states like Ohio, Missouri, and Pennsylvania, cannabis usage is greater than 20% for persons aged 12 and older, yet less than 4% is supervised by an MC program [3, 4]. Barriers to participation include provider and dispensary availability, certification costs, product costs, and complex access processes [4].
In 2016, the Federation of State Medical Boards published Model Guidelines for the Recommendation of Marijuana in Patient Care, recommending that programs prioritize established patient relationships, documented evaluations, shared decision‐making, written treatment plans, and ongoing monitoring [5]. The Montefiore Medical Center's MC Program (MMCP), established in 2016, successfully implemented these principles, certifying over 1600 patients in 5 years through a six‐step provider‐led process [6]. Similarly, a Canadian model described by Prosk and colleagues utilized an interdisciplinary team approach and was tested with over 13,000 referrals in 5 years [7].
Despite this guidance, programs vary substantially. A 2014 assessment by Williams and colleagues found that among 24 states with marijuana laws, only 42% included more than two components of traditional medical care and pharmaceutical regulation (e.g., doctor‐patient relationship, manufacturing protocols, testing/labeling, non‐smoked formulations, supply limits, prescription drug monitoring program participation, and physician training) [8]. Yet, the less comprehensive programs were found to enroll 99.4% of participants nationwide, highlighting a concerning gap [8].
Virginia's MC program has evolved since cannabis legalization in 2015. Although patients must obtain medical certification from a practitioner, they are not mandated to discuss use with their primary care team. Further, many providers feel uncomfortable in this role, potentially leading to fragmentation of care [9, 10]. A 2023 survey revealed that only 57% of MC users in Virginia consulted their primary care provider; the rest relied on online sources (30%), referrals (11%), or other paths [4]. Although patients may receive certification from telehealth providers, these often involve limited patient‐provider interaction and may not be covered by insurance. In Virginia, dispensaries require a pharmacist to be present to provide counseling. Although this counseling is available, it can be waived. Thus, it is unsurprising that only 30% of users received cannabis safety information from their provider [4]. Nevertheless, MC users consistently identify their doctor as the preferred source for cannabis‐related guidance [4]. Given their ongoing relationships and medical expertise, primary care providers are well‐positioned to guide MC decisions and education to ensure safe use.
The use of MC among older adults presents unique safety and efficacy considerations due to age‐related changes, geriatric syndromes, multimorbidity, and polypharmacy [11]. Evidence on the benefits of MC for pain, sleep disturbances, and dementia‐related neuropsychiatric symptoms is mixed, and while some studies suggest it may reduce opioid or benzodiazepine use, the risks are significant [12, 13, 14, 15]. Adverse effects in older adults include dizziness, drowsiness, fatigue, dry mouth, cognitive impairment, and in rare cases, hallucinations and paranoia [12, 16]. MC use has also been associated with hospitalizations and emergency department visits in this population [17]. The risks for psychomotor impairment and falls, cardiovascular outcomes, and liver injury are particularly concerning [13, 18]. Although older adults often begin with higher CBD:THC products to reduce side effects, no formulation fully eliminates risk [19, 20]. These vulnerabilities highlight the importance of involving primary care in MC decisions for older adults, ideally led by providers with expertise in geriatrics and complex care.
This paper aims to describe the development and implementation of a MC clinic in geriatrics in primary care designed to support safer MC use through enhanced care coordination between certifying providers and primary care teams, structured medication safety assessments, and informed, shared decision‐making. Development of our clinic was shaped by the guidance for State Medical Boards, the regulatory environment, and the unique needs of patients receiving geriatrics in primary care services. Implementation began in Fall 2021. We aim to describe the model workflow and preliminary implementation data.
2.Setting and Participants
The VCU Health Center for Advanced Health Management (CAHM) MC clinic is embedded within the Division of Geriatrics and staffed by an interprofessional team including medicine, nursing, clinical pharmacy, social work, and health outreach. Clinic protocols were designed collaboratively and influenced by the guidance for state medical boards, the regulatory environment, and the needs of patients seeking MC in geriatrics in primary care. At the time of development in 2021, both provider and patient registration were required—a mandate lifted in 2023. Certifying providers in Virginia may include physicians, physician assistants, or nurse practitioners with adequate training and clinical judgment. Our clinic includes one certifying provider, a geriatric‐trained physician who completed structured MC training during fellowship and who thus meets state certification requirements. As the clinic is an advanced comprehensive care model for qualifying patients with complex care needs, including older adults, it was important for the clinic to address issues related to multimorbidity, polypharmacy, and biologic changes with aging. Thus, the certifying provider is supported by a pharmacist, medical outreach worker, and nursing staff. Eligible patients are referred from within or outside the geriatric division and must have a specialty or primary care provider within the health system. Further, all patients are required to have capacity or have a decision‐maker present. In patients with an alternate decision‐maker, assent is always obtained.
3.Program Description
Potentially eligible patients are referred internally through the health system and approved by the certifying provider after chart review. Appointments are scheduled for 30 min and billed using standard CPT codes (9920X–9921X) that reflect a low level of decision making and generate 1–2 relative value units per encounter. Patient costs depend on insurance and are comparable to standard visits. This is in contrast to the cash rate often offered by electronic MC certification platforms. Integration into an existing primary care practice minimizes resource inputs. Approximately 8 clinic slots per full‐time employee are available monthly.
Each patient undergoes an individualized evaluation by the certifying provider, including assessment of qualifying conditions, symptom severity, prior management, cannabis experience, and any absolute or relative contraindications that may heighten MC risks. Absolute contraindications include confirmed hypersensitivity reactions, persistent or active psychosis, and an inability to obtain consent. Relative contraindications assessed include substance use disorder (SUD) or history of SUD (e.g., cannabis, alcohol, opioids, or sedatives), personal and family history of psychotic disorders or symptoms (e.g., hallucinations or delusions, regardless of etiology), cardiopulmonary disorders (e.g., unstable angina, arrhythmias, or moderate‐to‐severe COPD), and presence of drug‐disease and drug–drug interactions. Patients are counseled on adverse effects of, and considerations for safe use. Prior to visits, patients are also screened for drug–drug interactions with cannabis, either by the pharmacy team or the certifying provider. This screening includes a review of all documented prescription and nonprescription medications using at least two drug interaction databases. The results are summarized in the electronic health record (EHR) prior to the provider encounter and include any suggested monitoring parameters or recommended interventions. During the clinic visit, the certifying provider reviews these findings, discusses relevant safety concerns and recommendations with the patient, and, when appropriate, communicates with the primary care team or other involved clinicians to coordinate medication changes (e.g., deprescribing concomitant high‐risk medications), monitoring (e.g., therapeutic level monitoring for interacting medications), or additional follow‐up. A case‐based example of this workflow is provided in Box 1. Given the shared medical record, this communication occurs within the EHR.
BOX 1
A 77‐year‐old male with history of autoimmune hepatitis, liver transplant, prostate cancer, polyneuropathy, multiple squamous cell carcinoma of the skin, CKD 3a, and atrial fibrillation presented for initial evaluation of medical cannabis for the treatment of his painful peripheral polyneuropathy that had been present for 15 years and worsening. He had previously tried pregabalin, gabapentin, and electrical stimulation therapy without relief. He had no previous cannabis use history. His history of polyneuropathy prompted a discussion of the increased risk of falls with cannabis use. A medication review was completed by the clinic pharmacist prior to his appointment and reviewed during his visit by the geriatrician. The review described an interaction between medical cannabis and tacrolimus, as well as with warfarin. This was discussed with the patient during his visit. A decision was made to certify the patient, and a recommendation was made to his primary care doctor and his transplant physician to increase frequency of monitoring for his INR and tacrolimus levels. Subsequent monitoring by these providers revealed increased INR and tacrolimus levels with concomitant medical cannabis use resulting in medication adjustments to accommodate continued medical cannabis use. The patient's lab values subsequently returned to goal levels.
To ensure adequate monitoring and follow‐up both within MC clinic visits and throughout the continuity of the health system, cannabis is added to patients' medication and problem lists. All documentation, including pharmacist review, is accessible in the EHR. Patients are scheduled to be seen at least yearly for recertification. Patients are seen by the cannabis clinic annually for recertification. Earlier follow‐up with a patient's care team may be recommended for those with high‐risk medications (e.g., falls, cardiopulmonary conditions, cognitive impairment, or significant interactions). Communication regarding such recommendations is initiated by the certifying provider within the EHR. Because the clinic is embedded within geriatrics in primary care, and documentation of MC use is made within the electronic medical record, additional follow‐up can also occur during routine primary care visits.
The decision to certify or recertify is at the discretion of the provider. The clinic protocol does not use absolute exclusion criteria. In some cases, patients may receive certification but ultimately choose not to pursue cannabis (medical or recreational). Similarly, patients not provided certification could still obtain cannabis recreationally. As such, it is important that all patients using cannabis seek guidance from the clinic even when providers ultimately recommend against use. In such instances, we believe that offering a structured visit allows for a thorough safety assessment, informed counseling, and connection to follow‐up, even when certification is not pursued or advised. Box 2 provides an example illustrating how individualized assessment, shared decision‐making, and ongoing dialogue with family and primary care providers can support continued cannabis use in the context of functional gains and quality‐of‐life improvement.
BOX 2
A 79‐year‐old male veteran with a history of COPD, HTN, CKD 4 who lives in an assisted living facility was evaluated for initiation of medical cannabis for treatment of his chronic pain related to an injury sustained in the service and nightmares from PTSD. He reported that his pain and nightmares often made him stay isolated in his room and avoid participation in community activities. He also struggled to independently complete daily living tasks, such as transferring, grooming, and dressing. He had previously tried non‐medical cannabis for his PTSD and anxiety symptoms and found it helpful. He was evaluated in our clinic and provided with a certification for medical cannabis. Safety concerns discussed included falls risks, possible worsening of anxiety symptoms, as well as cannabis drug interactions. Several months after initial certification, his family raised concerns that his use of medical cannabis was too frequent. Upon further discussion with family members and his primary care provider, it became apparent that, while he was using a relatively high total daily dose, he had experienced a significant reduction in his anxiety, PTSD, and chronic pain symptoms which was allowing him to engage in social and physical activity regularly, as well as to complete more of his activities of daily living independently. It was decided to continue his medical cannabis therapy because of this symptomatic and functional improvement.
The role of the medical outreach worker evolved as the clinic and state regulations evolved. In the first year of the clinical program, the medical outreach worker would discuss the logistical issues related to MC obtainment through a dispensary following certification by the provider. As the role of the outreach worker in the health system evolved, and as regulations on patients to register eased, this role was absorbed by the certifying provider who now provides this counseling.
Although ultimate product selection is at the discretion of the patient and the dispensary, the certifying provider does provide tailored recommendations at all initial visits. The certifying provider generally recommends either topical or oral products, typically recommending against inhaled products (particularly in those with respiratory conditions). Products containing a 1:1 ratio of THC:CBD are frequently recommended. Alternatively, pure CBD products are often recommended for those concerned about or experiencing prior adverse drug events. A target dose of 5–20 mg daily of THC and/or CBD is recommended during the visit. Patients are counseled to start at low doses, and titrate slowly until they find an effective dose that is tolerable without adverse drug reactions. Patients are subsequently screened for adverse events at follow‐up visits to facilitate individualized discussions of dosing and formulations.
4.Program Evaluation
The demographic characteristics, medical conditions, and qualifying conditions of patients with a MC clinic visit between Jan 1, 2022, and July 1, 2024, were evaluated retrospectively. Data was collected from the electronic health record of eligible patients by using a standardized data collection tool. Data was analyzed descriptively. This program evaluation was determined to be exempt by our Institutional Review Board and the requirement for informed consent was waived.
In the 30‐month review, 144 visits were completed for a total of 122 unique patients. Most (84.7%) were initial visits and 15.3% were renewal visits, with a steady increase in renewals over time. All patients included in this evaluation were certified or recertified at the time of their visit. The mean age of patients completing a MC visit was 65 (SD 13.4) and 4.1% of patients were aged 85 or above. Most patients identified as White (49.3%) or Black (48.6%) and were predominantly female (59.7%) (Table 1). Over a third of patients (35%) have been found to be at risk for social drivers of health (e.g., food insecurity, housing insecurity, transportation needs, utility needs) on their annual screening. Most patients reported prior use of cannabis (52.8%). Nearly all patients (92.5%) had a primary care provider within the division of geriatrics, including the certifying provider (23%).
| Mean age (SD)—year a | 65 (13.8) |
| Age ≥ 85 years—no. (%) | 6 (4.1) |
| Median age | 67 |
| Female sex—no. (%) | 86 (59.7) |
| Race—no. (%) | |
| Black | 70 (48.6) |
| White | 71 (49.3) |
| Other | 3 (2.1) |
| Mean conditions on problem list (SD)—no. | 20.9 (11.1) |
| Conditions—% | |
| Cognitive impairment | 9.7 |
| Psychiatric condition | 54.2 |
| Cardiovascular condition | 88.2 |
| Pain syndrome | 91.0 |
| Mean total medications (SD)—no. | 14.7 (6.8) |
| Medications—% | |
| Pain medications | 59.0 |
| Psychiatric medications | 56.9 |
| Anticoagulant | 12.5 |
| Antiplatelet | 34.0 |
| Antihistamine/anticholinergic | 44.4 |
| Sympathomimetic | 31.9 |
| CNS depressant | 66.0 |
The top qualifying conditions included pain (88.9%), anxiety (13.9%), and insomnia (11.8%); 16.7% had other qualifying conditions. Patients had a mean of 20.9 comorbidities. Most had at least one pain syndrome (91.0%), frequently neuropathic pain (53.5%), and most also had at least one cardiovascular condition (88.2%). Patients had a mean of 14.7 concomitant medications. Of these, a mean of 4.6 medications per patient (range 0–11) had a potential interaction with cannabis (Table 2). A pharmacist completed a drug utilization review in 72.2% of visits. These drug utilization reviews revealed a mean of 2.4 pharmacodynamic and 2.7 pharmacokinetic interactions.
| Visits with pharmacist drug utilization review | 72.2% |
| Total drug‐cannabis interactions per patient | |
| Median number of total interactions | 4 |
| Mean number of total interactions | 4.6 |
| Median number of pharmacokinetic interactions a | 3 |
| Mean number of pharmacokinetic interactions a | 2.7 |
| Median number of pharmacodynamic interactions b | 2 |
| Mean number of pharmacodynamic interactions b | 2.4 |
Concomitant medications included CNS depressants (66.0%), pain medications (59.0%), psychiatric medications (56.9%), and antihistamine/anticholinergics (44.4%). Among patients using pain medications, 75.3% were on gabapentinoids and 34.1% on opioids. The documented morphine milliequivalents (MME) per day ranged from 3.8 to 423 MME with a median of 40 MME. Among patients taking psychiatric medications, 70.7% were on an SSRI and 13.4% on a benzodiazepine.
5.Discussion
This retrospective evaluation describes the development and implementation of an interprofessional, physician‐led MC clinic embedded within geriatrics in primary care. In its first 30 months, the clinic served a population of medically complex, diverse older adults, supporting the need for MC management to be connected to primary care, ideally with providers competent in geriatric care. The case highlighted in Box 1 illustrates how integration into geriatrics and primary care supports individualized risk assessment, drug interaction management, and close communication with other providers to maintain safety. Consistent with national patterns, pain was the predominant qualifying condition (88.9%) [21]. This finding, along with the high prevalence of pain and psychoactive medication use, suggests an increased adverse event risk, underscoring the need for education and monitoring in longitudinal environments. The average of 4.6 potential drug–drug interactions per patient highlights the value of pharmacist involvement and robust medication assessments.
Other models of care, including the aforementioned models described by Prosk and colleagues as well as New York's MMCP, offer important comparisons [6, 22]. The most notable difference is their more structured post‐certification follow‐up. In the MMCP model, patients were reassessed at 3–6 months following certification, and then annually [6]. The Prosk model included a nursing phone call at 1 month post‐certification and an in‐person appointment 3 months after until the therapy was determined to be stable, followed by visits every 6–12 months [7]. In contrast, our clinic primarily conducts annual recertifications, with additional follow‐up occurring during routine primary care. The case in Box 2 demonstrates how this flexible but connected follow‐up approach can support nuanced, shared decision‐making in response to evolving concerns from patients, families, and care teams.
This clinic model is strengthened by its integration into primary care. The certifying provider's access to the medical record and collaboration with longitudinal care teams facilitate a more thorough assessment of MC needs and safety. Although telehealth may increase access, our clinic model offers the added benefit of in‐network care, continuity, and medical oversight. Importantly, receipt of MC certification does not preclude recreational use. In Virginia, 90% of MC users reported purchasing cannabis from sources outside the regulated market, with only 23.6% of past‐month grams obtained from dispensaries [4]. Patients seeking recreational products may still benefit from clinical oversight through embedded primary care models and are not precluded from this clinic.
Given that over 60% of patients served in this clinic are over age 65, the involvement of a geriatric‐trained specialist ensures individualized, age‐appropriate evaluations–crucial given the complexities of older adults. Integration of MC certification into the electronic health record and problem list enhances care coordination. Pharmacist‐led drug interaction screening further improves safety in a population characterized by polypharmacy and altered drug metabolism.
Limitations to this clinic model are not unique. Like the MMCP model, our program faces long wait times and limited availability [22]. To address this, MMCP expanded available providers and visits [6]. Our clinic must either expand access or further restrict eligibility criteria (e.g., to those with neuropathic pain) to meet the growing need. The disconnectedness between the certification process and the obtainment of MC via a dispensary is inherent in the state regulation. Greater connectedness could allow for the dispensation of more tailored regimens. This evaluation also has several limitations. First, data were collected retrospectively and limited to information in the electronic health record. Thus, we could not assess clinical outcomes such as symptoms, quality of life, or subsequent medication changes, or the impact of safety measures. Further, findings are drawn from a single academic center and may not be generalizable. Finally, although pharmacists participated in most visits, limited resources prevented universal involvement.
Optimal outcomes for this clinic model include safer cannabis use through enhanced care coordination between certifying providers and primary care teams, structured medication safety assessments, and more informed, shared decision‐making between patients and providers. Future evaluations may assess reductions in high‐risk medication use (e.g., opioids, benzodiazepines), incidence of adverse effects or unplanned healthcare utilization (e.g., emergency department visits, hospitalizations), patient‐reported symptom relief, and self‐efficacy in managing cannabis use. As the clinic matures, systematic measurement of these outcomes will be critical to evaluating the effectiveness and safety of this integrated care model.
The CAHM MC Clinic demonstrates a feasible, scalable model for integrating structured MC care into geriatrics in primary care. As access grows, there is a need to develop models that ensure safe and effective use. Future workflow improvements include the development of patient education materials to support shared decision‐making, standardized protocols for high‐risk groups (e.g., opioid users, patients with cognitive impairment) and/or automated interaction alerts. Primary care teams with geriatric expertise play a critical role in advancing responsible, integrated MC care models that meet the needs of complex patients.
Funding
The authors have nothing to report.
Disclosure
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
I affirm that all individuals who contributed significantly to this work are listed as authors. All authors have approved this manuscript submission.
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Weaver R., Velez B., Weissberger M. L., and Zimmerman K. M., “Development and Implementation of a Medical Cannabis Clinic Within a Geriatrics Primary Care Clinic: Preliminary Data,” Journal of the American Geriatrics Society 74, no. 3 (2026): 838–844, 10.1111/jgs.70217.
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Footnote Group
References
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