Future studies will need to elucidate the mechanisms responsible for increased renal 2-AG levels in IRI and its potential utility as a therapeutic agent. The COVID-19 pandemic poses great challenges for older adults and their families, support systems, caregivers, and medical and mental health care providers. Increased mortality among older adults following infection with SARS-CoV-2, the novel coronavirus, is now well established. Older people already are vulnerable to the detrimental effects of isolation and face disproportionate adverse consequences from social distancing and shelter-in-place guidelines, which may trigger or worsen anxiety, depression, substance use, and other psychiatric disorders. As long as social distancing guidelines remain in place, older adults in recovery from substance use disorders may find themselves cut off from support if they are unable to effectively use online treatment and self-help resources. Here we outline several key areas of clinical concern for mental health providers who work with older patients as well as issues for consideration in future COVID-19 research.Alcohol is the substance most commonly used across the age span, and can lead to severe medical, functional, and psychiatric problems for older adults, as well as sleep disruption, falls, and other injuries and accidents. Unhealthy alcohol consumption is associated with a number of chronic medical conditions common in older adults.Of particular concern, suicide risk is elevated among older adults with both depression and alcohol use disorders. In 2015−2017, 10.6% of adults over 65 reported unhealthy drinking in the prior 30 days, an increase over previous years.Current National Institute of Health guidelines recommend that adults age 65 and over consume no more than 7 drinks per week and no more than 3 drinks in 1 day. However,cannabis hydroponic set up for older adults with common medical conditions or psychiatric disorders there may be no level of safe alcohol use. Because alcohol-related immune system impairment increases susceptibility to pneumonia and other infectious disease, minimizing alcohol consumption may be critical for older adults during the pandemic.

Providers working with older patients, either in-person or using remote technologies, should ask about current quantity and frequency of alcohol use and about any recent increases in drinking that may be connected to social isolation or financial stressors, anxiety, depression, or suicidal ideation. Pharmacologic treatments for alcohol use disorders and brief behavioral interventions such as motivational interviewing for patients with lower-severity alcohol problems can be effectively integrated into care, even with increased use of telemedicine.Although tobacco use in the United States has decreased over time, about 8% of adults aged 65 and over smoked cigarettes in 2018.In contrast, the proportion of adults 65 years and older who reported prior year cannabis use increased from 2.4% in 2015 to 4.2% in 2018, with a greater increase among those who reported receiving mental health treatment or who also used alcohol.There is strong evidence that smoking tobacco puts people at risk for more severe COVID-19- related symptoms; data from China indicate a case fatality rate of 6.3% for individuals with chronic respiratory disease, compared with 2.3% overall.Vaping nicotine is thought to be less harmful than combustible tobacco yet there are also growing concerns that vaping nicotine may damage lungs in ways that make users especially vulnerable to COVID-19-related symptoms.In the context of the pandemic, providers should advise older adults to eliminate smoked tobacco and nicotine vaping, and encourage patients to use nicotine replacement or anticraving medications such as bupropion. Among older adults, smoking cessation reduces cardiovascular and other health problems,likely improving COVID-19 survival chances. For people using cannabis, edible forms of cannabis should replace smoking or vaping. Finally, providers should remain alert to adverse effects of cannabis on older adults including falls, anxiety and dependence.Older adults have higher rates of chronic pain than younger adults and are more likely to be prescribed opioids ,leading to potential for dependence over time. As with younger adults, older people who misuse opioids are likely to have comorbid psychiatric and other substance use disorders.

The COVID-19 pandemic poses substantial challenges to effective pain management and to addiction treatment for older adults. For those who use medications as prescribed, interruption of regular medical visits is a barrier to careful monitoring. Among individuals with an opioid use disorder who are engaged in treatment, care disruption may lead to decreased access to methadone, buprenorphine, naloxone treatment for overdose, as well as critical social services.Lack of treatment access, in combination with social isolation, increases vulnerability to relapse and overdose for older adults during the pandemic. Older adults are also at higher risk of experiencing negative effects of benzodiazepines, commonly prescribed for anxiety and insomnia.Between 2010 and 2016, among older adults in the Veterans Administration, the prevalence of benzodiazepine use has ranged from approximately 9%−11% and incidence of new prescriptions has held steady at approximately 2%.As of this writing, there are no published data regarding changes in benzodiazepine prescription rates associated with COVID-19; however, previous research has demonstrated increased use associated with disaster situations.The American Geriatrics Society Beers Criteria strongly recommends avoiding benzodiazepine use, except in specific circumstances , because of the potential for cognitive impairment, falls, fractures, motor-vehicle accidents, other serious injuries, and delirium.These hazards may be magnified by concurrent alcohol consumption, illicit substance and opioid use, and opioid-replacement therapy with methadone or buprenorphine.Since the 1970s, Dutch drug law and policy have moved away from punitive prohibition toward a harm reduction model, with the objective of minimizing the harms associated with both drug abuse and drug policy. Scott Jacques, Richard Rosenfield, Richard Wright, and Frank van Gemert investigate whether the de facto decriminalization of cannabis in the Netherlands, with its semi-licit system of licensed retail sales in “coffee shops,” reduces the crime and violence often found in illicit drug markets.

I say “de facto decriminalization” and “semi-licit system” because, as the authors note, the Dutch have made it effectively legal for anyone older than 18 years of age to walk in the front door of coffee shops and buy small amounts of cannabis, but it remains illegal to bring supplies of that cannabis in the back door of coffee shops. This “back door problem,” as the Dutch call it, has caused trouble for coffee shop owners and growers and no shortage of debate in Parliament. But for decades, coffee shops have functioned reasonably well within this legally ambiguous space, with cannabis finding its way to consumers with few problems and little policing. To contextualize Jacques et al.’s contribution, it may be useful to recall how cannabis was criminalized and why the Dutch departure from criminalization is historically significant. Until the Netherlands shifted its drug policy toward harm reduction in 1976, cannabis was prohibited around the world on pain of criminal punishment . Cannabis criminalization began with “the malevolence assumption” , which still serves as its logical fundament. In national legislative histories, deliberations over the United Nations’ drug control treaties that globalized cannabis criminalization, or current claims by those who still defend it, one finds the same premise: Cannabis is so dangerous it cannot be allowed to be legally available. Dutch cannabis policy is interesting largely because it challenges this premise.U.S. officials cultivated the malevolence assumption. The legal status of cannabis was initially transformed from a prescribed medicine into a proscribed vice by the moral entrepreneurship of the Bureau of Narcotics during the Great Depression . A 1934 Bureau report to the League of Nations, for example, asserted that “fifty percent of the violent crimes committed in districts occupied by Mexicans, Turks, Filipinos, Greeks, Spaniards, Latin Americans and Negroes may be traced to the abuse of marijuana” . Beyond stoking racial and ethnic prejudice that demonized cannabis users,hydroponic system for cannabis the Bureau also generated fear around the effects of cannabis itself. The report approvingly quoted a narcotics officer who claimed that “Marijuana has a worse effect than heroin. It gives men the lust to kill, unreasonably, without motive – for the sheer sake of murder itself” . In 1936, just prior to passage of the Marijuana Tax Act of 1937 that criminalized cannabis in federal law, the Bureau-sponsored film, Reefer Madness, depicted American youth smoking a few puffs of cannabis and quickly engaging in wild sex, assault, and even homicide. When cannabis use spread among White middle-class youth in the 1960s, however, the alleged malevolence shape-shifted: Then drug control officials claimed cannabis caused not violence but an “amotivational syndrome” that sapped energy and ambition, leaving a generation of stoners.The Bureau helped lead the drive for global cannabis criminalization, which reached fruition in a 1961 UN drug control treaty.The Netherlands is a signatory to this treaty, so how did the Dutch manage—in splendid isolation until recently—to avoid the malevolence assumption and demonization and to effectively decriminalize cannabis ? .First, the Netherlands has long been known for its culture of tolerance , which has deep roots . With nearly half their land mass below sea level, the Dutch have always faced the primal threat of inundation. But as the enemy sea could not be defeated, they learned to accommodate it with dykes, pumps, and sluices that channel it in less harmful directions. The Netherlands also has a long history of bloody religious wars, being on the front lines of Europe’s Reformation battles.

Slowly the Dutch developed a pluralist state structure in which Protestants, Catholics, and later others agreed to tolerate each other under the same civic roof to the benefit of all . The pragmatic advantages of pluralism and tolerance were further highlighted by centuries of Dutch success in international trade . Add to this history the painful experience of Nazi occupation during World War II and you can see why tolerance remains woven into the cultural DNA of the Netherlands. Their pioneering move to a harm reduction drug policy was a natural extension of Dutch gedogen. Second, the officials who developed modern Dutch drug policy had an intuitive understanding of labeling theory and the risks of punitive prohibition. Their first moves toward cannabis decriminalization were based on reports from two expert national commissions in the late 1960s . Neither expressed moral approval of drug use, but both paid close attention to evidence showing that although experimentation was common, addiction was rare and controlled use was the norm. The culture of tolerance allowed both commissions to distinguish between acceptable and unacceptable risks, which led them to propose separating the market for cannabis from the market for riskier drugs. And both emphasized the importance of avoiding punishments likely to stigmatize and marginalize users, thereby intensifying their deviance and making it harder to return to socially accepted lifestyles. These consequences were the type labeling theorists hypothesized—what Lemert called “secondary deviance” and Becker described as developing deviant identities and careers. Both commissions concluded that cannabis use should be removed from the province of criminal law.Third, there is flexibility in the Dutch legal culture, starting with a preference for informal over formal social controls whenever feasible . The Dutch legal system distinguishes between law and policy and operates under “the expediency principle” , which is also part of European Union law; the words in Dutch denote something that is suitable and well timed. This principle allows prosecutors wide latitude to decide whether enforcing a law makes sense as practical policy “in the public interest” . As a matter of statutory law, cannabis remains criminalized, but the Dutch Prosecutors General have decided that enforcing that law is not expedient or practical and so have made it national policy to not enforce it. In short, Dutch policy makers had a more open juridical path to decriminalization than policy makers elsewhere.Returning to the article at hand, Jacques et al.’s beginning premise is that “prohibition undercuts the state’s regulatory capacity by producing zones of virtual statelessness” where law and legal means of dispute resolution are not available, which in turn increases the likelihood of victimization and extralegal retaliation. The Dutch Opium Act of 1976 that allowed cannabis sales and “separation of markets” was designed to reduce some of theseillicit market risks and had the added virtue of constricting the geography of any potential “gateway” from cannabis to harder stuff. Jacques et al. hypothesized that illegal drug sellers would be more often victimized, and in response be least likely to mobilize law and most likely to retaliate; that legal sellers of alcohol in cafes would be least victimized, most likely to mobilize law, and least likely to retaliate; and that the semi-licit cannabis sellers in coffee shops would fall in between.