By Michael Kani BScPharm, MSc, PharmD (candidate), RPh
Medical access to cannabis first came into effect in 2001, amended to the current ACMPR. As of October 17, 2018, Canada became the second country in the world to legalize recreational cannabis use. Lots of questions remain on the two streams and the implications for patients and health professionals.
What is or could be the role of pharmacists in the cannabis space? Will pharmacists ever even dispense any cannabis, and in a world where recreational cannabis is now legal, is there a need for medical cannabis?
- Key point: regardless of why cannabis is used, it is still physiologically active.
THE CANNABINOIDS + TERPENES
THC is the most researched cannabinoid. It’s the one that causes psychoactive effects, the “high.” The potency is often presented as a percentage of THC by the weight of specific part of the plant. THC potency in dried cannabis has increased from avg. 3% (1980s) to around 15%, with some strains as high as 30%. It’s used as an analgesic, anti-emetic, appetite stimulant. Cannabis that contains very low amounts of THC (less than 0.3%) is classified as hemp and falls under the Industrial Hemp Regulation.
CBD is not psychoactive, and there is some evidence it reduces the psychoactive effects of THC, especially when the concentration is equal to or greater than THC. It’s used as an anti-convulsant, anti-depressant, anxiolytic, anti-inflammatory.
The Access to Cannabis for Medical Purposes Regulation (ACMPR)
Access can come from:
- Purchase from licensed producers
- Personally grown
- A designated grower
Any registered physician (provincial physician colleges have different additional requirements) or nurse practitioner where provinces allow can authorize its use through the completion of a medical document form, similar to a prescription. Patients are allowed a 30-day supply (i.e. 30 times daily gram limit or 150 grams, whichever is lower) of cannabis, which comes in the forms of fresh and dried, oils, oil in capsule or similar dosage forms, or other forms, such as edibles, which cannot be sold by licensed producers.
The Cannabis Act establishes a strict legal framework for controlling the production, distribution, sale and possession of cannabis across Canada.
But there’s a world of difference between the medical versus recreational cannabis in terms of demographic, strains, forms, effects and route of administration.
What is going to happen now to medical cannabis?
Health Canada is scheduled to review the ACMPR in five years post-recreational cannabis legalization, so in 2023. The Canadian Medical Association wants medical cannabis scraped: it sees no need for physician involvement, and have taken their position due to in their view, lack of research and therapeutic evidence so that physicians are uncomfortable with authorizing.
The Canadian Pharmacists Association (CPhA) though wants the medical arm maintained and to position pharmacists to be able to dispense.
The Canadian Nurses Associations wants medical cannabis maintained post-creational legalization.
Is a medical cannabis system needed?
Recreational cannabis, cannabinoid-base drugs (including medical cannabis) are not equivalent. Eliminating the medical arm will lose access to support from the government, which fosters safe and appropriate use. Only the recreational arm will continue to fuel stigma and delegitimize medical cannabis users. The medical arm is needed to enhance cannabinoid-based therapeutic research.
The medical arm would reduce the risk to patients, and enable informed decisions whether it is an appropriate option for patient health need in conjunction with their healthcare provider. The medical system would support the infrastructure to provide increased and continuous education for healthcare practitioners. Plus, a separate medical arm does not mean an endorsement of cannabinoid-base therapeutic as a cure-all, but provides support and guidance for the needs of complicated patients and seniors.
- Key point. Medical and recreational cannabis are not equivalent and should have different systems for access.
Will pharmacists ever dispense cannabis?
Potentially, but not under the current ACMPR and Cannabis Act. A potential workaround would be to become a licensed producer but pharmacists cannot distribute directly to patients at the counter. There is strong lobbying by pharmacy stakeholders to allow medical cannabis distribution through pharmacies, but this would require an amendment to the ACMPR. Most pharmacists have said they are not interested in recreational cannabis distribution.
- Key point. The difference between medical and recreational cannabis access will be the knowledge and information that comes with what one gets.
Can pharmacists handle cannabis, e.g. compounds?
This activity is prohibited. According to Health Canada, any compounding activity involving cannabis would require enabling regulations or a ministerial authorization, in addition to complying with applicable provincial or territorial requirements.
Can pharmacists accept and dispose of cannabis?
Provincial colleges and regulatory authorities have yet to provide a position in this, but one would argue that those who profit from it should pay for the disposal, hence some pharmacies may choose not to accept it. For pharmacies that do, Health Canada recommends disposing companies that hold a controlled substances license should be able to dispose of cannabis (e.g. SteriCycle). It is not yet clear if the process and requirements are different from all other narcotics, so it’s best to check with the disposal company.
What is the role of the pharmacist then?
- Educate parents and young patients about cannabis use risks.
- Identify myths and debunk them.
- Adapt harm reduction strategies.
- Assist in the management of adverse effects.
- Assist in the development of organizational policies (HR, housing, etc.)
You might also consider setting up cannabis consulting as a pharmacist value-added service, much like HRT, travel medicine, diabetes education, anticoagulation clinics.
Such a service might offer a new opportunity for pharmacists to engage with patients, attract new patients and customers, and set your pharmacy apart from the competition. At the same time, it might draw attention to some of your other services, and it might also increase physician referrals and recognition of your pharmacy.
Michael Kani is a practising community pharmacist/owner of Michael’s Pharmacy in Saskatoon, Saskatchewan, and a consultant to the Community Pharmacy Professionals Advancing Safety in Saskatchewan (COMPASS) program where he educates and trains pharmacists on safe medication practices.