Health Canada in March 2024 released “Legislative Review of the Cannabis Act: Final Report of the Expert Panel” with the following:
“Recommendation 42: To improve patient access to cannabis for medical purposes, Health Canada should permit pharmacies to distribute cannabis products to individuals holding a medical authorization from a health care professional. Provinces and territories and the regulatory authorities for pharmacists should consider supporting this new access channel for patients once federal changes are made.”
As much as we are in favour of such a change in regulations, how would that look? What benefits does this bring to patients and the industry, but also, what challenges or unexpected results could occur? We will attempts to highlight some points for discussion purposes.
Benefits:
- Stigma Reduction and Single Point of Access: Finally, patients can proudly access their cannabinoid medicines with all their pharmaceutical options. The pharmacies can then provide a true, medication record for patients and physicians.
- Access to a Pharmacist: Patient’s can call a pharmacist now, but the interaction is not ideal, and a bit segregated. Patients coming to pick-up their orders, will always have the chance to speak to a pharmacist about ALL their drug-related therapies. Pharmacist’s can discuss dosing, and forms of administration in their scope of practice. They can discuss with a patient if their desired health outcomes are being achieved, or are they experiencing treatment failures, or adverse effects. It is a amazing where a conversation can go, just by being face to face, and asking “How are things?” We loose that in the “Amazon” Medical Cannabis delivery operation.
- Insurance: Currently, to our knowledge, no cannabis LP system can direct bill insurance plans online. Cannabis, even for those with insurance coverage, are a cash up front and submit model. Pharmacies can bill insurance directly, so that could be a major opportunity.
- High Dosing and rare Dosage Forms: There are concerns about high dose THC, and some formulations are not readily available in recreational environments – i.e. suppositories, low THC capsules. Pharmacies may be ideal to allow higher, prescribed cannabis doses in a safe, monitored manner, and be better served to offer, less common dosage forms for patients
Challenges:
- Space: Pharmacy dispensaries already tend to be small, and cannabis dried flower can become very large and bulky. When you start discussing “X” amount of cultivars, sizes, formulations, it can get tight very quickly.
- Distribution/wholesale: With 1000’s of cultivars, and 100’s of producers, their is no way pharmacies’ can stock everything. Pharmacies do not order pharmaceuticals from every manufacturer now. They order from pharmaceutical wholesaler/distributers. Essentially, this will need to be developed for the cannabis space. Is it a drug distributer add cannabis, for one stop shop, or a separate cannabis distributer? What products/brands get carried? Will this be just a reboot of 2018, and a brand war? What about micros and craft? Does the current medical cannabis LPs continue?
- Education of Pharmacists: Most pharmacists have done some basic education on cannabis, but to be fair, their is not a lot of clinical, evidence-based studies on cannabis. Medical cannabis may be the most individualized, personalized therapy that pharmacists have ever encountered. Pharmacists may not understand the concept of “cultivars” and the subtle nuances that not all cannabis flower is the same or interchangeable. Even capsules/softgels will have different carriers oils, inputs (isolate/distillate/resin) and ratios. Pharmacists are used to “interchangeability” among brands – not the case in cannabis.
- Smoking: As a pharmacists, we do find it conflicting to potentially recommend inhalation – smoking or vaping are both a risk for lung issues. However, sometimes inhalation is the best route of administration for the condition/patient – i.e. Chemo Induced Nausea Vomiting, Crohn’s, or the need for rapid onset with short effects. And because cannabis flower has well over 400 chemical entities, and is so complex, many refined products, simply do not have the same clinical response as a flower. Even orally, 11-hydroxy THC, is very potent and has a very different profile and effect versus inhalation. Dosing, titrating and clinical response simply may be easier/better with inhalation in some patients. We promote non-inhalation as much as possible, with full understanding that dried flower, or inhalation still may end up being the best product for an individual.
- Cost and Selection: Is adding a pharmacy, and a potential cannabis wholesaler for pharmacies going to add cost to medical cannabis? In theory it should be no worse that adult recreation pricing, but there will be wholesale fees for sure. Currently, some medical platforms are cheaper by selling direct to patients. And as mentioned before, will selection or limitations on Brands/SKUs occur in pharmacies, or amongst different pharmacy chains?
We do not pretend to know all the answers and potential issues, but yes, allowing pharmacies to carry cannabis would be a good thing. How to operationalize it to provide the experience that patient’s are looking for is not so straight forward. Adult-Recreational space still has issues after 5 years+.
We do not think the LP Medical Sale direct to patients can disappear, as it may be preferred for many patients and helps rural patients and those with mobility issues. Maybe only niche pharmacies get involved with medical cannabis? That happens now with pharmacies and compounding for example. Maybe pharmacies just order from provincial cannabis wholesalers, with a few tweaks? We are doubtful the pharmaceutical distributors with their established network of deliveries, and security with controlled substances will pass on their chance to access those wholesale fees.
The count down is on – it is coming. It will be interesting……