S1E4 - Pharm Phacts

 Should cannabis be sold in pharmacies? Is there a difference between recreational and medicinal cannabis?  Should an ER Doc have a record if a patient is using medicinal cannabis?  Trevor the Pharmacist thinks medicinal cannabis belongs in a pharmacy.  What do you think?


Sunday, 08 April 2018 21:16

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Episode Transcript

Dr. Shearer: Yes. Well I'm the CEO with Pharmacists Manitoba and I have been fortunate to work with the wonderful community pharmacists in Manitoba for the past five years and our role is to improve the recognition and compensation of pharmacists in the province to unify and advance the pharmacy practice and profession and to inspire excellence in practice and promote the value of pharmacists professional services. We have a board of directors that includes nine pharmacists from around the province both rural and also urban and we work really hard to make sure that pharmacists have important information and government policy decision makers and funders both provincially and federally recognized the role of pharmacists and engage pharmacists in productive services and great health care to all of the people that live in Manitoba.

Trevor: That's great. Now when I had people ask me what's the difference between the College of Pharmacy and Pharmacist Manitoba, I say the College of the people who license me and the Pharmacists Manitoba are the people who sort of promote pharmacy that is that a fair way to describe Pharmacists Manitoba?

Dr. Shearer: It is so the College of Pharmacists of Manitoba is a regulatory body enacted by law to protect the public to license and monitor pharmacists services and license pharmacists for practice. We on the other hand are the advocacy bodies so we promote the role of pharmacists. We increase the scope of practice and hopefully as an insured benefit we educate the public about the services we provide education to pharmacists and we negotiate contracts for the fees for services.

Trevor: Fantastic. So we are sorta looking at different parts of cannabis and how its coming and changing and seems every day it's in the news something new and exciting is happening. So let's start with just the really basic question does Pharmacists Manitoba think cannabis should be sold in pharmacies.

Dr. Shearer: Yes we believe that pharmacists have a significant and valued role in the dispensing and the distribution of medical marijuana to the public to those in need of medical marijuana. We are in line with the Canadian Pharmacists Association in that position and view.

Trevor: That's great. Now I think you brought up an important distinction not everyone would have caught. So do we think there does Pharmacists Manitoba think there that recreational and medicinal marijuana or cannabis are different things and should be treated differently.

Dr. Shearer: They are very distinctly different products. Before I answer that I just want to give a little bit of history about medical medical marijuana across Canada.

Trevor: Absolutely.

Dr. Shearer: To help understand why we've come to the position of where pharmacists may set and the value that they offer so medical marijuana was legalized in Canada in 2001. It's gone through a number of different acts and reiterations but it's the basis of it is to allow eligible patients to become registered users to access marijuana for medical purposes through Health Canada or grow marijuana for their own use. Most recently in 2016 the access to cannabis for medical purposes regulation came about and that was really to enable producers to have a better regulatory framework and to expand cannabis oil fresh marijuana buds and leaves. In addition to dried marijuana to allow authorized users to possess and alter different forms of cannabis. So we've really had a good 16 years of experience with access to medical marijuana for those in need in our province and in our country. And we've been able to understand the concerns and issues with the current industry framework and this has led to questions relating to an increased role for healthcare professionals in its management. So with the move to establish legalize recreational marijuana across the country by this summer in 2018. Now is a really good time to review any current and potential issues and evolve the access distribution safety and improved management options for medical marijuana. So now back to your question why it's important to differentiate between recreational and medical marijuana so all those are derived from the same plant. There are important differences between medical and recreational marijuana.  So for example medical users may seek out strains and forms to alleviate symptoms while minimizing intoxication whereas recreational users may primarily be taking marijuana for euphoric effects. Experience in other jurisdictions have demonstrated demonstrated the importance of differentiating medical and recreational marijuana by restricting product strains and forms as well as establishing distinct access channels for medical marijuana. One of our concerns is that the existing shortcomings in the medical marijuana regime could be exacerbated with the move to legalize recreational marijuana. If there are not policies practices and incentives employed to clearly identify and differentiate between the two markets so the move to legalize marijuana for recreational purposes could create harm for Manitobans and thousands of Canadians who use marijuana for medical purposes. If for example cost and access are more attractive than the recreational market should this be the case. Some patients may choose to access their supply through the recreational market leaving them with no medical oversight which would increase health complications for high risk patients and we know that about 8 percent of Canadians that use marijuana for medical purposes and obtain it through legal channels. This means that the majority of those using medical marijuana are either growing it at home or more likely obtaining it from the illicit market where quality and safety measures are unclear. So moving forward in time the concern that these individuals may switch access to recreational marijuana outlets is a real and justified concern.

Trevor: Thank you that's very thorough. And as some of this is from the CPhA or Pharmacists Canada study that they had KPMG help them put together and get so I just want to sort of flip again to something that came straight out of the study. The they seem to have six sort of overriding principles. They thought that it might be useful for having medicinal marijuana in pharmacies so they thought protecting patient and public safety. Just the one we were just talking about differentiating between medicinal and recreational marijuana. And number three was reducing risk to patients through evidence based clinical practice. So I assume that's one of the arguments that Pharmacists Manitoba would also make for why having the we'll call it the medicinal end of things through pharmacies with a health care professional.

Dr. Shearer: Yes. So all health care professionals need better information and evidence from research and studies to understand what the guidelines should be and how marijuana interacts with other drugs in a medication regime. Everybody can benefit from that. And since the original study that was done with the Canadian Pharmacists Association and KPMG back in March 2016 more associations more national bodies have come out with the same recommendations recognizing that the public needs more information. Health care professionals need more information and specifically there are some clinicians so physicians and nurse practitioners who can prescribe now for people to be eligible and access medical marijuana through the Health Canada channels. Not all of them understand the information research benefits harms and interactions and may not be supportive of that medication prescription and so people do go to the illicit market to get different types and forms of marijuana thinking it's medicinal. So we really need more information to help us process understand plan and provide the best services and pharmacists are the medication experts. They are the important people in the health care team to help everybody manage their medications especially people who are taking medical marijuana often have other medications that they are taking. And so you increase the risk of interactions if you're not sure where the strain or form is coming from. You don't understand the clinical evidence you're looking at dosage and so pharmacists are the really the health care professional amongst the team with the patient and other health care providers. That helps to provide that review monitoring evaluation and support to improve the medication management.

Trevor: No I think that's an excellent point. I'll toot the pharmacist horn and Kirk my nurse can you know tear me down later but it's come up. You know already I've got two or three people in our various care homes who are on the medicinal marijuana. This comes directly from the licensed producer to the patient but the only way I knew that these patients were on it was because the doctor said help had me help the families fill out the paperwork and get it all done. Theoretically they could have you know completely skirted the pharmacist and although you know we're responsible for every other medication that goes into that care home and the interactions and everything else that goes on with properly getting patients to safely use their medications in the care home because of the way it's set up now I would have had no idea that patient was even on medicinal marijuana because right now it can't go through my pharmacy the best of my understanding. So I'm obviously biased but I agree there should be at least some form some way of having medicinal cannabis go through a pharmacy.

Dr. Shearer: Absolutely. So it goes back to you know what is the benefit of separating the sale of the products. And that's really to ensure that marijuana use for medical purposes has a focus on health care professional oversight which improves patient safety enabling patient education and the health care providers support and counseling for that purpose and includes review and monitoring of potential medication interactions and contraindications and health professions support to manage those interactions.  And that's really the starting point is the pharmacist and you know marijuana is a drug with potential health impacts including drug interactions and negative effects from smokeable forms. And with more than 400 chemical agents our understanding of the long term effects of marijuana as well as the health benefits continues to evolve and we need continued research into the effects of marijuana that are critical to ensure that pharmacists and health care providers have the appropriate knowledge of this drug and patients use marijuana safely as possible. But having pharmacy become part of the system for medical marijuana distribution access and management is really important. So we have in Manitoba the drug product information network. Right now when people access medical marijuana it's coming from a licensed producer. There are 69 in the country of which two are in Manitoba. And nothing goes through the health care professional current network of information. If it was coming from a pharmacy to the patient directly in their community you improve access. Of course you increase the health care professional ability to provide education counseling support and management but you also have a way to collect information about use dosage and quality which improves a patient's healthcare system and is really valuable to you as a pharmacist and anyone as a pharmacist and any other health care provider physicians nurses nurse practitioners in the care of the patient.

Trevor: That's a great point. Actually, I hadn't thought of that for those who haven't heard of it before the DPIN network that Brenda was just talking about if you went and got your blood pressure pill in you know Lac du Bonnet and then your cholesterol pill in Winnipeg and then you filled something else in Grandview Manitoba. The pharmacist would be able see what you got in the different places and no we're not just spying on you but we can see if there was an interaction or a problem with something you filled at another place and physicians have access to it. Emergency rooms have access to it so if the medicinal cannabis isn't in that system then you know there's a big blind spot.  I just want to switch gears just quick quickly before we let you go back onto this one. I know it's going to come up so I know some of my other rural colleagues because you know some of us are in quite small towns of the pharmacy and the liquor store in the same building. So does Pharmacists Manitoba have any thoughts about whether recreational marijuana should be in pharmacies too or just cannabis or just the medicinal or do we have any thoughts one way or the other.

Dr. Shearer:  Certainly most of the responses and the focus of our communication both nationally and provincially has been on the medical marijuana. And that's because of its relationship within a medication regime for patient healthcare. Patient safety like any other drug. Recreational marijuana. And I mean the timing of this conversation is great because just this week in November the provincial government in Manitoba announced its initial phase of how it's going to start implementing recreational marijuana access in our province. One of the pieces that we have to remember is the National Association of Pharmacy Regulatory Authorities which is NAPRA of which each provincial regulatory body has a position on. And just this July in 2017 NAPRA's position very very specific in that pharmacy practitioners must not be involved in the distribution of cannabis for nonmedical purposes. And there for that reason we've stayed in the direct focus of the role of the pharmacist and the value of the pharmacist in being engaged with medical marijuana and leaving the recreational marijuana in. Government provincial governments decision as to how they want to implement it and across the country we have a real patchwork approach right.  So Ontario the province is going to sell recreational marijuana through 150 government run stores.  Alberta is looking at a somewhat similar to our Liquor Commission a government run scenario and looking for public feedback and New Brunswick is going to do it most likely through their liquor set up in Manitoba. Wholesaling and distributing and quality is going to be through our Manitoba liquor and Lotteries Commission but it's going to be sold through retail outlets and given NAPRA's position no one. We have not challenged the role of the pharmacy in selling recreational marijuana at this point in time. I am not sure given our province's current position on. It's called a hybrid model for recreational marijuana. If that will be challenged by anybody.

Trevor: No, fair enough and I'll throw in my two cents. I would just as soon see it stay separate have medicinal marijuana go through a pharmacy and would recreational go through another outlet. So Dr. Shearer both Kirk and I when we talk to our respective licensing colleges we're being told you know just take a wide path around cannabis. Don't ever be seen as promoting it. You know in pharmacy world we are told don't even let it sort of darken the threshold. What would you do if me if I had the register of the College of Pharmacy in front of me what would what would you tell me to say to them to possibly convince them to change their mind.

Dr. Shearer:  Pharmacists are the medication experts we know from the current medical marijuana system that's in place. Access is an issue and not everyone who's using it for medical purposes is procuring it from licensed producers. So enabling access through a community pharmacy improves people's use and access to the right kind of marijuana for their medical purposes and enables health care practitioner oversight involvement support and management and inclusion of pharmacists in distributing medical marijuana improves not only medical management but also intra-disciplinary care relationships between the patient the pharmacists and other providers. And this improves the quality and monitoring of patient care and potentially mitigates and reduces the costs of health care services when adverse events from medication interactions require medical attention or acute medical services and pharmacy is accustomed to managing controlled substances such as narcotics. As part of a standard of practice measures include secure storage security mechanisms to deter diversion theft and robbery and a well-established infrastructure to enable product traceability for recalls. So as a secure supply chain a staple strength of community pharmacy enables regulated processes similar to those used for controlled substances and narcotics. And this process that's already in place seems to be the most effective process to date in our country. The required infrastructure is already in place. Pharmacy is well equipped to handle controlled substances and pharmacy is part of the distribution and dispensing system already. Pharmacists have experience and medication and a broader health care management knowledge and pharmacists are a unique asset to medical marijuana as a healthcare treatment medication option and we know that pharmacists are often a person's first point of contact into the health care system. And if we look also at other health care professionals in the province everybody's part of a person's team. There are some that prescribe some that monitor some that educate and counsel some that monitor and make sure that medication management works. And I think the current system of medical marijuana access while it's been in place since 2001. And we're fortunate in this country to have such a system in place. I think we have enough knowledge to know that we need to improve the direct patient care direct patient access and better safety and education for the patient. And I think now we can say we should do that by a greater involvement of our local community of health care practitioners.

Trevor: Well that's fantastic. I couldn't have said it better myself. And just so finally any other thoughts from from you personally or Pharmacists Manitoba in general about cannabis pharmacies and sort of where things may or may not be going on next six months or so.

Dr. Shearer:  Well we have submitted a response to the expression of interest that our provincial government asked looking at distribution supply and retail of recreational cannabis was the expression of interest and we submitted that in September jointly with the Canadian Pharmacists Association and again our focus was on medical marijuana and the valuable role of pharmacists in improving the infrastructure and the services and healthcare we can provide to Manitobans.  We have not heard anything back to date but we are open and hopeful that we'll be part of the discussion and engaged in discussions now that we know that the two streams of marijuana will be distinct and hopefully talking with our government about how pharmacists can be engaged and become part of the system for medical marijuana to benefit patient health.

Trevor: OK. That's fantastic. And Kirk's got one final little thing we said it might lead into some of our future interviews during Pharmacist Manitoba or the Canadian Pharmacist Association research did anybody look at we'll call them the gray area dispensaries at all on how they're running or is that sort of been outside of your the proposals that were put in.

Dr. Shearer:  No some of the research that KPMG and CPhA have done have identified that since legalization of marijuana has come up and is coming to be. There are a number of shops that have opened up selling marijuana. They use the term dispensary they sometimes have the green cross symbol to make it look like a health care and people are confused and think that those are sites where they can get medical marijuana or medical grade and use it for medical purposes. And that's become an issue and a concern and a very strong recommendation not only from the Canadian Pharmacist Association, Pharmacists Manitoba but also the National Association of Pharmacists Regulatory Authorities is that those terms shouldn't be used in the retail market for recreational marijuana because we don't want people who need marijuana for medical purposes to be confused about what type of marijuana they're getting and what's the best purpose of it then I'll call that the gray area. And again, going back to the illicit sale of marijuana if only 8 percent that are using it for medical purposes or acquiring it from a licensed producer. That means 92 percent aren't. There's a good proportion a good chance that a proportion of those are going to the illicit market where you don't have good quality controls may not know what you're getting. And we really need to ensure that the cost for recreational marijuana is consistent with the cost of medical marijuana so that people don't choose the recreational stream because it costs less and it's more affordable and that whatever. You know retail outlets are there don't use the word dispensary don't use that. Green medical cross so that the public can differentiate the differences as well.

Trevor: No those are excellent points. Especially the cost one just again it can't go through the pharmacy we're just talking to patients you know people who are getting their medicinal marijuana from the licensed producers you know are telling me you know they could be spending a hundred dollars a month on their product which you know is not the world's most expensive thing. But you know if they could go down to the recreational store and get it for 20 you know you could see why they might.

Dr. Shearer:  Yeah cost and sales tax. All of those pieces have to be considered discussed and decided upon and make sure that both streams of marijuana both markets are consistent in whatever the decision is and the policies are.

Trevor: No that's fantastic. Dr. Shearer thank you very much for your time this has been very interesting. We we've learned a lot and yeah keep up the Keep up the good work as you know pharmacists are great and should be promoted.

Dr. Shearer: Yes we believe pharmacists are great we know they're great. We know that the public thinks they're great too.  So thank you for the opportunity this has been a lot of fun and I really appreciate the time that you've taken to ask us for our opinion and allow us to promote the role of pharmacists in health care in Manitoba.

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