S2E6 - The Chemist and The Pharmacist


My cannabis is labeled 17% THC.  What dose that mean?  Emily Kirkham, an analytical chemist, talks to Kirk and Trevor about cannabis potency testing, cannabinoids and terpenes.  She also gets into pesticide testing and micro-contaminants like lead. 

Ever wondered about the alphabet soup of regulations like the MMAR, ACMPR and how they came to be?  Mike Boivin, pharmacist and designer of cannabis continuing education programs, gives us a great history lesson on the lawsuits that got us from 2001 to 2018.  He talks about how proper use of medical cannabis can reduce polypharmacy and clinical pearls like if a medical patient feels high all the time on their cannabis try something different like a new strain or dose.

As an extra bonus, if you live in the Winnipeg area....go see Reefer Madness the Musical Dec 6-16, 2018!  They provided us with the music this episode, and it will be a very fun and educational show!


Episode Transcript

Emily Kirkham Interview

Emily: Hello.

Trevor:  Today we have Emily Kirkham. Emily is an analytical chemist with National Laboratory Services. Emily why don't you tell us a little bit about yourself.

Emily:  Hi Trevor yes. I've been working as a chemist for 20 years but just in the last four years I started working in the cannabis industry and doing consulting for analytical chemistry helping people set up their labs their methods basically just anything to do with the fun sciencey stuff of cannabis which I love.

Trevor:  I am a big geek too. I love the my cohost Kirk gets a little bored by this part but this is my bread and butter. I love this stuff so I guess our big thing for you because you know you you would literally test how much THC CBD etc is in a product. Let's talk about potency testing what's and you've been in various labs How's it how's it done right now. If the product I have in my hand says you know 12 percent THC how do it how do we figure that out.

Emily:  Well it really at this point the main method is that people are using HPLC which is high performance liquid chromatography. And the key to that in analytical terms is that chromatography is is basically a separation of components. So you take this material we have like a flower or an oil or an edible and then we have to basically extract the components of interest out of that material and then that soup that you have is going to contain all these different components inside it.  We want to be able to isolate each individual compound so that we can quantify and find out how much is in there. So once you have that extract then you're going to use a method of chromatography in order to separate those components and then detect them in the end. So most labs are using high performance liquid chromatography now now it's pretty much the standard for analysis. There are different ways. And you know if you really want to know I could give you a great lecture on the differences of all these different chromatography methods I'm not sure how far down the rabbit hole you really want me to go.

Trevor:  I have actually heard you talk about the different types of chromatography and and I think we'll get to that in a bit. But one of the interesting things I think you're alluding to is not all labs test the same way and there is there is it right that there's not really a standard way or a third party that sort of making sure what one licensed licensed producers putting out and versus another.

Emily:  No unfortunately there's no real standard methods currently. There was the American Herbal Pharmacopeia published a cannabis method and it's used in some places but unfortunately like there are some downsides to that method. And most labs don't choose to use that in the regulatory Health Canada's not requiring anybody to use a specific method. That's not to say that it's not coming. There are regulatory groups that are working on a standardized method and I'm pretty sure that's going to be in place.  What is required is that each lab that is testing for potency and they're using that for release testing for their products. They have to validate that method and they have to make sure that that method is producing an accurate result. So all things created equal if you are using a validated method then you should be producing accurate results.

Trevor:  Okay. No that's good. Let's go down the chromatography rabbit hole for a second now. Honestly I didn't remember all this back from university chemistry had to look it up a little but. So there's things like thin layer chromatography, gas chromatography, and liquid chromatography and I understand the different. They measure different things and this has a little bit to do with you know whether something is smoked or heated or used as an edible. Can you go into that a little?

Emily:  Yeah sure. Now the difference between these things is really in how the separation is actually occurring. So in liquid chromatography and it goes back to where I was talking at the beginning about how you have this soup of compounds that you need to do a separation on and in liquid chromatography you're using a liquid to sort of carry that soup through your instrument and do the separation if it's in a liquid it will stay in the liquid form and then the compounds will come out and get detected at the end. Usually it's done by ultraviolet. So UV detection and the cannabinoids that are in cannabis. They have a really good you know they absorb really well in UV. So that works really well for gas chromatography. You're using gas to move through the chromatography and do the separation, and in order to do that you actually have to put that liquid that original extract into the gas state. And as you probably remember from your chemistry days if you want to move something from a liquid to a gas it needs heat to do that. And when you do that you actually will transform some of the cannabinoids in in a process called decarboxylation.  So its the same reason why people do smoke a joint in in the flower product. What you have is a lot of the cannabinoids. People always talk about THC THC is in it's acidic form and that's not the desired compound the psychoactive compound is actually the neutral form of THC.

Trevor:  So is that when people talk about THC versus THC-A that's what they're talking about.

Emily:  Exactly yeah. So THC-A is the acidic form. When you heat it, it decarboxylates into the neutral form of THC that's the psychoactive form. So going back to the chromatography discussion if you're using gas chromatography you have to heat that extract at the beginning before it will go into the gas phase then you get decarboxylation. So what you actually detect at the end of that technique is the neutral forms of the cannabinoid. It should be relatively equal because you know if you're talking about what the patient is actually consuming if you're looking at flower they're decarboxylating it so they should be consuming. You know all of that THC-A converted into THC.

Trevor:   Ok but if they going.  Right but if they're going to do an oil or a capsule that we might be measuring something different than what the patient will be consuming.

Emily:  Yes that's that's very true.  So if you're edible if you're if you're just eating something you're not doing any heating you're not sprinkling the marijuana on top of your pizza before you bake it you know whatever you may be doing if you're just consuming it as is then you need to know what if there are acidic cannabinoids in the product that's useful information for the patient. There's also a lot of research these days that is pointing towards these acidic cannabinoids having possible medical benefits. So it's useful information to the patient.

Trevor:   Absolutely percentage of THC or CBD what's its . What is it a percentage of?

Emily:  Now this is where cannabis is really crazy you know and for us chemists we don't usually and deal with things in percent. And Percent is something out of a hundred. Usually when we're analyzing things in the chemistry world we're talking about things in the parts per million or parts per billion level. You know and that's a difference you take 100 pennies and put them in front of you. You can count out 20 of them and you know what that's 20 percent of of your dollar or that you've got there. You can't visually see parts per million or parts per billion that's like a drop of water in a lake. So you analytical chemists are kind of unfamiliar with this whole world but we do you handle this well. The percent in the cannabis if you're talking about something that's 10 percent THC in a flower it's actually the weight of that THC is 10 percent of the actual product that you're consuming.  So that's really unusual in a natural product like that you have something that's so high in one particular organic compound.

Trevor:  So it could be. So it really does mean sort of 10 percent by weight of the dried flour so like 10 percent of that flower is THC or CBD. That's a huge amount.

Emily: It's huge. Yeah and some of these some of these flowers are producing upwards of 25 percent or more of TCH and it's quite amazing really.

Trevor:  So again just because there are natural products and you know in pharmacy world when I talk about you know 25 milligrams of atenolol in a pill. It's you know it's been double checked by Health Canada and you know every pill has you know 25 milligrams of atenolol in it you know plus or minus a couple of percent. You know it's pretty tightly controlled but I'm guessing because cannabis flowers are natural products. Some flowers are going to be higher percent. Some are going to be lower. How does the testing account for the variability in the plant or the variability in the batch or variability from one one grow to the next grow. How do we how do we look after that.

Emily:  Now this is a big problem for sure. I mean this cannabis is being regulated more like a pharmaceutical product right now but it's a natural product it's a plant that grows and conditions change. So as it stands right now the license producers that are producing under our regulated program and in Canada they when they harvest a batch of a particular size they have to follow a sampling protocol for that that's based on Pharmacopeia methods.  So they sample you know distributed throughout the batch and that becomes the representative subsample that they're going to test at the lab. Once it goes to the lab you know it's homogenized, so it's all uniform and then it's tested many labs will do replicate tests of that one batch flower and then average the results of those together in order to give their final number. It still is a natural product though so there will be natural variations throughout the batch. It's not like testing like you said a pill thats got a defined amount of the active ingredient but you know they were also producing those type of products in the cannabis industry medical industry as well. So you know they should have a tighter tighter scope.

Trevor:  Okay so just make sure I got my head wrapped around it. If I was a patient and if I was smoking or vaporizing the flower the bud there's probably going to be some variation from batch bud to bud of what I'm consuming but if it was something like a pill form or oil form that would be more homogeneous in what I'm getting for because of because it's all been mixed together do I have that right.

Emily:  Yes ideally. Now it is being regulated closely by Health Canada and not to say that they are testing every product and that's the same in the pharmaceutical industry as well. The the onus is on the producer to ensure that they are testing appropriately and according to the regulations and they can back up those results. So you are correct though if you are smoking a flower there is going to be more variability in that as opposed to taking an oil or a capsule.  You know they should be testing for content uniformity within those capsules that are in a particular bottle. So they should be you know within a very tight specification and acceptance criteria just like in the pharmaceutical world.

Trevor:  Oh that's fascinating. Testing. Who's testing? Are the licensed producers do they all have in-house labs or do they farm it out to one or two national labs and when Health Canada wants to see whether or not someone sort of within the stated criteria like who's who's doing the testing where where are the labs?

Emily:  Well we've got kind of a mixed bag of everything you just said there. Some licensed producers do in-house testing some of them do only testing for research and development and for product development. There are third party labs that are licensed under Health Canada right now to test for the licensed producers and they have to follow the same regulations of having a validated method in place to do the testing. And Health Canada has a lab as well but they are not testing for release. They're you know taking a retained sample and testing is spot checks against what the producers are saying. So who's to say what the regulations will come up with in the future. Some people are saying that it should be all third party testing. If you look at the pharmaceutical industry though most big pharma companies have their own in-house testing. They're very tightly regulated though so they can't step out of line or they will lose their, you know they won't be able to sell that product. That's really what it comes down to and with a lot of money on the line they are very closely monitored in that regard.

Trevor: No that's that's great.  So maybe we'll still step out of testing and potency unless there is something else I sort of missed. And what what a consumer should know about potency testing did I miss anything on that end.

Emily:  Not on potency testing now it's I mean it should. I should note that in Health Canada under Health Canada's regulations right now the producers are required to do third party testing for pesticides. That is the one required test that they have to do not in-house.

Trevor:  But honestly if I'd heard that I'd forgotten about it. So is pesticides in the licensed producers a big deal or where did that where did that requirement for Health Canada come from do you know?

Emily:  Now this is it's interesting little historical situation with our program because it started out and still is the case that there are no pesticides that are allowed aside from a few anti-insectal soaps and things that most people would not consider to be like the harmful type pesticides. So they started out saying you cannot use pesticides. And if you say that you're not using pesticides we won't require you to actually do the testing for it and if you do the testing for it what we would like you to do is test according to Pharmacopeia method. Unfortunately the pesticides that were in those Pharmacopeia methods were completely irrelevant. Those pesticides would never be used on cannabis. So it was kind of a requirement that was put in place to test for pesticides that wouldn't be used anyway.  More recently there's been some recalls that have happened because Health Canada has gone in and tested at their own labs for pesticides and they've found some in a few cases. And that's what sort of started this whole open this can of worms so to speak. And then Health Canada came out and said OK well now we actually have to start testing for pesticides and you guys all have to do third party testing.

Trevor:  Wow. That is an interesting little sidebar on pesticides isn't it.

Emily:  Oh yeah.

Trevor:  So since I've got an analytical chemist on the line, can we talk about some of the components in in in cannabis like I think by this point we've probably all heard of THC and CBD. What else is in there that we know about and think might be important.

Emily:  Wow. I mean cannabis is a really interesting product there are so many different compounds in there cannabinoids are just just the start of it. Most people will test for their sort of a suite of about 10 to 12 well-known cannabinoids out there. Cannabigerol (CBG) may be one and cannabidivarin (CBDV) is another one cannabichromene (CBC). So they have acronyms like CBC CBDV THCV but they're discovering more and more as research is sort of continuing. So there's this suite of cannabinoids that are out there aside from THC and CBD and their breakdown products which is CBN and the rest of the cannabinoids are fairly minor they're very small so there haven't been a lot of research done on what might be the medical benefits of these other smaller cannabinoids but even at the levels that they're at they could have medical relevancy. And that's just the cannabinoids.

Trevor: Then I'm going to jump into another one.  I've heard the word terpene and I've heard that that makes that stuff smell good bad or indifferent. How about can you give us a quick quick story of what's a terpene and what we think it may or may not be doing in cannabis.

Emily: Oh yeah. Terpenes that that sort of opens up this whole other suite of compounds and when terpenes are really like the smell and taste compounds that are in cannabis that a lot of people are you know when they smell cannabis you might smell that skunky like smell or that pepper smell or a pine like smell. I mean cannabis has got a really interesting you know smell to it and you know a cannabis user one of the first things they'll do is pick up their bud and smell it. You know it's it's it's it's part of the industry. There's there's literally hundreds of these different terpenes that are out there and they have been finding that they are you know there have they are going to have some medical relevancy. Lots of research has been done on the individual terpenes themselves in animal studies to show that they have some effects. Anecdotally though you know people will say well I smoke an Indica strain for example later in the day because it it helps me go to sleep. And what they've found that it doesn't it may be more connected to the terpenes like Indicas tend to be higher in beta-myrcene which is a terpene that has been known to be a relaxant and may help you sleep. People may feel the same thing when they drink a hoppy beer for example and hops are also high in beta-myrcene, kind of makes you sleepy at the end of a day. So we may be finding a lot of the similar type effects from these from these terpenes.

Trevor:  Thank you getting as a pharmacist we're always worried about how we get stuff into people you know. Is it a pill is that you know. Well we have inhalers do we rub it on the skin and there seems to be a many many ways of getting cannabis into people from a chemist point of view is there different things about different routes of administration or there are different compounds that we think go into the body easier if it's inhaled versus rubbed on the skin versus swallowed do you have any comments and serve routes of administration and the different cannabinoids or terpenes.

Emily:  Well I can I can speak to you know it's sort of happening chemically to the compounds on the different routes of administration as far as like there you know how they would be approached medically. I mean I don't have any medical background. I.

Trevor: We will take the chemist's background.

Emily:  Yes take the chemist chemist view of it there certainly is a big debate about the smoking versus vaping forms of administration. You know if you look at vaping just the flower for example it allows you to control the temperature that you're doing the decomposition of the product. So when you when you just you know use a joint and a flame the temperatures can be upwards of like 230 degrees C and at those higher temperatures what you get more of the pyrolytic compounds things like poly aromatic hydrocarbons which have been known to be carcinogens.  So they're thinking that it's better to do the vaping because you can do that at a lower temperature which still allows you to combust the cannabinoids. You know to do that decarboxylation that you need in order to get THC-A into the neutral form but you maybe don't get some of the harmful compounds and some of the tar and noxious smokes that you might get. So that's just on the smoking versus vaping there still needs to be more research done on this. When you look at things like see the juice that they have like you know e-cigarettes for marijuana that's that's another hot topic because there just hasn't been enough research to show, like a lot of these cannabinoid juices are made from you know vegetable glycerin or propylene glycol which are good safe products. But there's no research to show that they're safe for inhalation in vapor form. So, you know I think we really have to take the precautionary approach with some of these some of these techniques before we really have any evidence to show that they're safe or not safe.

Trevor:  I just had a moment. They're both glycerin and propylene glycol, we do some compounding in our pharmacy here so I make stuff up with propylene glycol and glycerin all the time but top my head I can't think of any inhalation of products I've made with them so I think I'm OK. They're all usually end up being oral liquids or are going through the skin. It's a good. No I'm not killing off the patients it's good to hear.

Emily:  Well I'm and I'm not saying that they are unsafe it's just you know there's a lot of things out there that are going around saying oh well you could get like these breakdown products from them or lipid pneumonia but there's really no studies yes or no that really prove that that is the case.

Trevor:  Do we know anything chemically about what goes through the skin. Well or what not. Because I'm hearing more. You know even just this week a friend of her friend ordered something from a licensed producer and they were recommending that it be mixed into a cream and rub it on the skin. Do we know anything about what goes through the skin well or not in the cannabinoid world.

Emily: I think there is. You know certainly again anecdotally people are finding that they are getting relief from some THC based creams like for people who have arthritis in their joints. It's supposed to be very helpful. I think it would have to be formulated in you know in a format that's going to the cream that will actually penetrate the skin and allow the THC to go through it as well. And with all of these types of formulations whether you know you're taking a pill or you know a juice whatever it should be it has to be able to be delivered the product too. You know it's a drug delivery mechanism. And so if you put it in a pill it has to be. You have to be able to digest that has to get into your body has to be bioavailable. So there's a lot of producers that are doing the appropriate research. I mean this is not new science Pharma has been doing this for decades. So it's just new to the cannabis world.

Trevor [00:26:36] Yeah no absolutely again back to my bread and butter. You know we have medications. My favorite is you know medications that reduce the amount of acid in the stomach they're called PPI's. PPI's happened to all be very acid labile meaning if you just put them into regular gelatin capsules swallow them they'd be blown up by your stomach acid before they could do any good. So we have to put them in a special special thing they'll get all the way through the stomach acid into the intestine where they can be absorbed so yeah you're right I haven't seen you know mounds of research on saying that cannabis oil or cannabis powder whether it should is acid labile whether it should be entero-coated to go through the stomach in that kind of thing so I assume those are probably all parts of research that should be done down the road to figure out the differences.

Emily:  Yeah absolutely.

Trevor:  Well because we're running short on time and I don't want to keep you here all day it's been fantastic. Anything else you think a regular medicinal or I guess recreational user of cannabis should know sort of from an analytical chemist point of view.

Emily:  Maybe just briefly on the on the other contaminants. You know I think that's something that you know there's potency and the active ingredients are one thing but you know I think we all have to be very aware of what the possible contaminants are and make sure that the products you're using wherever you're getting them from are actually being tested for for pesticides for micro heavy metal aflatoxins.  I mean these are all things that you know are very harmful and we have to make sure that we're not consuming them just because you're smoking something doesn't mean that it's actually destroying these contaminants. And that's research that has been done. So it's important that we make sure that these these products you're using are safe.

Trevor:  I had never thought of that. I'll poke that a little bit so insecticides make sense as whether or not the producer put it on. Where are things like micro heavy elements going to how are they going to end up in the plant and then eventually in me.

Emily:  Well well you. These plants are actually really good at absorbing metals. You know I think they were using hops which is a related plant to absorb metals from contaminated sites. So if you grow it in a material either or use a fertilizer that may be contaminated or a pot that's contaminated or or its an outside grow there is a risk for getting metals and other contaminants into the plant and further it further to that if you have a small amount of that contaminant in the plant material and then extract it. You're concentrating the cannabinoids but you're also concentrating all the contaminants that you had in it. So if you have a heavy metal in there it may be safe in the flower and small amounts. But if you concentrate it down and are consuming it in higher doses in the extract that's more of a concern.

Trevor:  Well that's fascinating. I had never thought of the amount of lead etc. We could get a cannabis product. No that that's good to know.

Emily: It's a very rare thing and it's more of an issue with like an outdoor grow which we don't have in our regulated system here. But you know it's always important that we are doing this testing things like the micro contaminants and all the food safety when it comes to edibles those things are are maybe a little bit of higher concern at this particular time.

Mike Boivin Interview 

Mike:  Thanks for having me Trevor. As you mention my name is Mike Boivin I'm a pharmacist consultant from Barrie Ontario. I'm I've been a pharmacist for a very long time I feel very old many days. And in 2009 I left what would be normal pharmacy practice and started to go into continuing education. So I've been working in this space for a long period of time what my interest in cannabis has been since 2013. I am I developed a really big program on on cannabis just as the MMPR regulations were coming into market for physicians pharmacists nurses and you know it just kind of took off from there in terms of my overall interest in using cannabis as a medicine.

Trevor: Thank you very much. And actually that leads nicely into the alphabet soup that sort of gets us to where we are today. So I've heard letters like MMAR and MMPR and ACMPR.  Can you give us sort of a brief rundown of the regulations and how we got where we are today.

Mike:  Absolutely. So Canada has been really interesting because we were one of the first countries in the world that allowed legal medical use of cannabis. So the first regulations were in 2001 which is the Medical Marijuana Access Regulations. And a lot of people think that we were very progressive. We really wanted to do this what we're going to lead the way. But that simply was not the case. In every one of these regulations it was all because somebody sued the government and the courts decided that we needed to bring in these regulations.

Trevor: Damn lawyers.

Mike:  The first iteration of it was the Medical Marijuana Access Regulations which is the MMAR. It started in 2001. What was unique about this one is Health Canada needed to put some control on it. So if anyone wanted to end up using cannabis the physician would have to complete typically 20 to 30 page document. It was submitted to Health Canada for specific and it would only be approved for specific indications.

Trevor:  Yeah I remember those. The doctor showed me. They looked like telephone books.

Mike:  They were huge and so many of the people actually refused to were refused. They didn't qualify. I think even at its peak I think it was only 30,000 Canadians that did qualify for this. Other limitations with it is that they had this was one strain of cannabis that was the only strain that was accessable through this one so you can get it either as a flower or a dry bud or you could get it as seeds that you could grow yourself.

Trevor:  And that was the stuff that was grown up in Flin Flon in Manitoba, right?.

Mike:  That's right. Yep. Ok. And that was the only one that was available at that point. Nothing else. So as we know with government you know government themselves are typically they they don't like to be this involved. It was a lot of work. So they were looking at how they can pawn off more work and other people. So this is when we end up developing the MMPR which is the Marijuana for Medical Purposes regulations. And this changed in 2014. So Health Canada came out of we're no longer going to be dispensing cannabis to people anymore. We don't want to do this anymore. So what they did is they changed the structure to allow for the what we currently have these licensed producers. And they were going to be involved to ensure that the strains are the products that were going to be available were the best possible quality you could access a variety of different strains and they would regulate these licensed producers. They would only make dried bud and flower available through these licensed producers. So it was illegal at this point to sell seeds.  So anybody who had under the MMAR that that could grow their own product were told you had by this date you needed to destroy your seeds or destroy your plants by that point. Cannabis only cannabis distribution through the licensed producer. And instead of it being through shipped from Health Canada it came from directly as we currently have licensed producer by mail order to the individual patient. What's what was nice about this one is Health Canada said We don't want to be involved in determining who should have this. So we think that physicians can do this very effectively or nurse practitioners depending on the province.  So what they said is you guys can determine if you want to end up using it. We're not going to have any regulations on this. So what a lot of physicians are upset is they had no training on this one and it was just kind of felt dumped on their plate. So this is where we see this this very negative by a lot of physicians back in 2014 and health care and practioners in general is that Health Canada was pawning this off on health care professionals without any additional training or additional support.  So that was the 2014 that was a major change at that point. So Health Canada went from being the gatekeeper in the 2001 regulations to 2014 where the prescriber became the gatekeeper. Fast forward to 2016 where were the Access to Cannabis for Medical Purposes Regulation or the ACMPR.  And guess what. It's another court filing that came out again somebody sued the government saying that we want more products available. And one of those being herbal cannabis being available in seeds again.   And one of them being oils.  Huge. It's been the biggest change that we've seen since this regulation came into effect in 2016. And it was interesting.  I talked to a variety of colleagues in the space and nobody was really talking about oils before and now everybody that's exclusively what we're almost using for almost every single patient now within the medical space or they would just because again safety in terms of dosing in groups that were using them for such as people with chronic conditions elderly patients. It's you can dose it very very easily titrate it very easily versus somebody inhaling cannabis itself.

Trevor:  And some of the patients we've talked to that specifically their complaint or concern that they don't want to be smoking anything.

Mike:  I think it's a stigma associated with it so if you're seen as smoking cannabis there's a smell with that. What if you're living into assisted housing or if you're living in it in an elderly home you can't smoke. You can't be jeopardizing the health of any of the other individuals that are there. So it really comes down to limiting the options and the one of the big problems with smoking and vaporization that we see is it only lasts for three to four hours for the majority of these individuals. So if they have a chronic condition where the symptoms are happening all the time they have to smoke or vaporize regularly to keep their senses under control. The nice thing about with the oils is that they last for about eight hours. So 6 to 8 hours for most of these individuals so you can take it just a few times a day versus you know six or ten times a day.

Trevor:  Thank you very much for getting us up to date. That's great. And sorta segue into well listeners have heard one of my local beefs is we've got five care homes here and I can't people in the care homes are on medicinal marijuana but it doesn't go though the pharmacy at all which just doesn't make any sense to me at all.  You know we don't have any control over it it's only sort of by the grace of local doctors that they tell us that the patients are on it and have us fill the paperwork. But you know we deal with everything from fentanyl to chemotherapy going to the care homes. It makes no sense not having the pharmacist involved in someone's medical marijuana. And that brought me to a very recent article that you wrote about apparently in New Brunswick their College Colleges is being as obstinate as my College here in Manitoba. You had a few things to say about that. So what sort of ticked you off the College of Pharmacists of New Brunswick.

Mike:  So let me first clarify. From the standpoint I was I was born and raised in New Brunswick for a big chunk of my life. My mom lives there now and I thought New Brunswick typically tends to be one of the most progressive areas as much as a small one of the poor provinces of the country. It is relatively progressive in terms of making changes. And I was quite surprised with the approach they took. Originally I thought that New Brunswick is going to be one of the first provinces to allow pharmacists actually dispense cannabis when the changes in terms of legalization were going to occur. And that didn't happen and in reaction what ended up happening is the college came out with a statement that I couldn't believe it when I saw that they didn't feel that pharmacists should be involved in this in any way.  Under the current basis and a cannot or should not be dispensed within pharmacy because they didn't feel that the there was enough research to actually justify that. What bothers me is that these colleges are actually for the protection of the public and we know you and I both know there are many people within the public that are actually using medical cannabis.  The issue is that they're not getting the support they're not getting the education they're not having people to turn to and my colleagues are not necessarily taking the education that they require because you know their colleges are saying well why bother. You shouldn't be doing this because you have no role with it. So I really think that there's an opportunity for pharmacists end up helping these people not only again reach the best possible health that they possibly can but any issues that come up how to administer this what dosing do I take. Should I be adjusting this one and any side effects. That's what pharmacists do on a daily basis and I just don't understand why all these colleges that said we don't want any pharmacist have anything to do with it.

Trevor:   No I completely agree. I'll only to editorialize a little bit like it. We've got a provincial system that you know any doctor in any emergency room can look up to see what this unconscious patient is on but if it doesn't go through a pharmacy if it doesn't go through our drug programs information network.  How is that emergency room physician going to know and even if you think that medical marijuana is completely bunk and doesn't do anything at least from a harm reduction standpoint why wouldn't you have the pharmacist involved to say hey you know you're on this anti-psychotic or you're on this whatever else you know maybe let's be careful about your medicinal marijuana usage. It doesn't make any sense.

Mike:  Yeah it really bothers me quite a bit. The issue if you look at pharmacists in general we distribute medication regularly. We have a network in place in terms of structure wise doesn't go through a mail order basis it comes directly through from the manufacturer directly to a wholesaler to us so that was an all of this is controlled all the way through. We have storage facilities that can manage this effectively we do this regularly but it's never been take into consideration. And this is one of the key concerns that I have is until medical cannabis comes in through a pharmacy which is what's occurring in other parts of the world until it comes into pharmacy will never be legitimately seen as a treatment for anything. And you know what I I'm sure you have I've seen many many patients that are responding quite well on this therapy. And for me it's when we have statements like this you're stigmatizing these individuals. So if you're ending up using cannabis just because enough at a pharmacy well then that's not a legitimate treatment. And basically you don't have legitimate pain. You don't have a legitimate condition so this treatment is not valid for you.

Trevor:  Well thanks Mike. I love that article when when I read it and that was sort of one of the reasons I reached out to you again. So for the listeners Mike I've met but we're both getting old now I could be 15 closer. 20 years ago.  But yeah I read that one all I really want to talk to you I hope you get back to me and I'm glad. I'm glad we managed to touch base again. So you alluded to stuff you've done in other countries and I've read a little bit about this. Can you sorta go into maybe some of the things you've done recently in South America.

Mike:  Well you know it was an interesting trip. So about three to four weeks ago I had the pleasure of actually flying to Bogota Colombia to talk to physicians about the use of medical cannabis. And that's may seem strange to some of your listeners that. What do you mean you're going to go out to Colombia to talk about cannabis. In Colombia, just until recently cannabis was completely illegal. It was never considered for medical purposes and they're just passing the legislation now. What was very different though is what I found is when the new legislation came in in 2014 in Canada very few physicians even wanted to discuss it. Nobody really wanted to talk about it. There was a few outliers that would come in and want to learn about this but generally they never thought this was going to be a major treatment. This was the first conference that was ever done on medical cannabis in Colombia. We thought maybe they would get 100 people to show up. We had close to 500 physicians from all over the country that came in mostly neurologists and neuro neurologists and neurosurgeons that came in because they're thinking of this as a potential option for their patients with treatment resistant epilepsy, for MS and for chronic pain.  So they're looking at new options that are there as well.

Trevor:   Well that's cool we talked about MS a lot here as a lot of MS in the Parkland. But that's fascinating the neurologists were there.

Mike:  And they all wanted and it was interesting they all wanted to learn about as much as possible that simply wasn't the case here in Canada. So I think that we're leading the way in terms of the expertise and sharing what we know based on the people that we've already treated since 2001 and really be able to end up helping those individuals in other parts of the world.

Trevor:  That sounds like fascinating trip. Mike thanks for sharing with us now something that I know you and I both share. Like I said we look after several nursing homes but I know you've got a special interest in cannabis and the elderly. What do you think about you know are our seniors and can give us the stigma how that that all goes together.

Mike:  Well my biggest issue with cannabis and the elderly it's we really treat a lot of chronic pain in the elderly. It's one of the most common conditions that we see as we get older the likelihood of you having chronic pain is going to increase dramatically. But the problem is as you know Trevor is our treatments are really minimal and in terms of what we have in terms of options and in the ones as you get older there are potential problems so you know one standard Tylenol or acetaminophen can be used but in a lot of people don't find it effective. So what do you do after that point. Nonsteroidal anti inflammatory drugs this would be your ibuprofen your Advil or your Alleves the issue that we see with those is that if you have chronic conditions you have a heart condition you have diabetes you have a kidney condition you can't take these long term. We all know what's happening with opioids whether that be fentanyl or any of the other ones. Should we be using those in the elderly who are more prone to having some of the side effects from those. Cannabis as for good or bad it its very well tolerated from a lot of individuals. It works well for chronic pain comes in an oil format makes it really easy for elderly patients to start on them and we can start with something like a CBD only CBD only which doesn't have any of the you know the high effects that we see with THC and some people respond really well to that. So for me I think that the biggest growth is going to be in elderly patients who are going to want something to end up living productively for the longest period of time that they can feeling good. And I think that's where cannabis is going to fit a nice role.

Trevor:  Thank you very much and yeah the CBD keeps coming up a little while ago we had our local neuroscientist on and he actually does research into cannabinoids in general but CBD in particular and he specializes in MS. But he also does a lot of work with chronic pain and he goes on and on about you know he tries to avoid the THC at all costs because the CBD and his both research and clinical end seemed to be the thing to go to. So.

Mike:  You know I would agree.  I think that's one of the biggest issues that we see is that both health care professionals and patients tend to focus on THC but in reality cannabis is not one product but it's a plant. There's a variety of different things that can end up happening. So it's not just one component but everything else that's within that plant. So it can be the terpenoids the flavonoids which are not you know there are in other plants not just cannabis but they could also potentially have some impact on this entourage effect of everything working together to offer those symptom relief.

Trevor: I think entourage effect might even end up being our word of the day. I think every other guest we've had on has tried to teach us what entourage effect is but yeah it's fascinating. You know when I give somebody an enalpril for their blood pressure I don't care about all the other things in the tablet but yeah. When when we give them some extract of the cannabis plant then yeah all the other things besides the THC or CBD seem to be really important.

Mike:  What I love about it from from just from a clinician standpoint so looking at this from health care professionals is one of the most interesting thing about cannabis is where I get excited is a polypharmacy that we see so for people that are not familiar with polypharmacy that's a matter of taking many different drugs for many different symptoms. So you have this burden of all these people taking all these pills all the time. What's interesting about cannabis is that in many of these people especially those chronic pain people.  Because what we see in chronic pain is many people suffer from anxiety. Many people also suffer from sleep problems because of the pain that they have on a regular basis.  What's nice about cannabis is that in many of these individuals and we treat their pain with cannabis things such as their anxiety start to decrease. They're able to sleep better at night time so instead of having all these different pills to treat all these different things we typically have one treatment. So this cannabis oil for a lot of individuals can do everything. So for those specific patients who help for the sleep, help for the anxiety, and help for the pain. So we're quite excited to be able to reduce the amount of medications that some of these people are taking as well.

Trevor:  Oh that's that's wonderful. Now because you know people can't get away from top 10 lists and top five list I hear a really smart pharmacist who's on the other at once written a top 10 list for pharmacist's role in cannabis distribution because you know sooner or later my my registrar will accept my invitation for an interview and I'd like to make the case to her why you know Manitoba pharmacists should distribute cannabis so what are some of your top reasons why pharmacists should be involved in cannabis distribution.

Mike:  From a distribution standpoint. I think it's legitimizes it as a treatment. So we have all these people here that are reporting significant benefits of what's happening because they're getting it shipped in the mail. This would be different no different from any other the mail order stuff that we're seeing if it's in pharmacy it's a legitimate treatment it's going to be treated as legitimate.  It's going to increase access. So physicians are going to come up and say if I can order it I can call the local pharmacy and be able to pick it up. I think that's one of the key things that I like about I think a pharmacist can and have an impact.  Now the things is different for me it's it's looking at my mom who lives in rural New Brunswick. If she needed to get cannabis now and the issue there would be is it would be easy if she was in her community. There's a pharmacy there she could pick it up on a regular basis versus having to wait weeks for it to be shipped by registration verification could take under the current legislation. Other concerns that I had with it is that for me one of the biggest my biggest beef is that it's going to be easier to get recreational cannabis than it is going to be to get medical cannabis for a person. So if I'm a recreational user or I can decide the morning I want to go and buy some I can walk into my local retailer pick that up and use it if I wanted to get medical cannabis which could be a very different strain that was being used in the recreational side I would still have to go in to see a physician get a prescription verify that with the licenced producer and have that shipped to me so it could delay treatment for weeks for people who are using it legitimately. Those are some of my main concerns about why I think the pharmacists should be really involved in this.

Trevor:  No that that's great.  Like I said I'm to serve collecting a list of points for if when I ever get that interview with my my registrar. See. See what she has to say about why you know it's not even being considered for Manitoba pharmacists.

Mike:  I think my biggest issue Trevor and we talked about this thing you know one of the things that I've mentioned is that there are so many products that are pharmacies are selling now which have you know not only are not offering really any benefit but potentially causing harm.

Trevor:  I feel like we're getting I feel like we're getting into nosodes. I'd love for you to do a sidebar on nosodes.

Mike:  So if I work also in the immunization space and I do a lot of work in public health and I had the pleasure of working with some Immunologists in pediatric immunologist from across Canada and they were not able to immunize all of our kids or protect them with vaccines against conditions such as measles and a variety of others. These vaccines are effective. They worked very very well. What's happening is there are some pharmacies from across Canada selling nosodes. And it's a new term for a lot of healthcare professionals and people as well. Nosodes is essentially a homeopathic vaccine is what they're looking at. These have no evidence or data to support that they do anything whatsoever. So they've they're basically like water from the standpoint from the clinical studies that have been done with these. So they don't really work.  But they're being marketed and sold by pharmacist and not every pharmacy by some of our colleagues saying this could be an alternative for people they don't want to immunize their children. This not only puts those children at risk but puts all of the community that they're there not being vaccinated. Exactly. So from my perspective I'm I'm really concerned that you can't come up and say you know cannabis is not a legitimate treatment so it should never be sold in pharmacies. But there's no problem with selling those individual products. I have a fundamental issue with that.

Trevor:  No. I love that point. Yeah homeopathic treatments everyone's heard me editorialize on it before. But real quickly like if you do the math you statistically have a chance almost zero chance of having a molecule of active ingredient in them. By definition homeopathic preparations if they're done properly are placebo just full stop. If if they're done right there's nothing in them so they shouldn't be promoted to cure treat prevent anything.

Mike:  Well exactly is actually an in from a placebo effect that's fine but when it comes down to vaccines we need to be able to protect those kids. And I really worry that we had deaths associate with measles in Canada that shouldn't be occurring now and there's a way that we can prevent this with really great vaccines that we currently have that we've been using for a long period of time as well.

Trevor:  Anti-vaxers to send your hate mail towards me I love it. I get it every every time I say something positive about vaccines. So Mike that's been great. And I know you've got lots of good experience. How about anything I've missed anything that.

Mike:  No I was thinking about doing another top 5 for you.

Trevor:  Sure.

Mike: Things that I would want everybody to know about medical cannabis. So the top five that I have we're not everything is about THC. So we've already discussed a little bit. CBD seems to be some focus and there may be other of the other cannabinoids that are in the cannabis plant that may be having a lot of these effects so it shouldn't be that focus on. I'm going get the highest THC lowest CBD and getting the benefits. So if moving forward for a lot of the individuals we've started on cannabis we start them off in a 1 to 1 mixture or CBD only product and then adjust based on how they respond.  Second one for a medical cannabis user you should not be getting high every time that you end up using it. So we seem to think in a lot of healthcare professionals as all these people want to use cannabis just to get high all the time. And this is not the case if a person is getting high. That is almost like an adverse effect. So for that reason we usually will adjust the cannabis either slow down the titration how much they're taking or change to a different strains of the all of the time we want to use it for symptom relief not about getting high all the time.

Trevor:  Well it makes perfect sense so like in regular pharmacy if I've got someone with anxiety if and I'm giving them benzodiazepine and they're sleeping all day well then the dose of the benzodiazepines wrong.

Mike:  One of the little things we can do when there's a lot of things that we do to adjust that strain or how the person is using the products so they don't they're not high all the time.

Trevor:  OK. What about number three.

Mike:  Number three cannabis is not a magic bullet. So if you go on to a lot of the consumer sites they can say you can use cannabis for everything. First and foremost I would always recommend and encourage people to try treatments. We have good data support it works and it's effective. If those are not working or you cannot use those products that's what cannabis can really be considered. And it's not for everybody it's for some of the people some of the time. So some people do really well with cannabis and some people don't. Just like any other treatment that's out there. So if you think of it as not a magic bullet it's just like another drug just like everything else. It becomes a lot easier of determining when to use cannabis for a specific person.

Trevor:  Perfect number four.

Mike:  Don't smoke.

Trevor:  Don't smoke.

Mike:  There Are a lot of different ways that we can end up administering cannabis using a water pipe or bong using a joint or a standard pipe is not the way to do it. This is just as harmful as smoking tobacco as potential risk factors same poly aromatic hydrocarbons or the same carcinogens are also in the in cannabis as they are in tobacco vaporization looks pretty good if you want that rapid relief onset. It's more effective in terms of extracting all the THC and CBD from it.  So it works better and is more it's cheaper in the long run because about half of these cannabinoids so the THC and CBD actually escape inside smoke if you are actually smoking it. So avoid smoking look at oils looking at vaporization.

Trevor:  Ok and hopefully number five

Mike:  number five the final one that I always encourage every healthcare professional and every patient I know is. Be careful when you start on this one about driving. So we always want to caution patients about driving with these particular products. If you're looking at if you're looking at smoking at a minimum of at least three to four hours especially when you're starting off before driving. 6 to 8 hours or if you end up getting if you're taking an oral form a six to eight hours and eight hours or more if the person became high with it. So those are just general recommendations especially at the beginning you want to be careful. We just don't want to have people that are potentially impaired out on the road. And the other thing is storage storage is really important we don't focus enough in the pharmacy. We should also focus with cannabis make sure they store in the right spot so that children can't get to it and if there's somebody in the house that could be potentially having a problem then they're not taking their product so lock it up stored away so nobody can have access to it. I think those are five things I really want. Every medical cannabis person to know.

Trevor:  Those are fantastic. I think we should put those on a T-shirt somewhere maybe a series of five t shirts Reefer Medness Top 5 t shirts I like that.

Mike:  It works.

Trevor:  Mike that was fantastic.  Any other any other last thoughts because we managed to squeeze that all into 30 minutes and anything else that you think we should know.

Mike:  Well I'm really excited what the next few years are going to bring them when medical when we see the recreational market changing. I think that we're going to see so many new users on on cannabis because they're not necessarily getting access to it now. So as as a society as a country I think we're going to have a good idea of leading the world of where cannabis should be used. When should it be used when should it be avoided. How do you properly use it and moving forward. That's pretty exciting to me. I think there's gonna be a lot of interesting things over the next couple of years.  




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