Pharmacists’ role in cannabis dispensing and counselling

We read with interest the article entitled “Pharmacists should counsel users of medical cannabis, but should they be dispensing it?” by Grootendorst and Ranjithan¹ in this issue of the Canadian Pharmacists Journal. In this piece, the authors conclude that pharmacists are ideally situated to provide additional clinical oversight of patients taking cannabis for medical purposes but felt that certain logistical issues arising from the current community pharmacy business model could create obstacles to pharmacist dispensing. We applaud the authors for recognizing the integral role pharmacists play in medication stewardship and harm reduction and would like to take this opportunity to expand on some of the points they made and address some potential implementation challenges that were raised.

Pharmacists are regularly approached by patients and prescribers about the use of cannabis for a variety of indications. As Grootendorst and Ranjithan note, those interactions are increasing. The number of patients accessing cannabis for medical purposes has increased exponentially in the past 2 decades, from just over 100 patients in 2001 to over 270,000 currently.² Patient surveys confirm that patients rely on the opportunity to speak with their pharmacist about cannabis, just as with any other medication or substance.³

Prescribers often initiate cannabis as third- or fourth-line adjunctive therapy on top of other medications, compounding the potential for drug interactions and adverse effects.^4,5 Determining a safe and effective cannabis dosage requires appropriate and informed contextualization within the patients’ overall medication regimen. This is a role uniquely suited to pharmacists, supported by their ongoing relationships and frequent touchpoints with their patients. In the current medical stream, patients have latitude in selecting the potency of the cannabis authorized to them by their prescriber. Cannabis effects are individualized in patients, so the current approach to dosing and titration is highly patient specific, involving a “start low go slow” dosing strategy, including patient self-titration.⁴ Pharmacists can provide support and guidance to patients and prescribers with respect to these individualized dosing strategies.

The Canadian Pharmacists Association (CPhA) supports pharmacist dispensing of cannabis for medical purposes, with a clear distinction between medical and recreational cannabis streams, including product and pricing differentiation as well as separate access points. We believe that these measures are essential to ensure that patients are not unintentionally diverted into the recreational stream and left to self-medicate without the additional guidance that comes with pharmacist care.⁶ CPhA’s position was informed by several pieces of research, including an independent report by KPMG, and patient and pharmacist surveys, as well as frontline experiences of pharmacists across the country.^3,6

We also recognize that as the recreational cannabis stream has become legalized in Canada, pharmacists have an increasing public health role in safety and harm reduction, including counselling recreational users on how to minimize risk in general, as well as counselling on impacts of cannabis on their existing medical conditions and medication therapy.

Despite their clear support for a counselling role for pharmacists, Grootendorst and Ranjithan speculate that medical cannabis dispensed through pharmacies would likely be more expensive than cannabis distributed through licensed producers or unauthorized channels, particularly given that there is limited insurance coverage from providers. A study from the Conference Board of Canada that was commissioned by CPhA in August 2016 suggests otherwise, concluding that a pharmacy dispensing model would be able to leverage bulk purchasing and result in potential savings. Costs could be reduced by more than half per patient, down from an average of $3719 per year per patient to $1826 per patient. If the number of medical cannabis patients increases to 433,688 by 2024,² this would result in a total cost of $1.6 billion under the current distribution model and $827 million under a pharmacy dispensing model.⁷

With regard to insurance coverage, it is worth noting that coverage of medical cannabis from private insurers is on the rise, with a few recent announcements of coverage from Sun Life Financial Canada, Medavie Blue Cross and SSQ Insurance. Further, Health Spending Accounts included within health benefit plans often accept medical cannabis as an eligible expense.⁸ As coverage for medical cannabis expands, encompassing cannabis coverage into pharmacists’ daily management of patient drug and benefit claims could be a natural and efficient progression, supported by both patients and payers.

The authors also suggest that it would be costly to maintain inventories for the broad variety of different cannabis strains and dosages. This is a valid concern at present. As more evidence becomes available with respect to effective and safe dosage ranges, we anticipate that the available options will accordingly become much more streamlined. Maintaining a medical stream will contribute to the strong evidence base necessary to isolate optimal dosages and regimens for those using cannabis for medical purposes.^4,9

The authors believe that cannabis counselling should be available in the form of a formalized publicly funded pharmacist consultation service. We feel that this is a valid point but that publicly funded consultation should exist as an additional layer to dispensing just as with any other drug. Identifying the most appropriate patients suitable for consultation would be much more straightforward through case finding from medication profile records.

While the commentary by Grootendorst and Ranjithan¹ raises some potential practical challenges to pharmacists’ dispensing, patient needs must remain at the forefront. Pharmacists’ access, relationships and expertise contribute to positive health outcomes and harm reduction. Evidence supports that a pharmacist dispensing model for medical cannabis is a cost-effective strategy at both the individual and health care system level.⁷ As the recreational stream is legalized, it will be important to further define and shape the additional harm reduction role that pharmacists can play in protecting public health and safety.

Patients should have as much support from health care professionals as possible. It is our view that cannabis used for medical purposes is no different from any other drug and so should be dispensed by a pharmacist. Through the well-established and accessible framework of pharmacist dispensing, patients will benefit from the invaluable contribution that pharmacists bring to protect their health and safety.