Canada's medical marijuana industry has recently become a battleground between the nation's "gray market" dispensaries - illegal storefronts selling marijuana in cities like Vancouver and Toronto - and licensed producers such as Tilray and OrganiGram, who sell cannabis to patients through Health Canada's mail-order system.
Now a third party is clamoring for a share in the industry. In May, Phil Emberley - Director of Professional Affairs for the Canadian Pharmacists Association (CPhA) - wrote a guest column in The Globe and Mail that called on the federal government to let pharmacists dispense medical marijuana.
"As experts in medication management," Emberley wrote, "we work with controlled substances daily and have a proven ability to secure the supply chain ensuring the safety and security of the products we dispense."
Those safeguards aren't currently available for the majority of medical marijuana patients, Emberley argued. He claims that only eight percent of Canadians using cannabis medicinally are buying their medicine legally.
"This means the majority of those using medical marijuana are either growing it at home or, more likely, obtaining it from illicit market, where quality and safety measures are unclear. We are deeply concerned about the proliferation of these so-called medical marijuana dispensaries that are illegally providing health care advice to thousands of Canadians – this cannot be allowed to continue."
But are pharmacies the answer to this problem? To find out why the CPhA thinks that Shoppers Drug Mart, London Drugs and other pharmacies across Canada should be dispensing medical marijuana, we reached out to Emberley. Here's what he had to say.
1. Treating marijuana like any other medication
The CPhA's basic position is that - like other medications - pharmacists should handle dispensing marijuana.
"Our basic premise is that medical marijuana - as its name applies - is a medication," Emberley told Civilized. "And we see pharmacists as - in our healthcare system - as the medication experts. So for that reason, we do feel that there is an important role for pharmacists to play in the clinical oversight of making medicinal marijuana available to patients."
2. The industry is growing up
Some have criticized pharmacies because they declined an opportunity to take part in the industry back in 2013 when the federal government introduced new regulations.
"It's ironic because they wanted no part in being a stakeholder in the MMPR [the 2013 regulations]," Denis Arsenault - CEO of OrganiGram - told Civilized in April. "The licensed producers have made investments with people and training, and now the pharmacy is saying they're the only ones who can handle this. We've lived it on the front lines for three years. We've put the protocols in place. We've put the training in place."
But Emberley argues that Canada's medical marijuana program was underdeveloped in 2013. Now that the medication is becoming mainstream, it's time to bring pharmacists into the industry.
"This is something that we are moving forward with as a society in terms of enabling greater access to medical marijuana...We therefore feel that pharmacists - because they weigh in on drug therapy and issues around patient safety - that they should be involved. It would have been difficult back in 2013 for us to see how things were going to evolve. But now that they have, we feel that given this evolution it makes sense for us to be involved."
3. Pharmacists are experts at playing catch up
Arsenault also argued that pharmacists are ill-equipped to serve medical marijuana patients because they're unfamiliar with handling marijuana as medicine. "With the various strains and symptoms, there is a tremendous learning curve to be able to be trained to serve a patient properly," he said.
But Emberley thinks pharmacists will be able to catch up quickly because part of their job involves learning about the countless new medicines that come on the market each year.
"There are a lot of new drugs that come on the market - every month," he said. "In a given year, I can't even guess the number of new drugs that are introduced. And pharmacists have to be competent in knowing the dosages, the use, the mechanisms, the interactions that they have with other medications because they need to explain this to patients."
4. The CPhA's cannabis crash course
To help pharmacists catch up, the CPhA will develop a special cannabis curriculum.
"One of our key roles is the education and training of pharmacists, post-graduation. So we actually design and disseminate training programs for pharmacists...I see that as a key role and something that associations like ourselves will be very active in in providing that sort of training."
And while he admits that there are unique challenges in handling medical marijuana, learning about them will be similar to the other controlled substances that pharmacists have to study.
"There are other medications - not in the same class as cannabinoids - but other medications that have similar uses and similar side effects. So it's not a complete unknown. Although there are some unique attributes to medical marijuana that are a little bit different. So obviously pharmacists would need to learn those."
5. Addressing drug interactions
Emberley added that dispensaries and licensed producers may be able to offer expert advice on using marijuana, but they can't speak to the other medications that a patient might be using. "A lot of people who are using medical marijuana have disease states for which they are taking a lot of other medications."
And that raises a lot of questions that patients need answered in order to use their medicine safely and effectively.
"How does medical marijuana fit in with those other medications? Are there potential conflicts? Is it appropriate that they are using all these medications at once? And that is, of course, what pharmacists are able to weigh in on. So if someone is getting their medical marijuana through a dispensary, there's no way to really reconcile that in one spot."
But pharmacists can identify and resolve those conflicts by making adjustments to a patient's prescriptions or their dosages. "All of those things happen in pharmacies today," Emberley says. "And they would happen in the future if pharmacists took on medical marijuana. So we feel it makes a lot of sense."
6. Identifying unknown interactions
Emberley also gave us two examples of potential side effects that pharmacists would be able to identify and address for patients.
"If, for example, someone is taking a sedative such as a benzodiazapine...in combination [with cannabis], there's quite a high likelihood that this could further decrease cognitive ability or also awareness. If someone is also driving or using heavy machinery, it could really impact their awareness. There's also some thought that for patients who are taking blood thinners like warfarin, marijuana could possibly cause a higher chance of bruising or bleeding. So these are some of the things that are thought to occur."
But other potential interactions are unknown because marijuana hasn't been researched thoroughly yet. So Emberley argues that pharmacists need to have a stake in the industry so that they can study marijuana closer.
"We don't know all of them yet. And there will likely be more that become identified. So I think that the take-home message really is that caution is required. And we know that the patient population that may have epilepsy or may have multiple sclerosis, they're likely taking a significant number of other medications. So keeping in mind that patient population, I think that caution really is advised."