Evolving Global Perspectives of Pharmacists: Dispensing Medical Cannabis

Abstract

Introduction:

Different countries have employed a variety of methods for their populace to access medical cannabis.

Objectives:

The purpose of this literature review was to assess the international literature on pharmacists' beliefs and attitudes towards medical cannabis.

Methodology:

This literature review summarized the various countries that utilize pharmacies and pharmacists to dispense medical cannabis. The countries included in this review were: Australia, Canada, Denmark, Finland, Germany, Israel, Italy, Netherlands, Poland, Serbia, Switzerland, USA, and Uruguay.

Discussion:

The pharmacist perspective has been of key importance within the medical landscape, as they are the ones who not only dispense medication but also counsel and monitor patients and it is this perspective that is lacking.

Conclusion:

Overall, this review found that even though pharmacists are generally comfortable with dispensing medical cannabis; they still require further education to do so as safely and effectively as possible.

Introduction

As we develop a greater understanding of the multiple mechanisms of actions and development of formulations (oral liquids, oils, tablets, capsules, vaporized extracts, edibles, etc.), the potential clinical applications of medical cannabis (MC) have been expanding exponentially. However, questions remain regarding the role and responsibilities of the pharmacists in this new medical landscape. The purpose of this literature review was to review the international literature on the beliefs and attitudes of pharmacists globally toward MC.

The roles and responsibilities of pharmacists are centered around the supply, safekeeping, and monitoring of medication and thus, the pharmacist's point of view is one of the more important perspectives that should be considered, when discussing pharmacies dispensing MC. This global literature review of pharmacy dispensed MC is organized by continent and then country, where information was available. Not all countries where MC is legal were included owing to a lack of accessible information.

Methods

MC is not available nor dispensed in the same way in all countries, and even within a country, governmental legislation and professional regulatory body guidelines are ever evolving. For this review, only the countries where MC was dispensed in a pharmacy were included. This global review expanded on a previous 2019 short article titled “Pharmacists and MC: A Global Perspective.”¹

A literature search was started on June 2, 2019 and ended in September 2019. Most of the articles reviewed were published after 2010; however, certain key articles from earlier years were included. Only peer-reviewed full-length English language articles were included. Care was taken to ensure that all articles were captured; however, it is possible that some studies could have been missed if unpublished at the time of writing this article or in lesser known journals. All studies were screened for relevancy by two reviewers.

A combination of terms used in PubMed from June to August 2019 were searched. These terms included: MC, pharmacist, pharmacy, cannabis, marijuana, and medical grade cannabis. Other literature reviews were included. Articles were considered relevant if they discussed pharmacists' feelings/beliefs/attitudes on MC; pharmacy students' attitudes/beliefs and knowledge on MC; or safety and efficacy of dispensing MC in a pharmacy compared with other methods of supply. A total of 61 articles initially proved relevant. The references for key articles were reviewed to ensure that no possible study was missed, to the best of the reviewers' abilities.

Key information from specific countries was included, which had to be translated to English, including government websites and specific MC-dispensing information. Overall, this review focused on “herbal” or “raw” MC, not cannabis-based drugs (i.e., nabilone). A summary table (Table 1) is given, which enumerates the references utilized for each country.

Table 1.

Herbal Medical Cannabis Country Legalization

Country	Herbal medical cannabis legal status	Sold in appointed pharmacies^a (yes/no)
Australia^1,25–29	Legal	Yes
Canada^29,46–51	Legal	No
Denmark^8,12	Legalized on 4-year pilot project	Yes
Finland^12,19	Legal (exceptional use)	Yes
Germany^2,9,12,19	Legal	Yes
Israel^10,12,19	Legal	Yes
Italy^10,12,19	Legal	Yes
The Netherlands^{1–7,10,12,19}	Legal	Yes
Poland^{10,12,15,16,19}	Legal (exceptional use)	Yes
Serbia¹⁷	Illegal	No
Switzerland^{10,12–14,19}	Legal (exceptional use)	Yes
Uruguay^1,19–24	Legal	Yes
United States^18,29–45	Legal in following 33 states and the District of Colombia: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Washington, and West Virginia	No

Can include all or registered pharmacies only.

Europe

The Netherlands

The Netherlands has been dispensing MC for over a decade.^1–5 It was felt by the Dutch government that it was safer for patients and their associated health needs to have MC meet a high pharmaceutical grade standard in quality control and be only available by prescription.⁵ In the Netherlands, MC is seen as a last resort medication to be used after “more conventional” medications have failed.⁴ In the Netherlands, only one company has been certified to grow and provide the pharmacies with MC. By having only one company control the supply, safety regulations have been ensured and easier to maintain.¹ Research into the Netherlands MC landscape has found that certified laboratories consistently test the MC to ensure this high standard of safety and quality.^1,4

The Netherlands Office of Medicinal Cannabis has dictated that, when a pharmacist dispenses MC, it may only be as dry flowers and that the patient should only ingest the MC through herbal tea or a vaporizer. Five different standardized strengths have been available at the pharmacy (∼22%THC: <1%CBD, ∼14%THC: <1%CBD, ∼13.5%THC: <1%CBD, ∼6.3%THC: ∼8%CBD and <1%THC: ∼9%CBD).⁶ In 2015, cannabis oils were introduced to the market. De Hoop et al. found that cannabis oil prescriptions outpaced MC prescriptions for 2016.³

In the Netherlands, cannabis can also be obtained from coffee shops; however, there are questions about the quality of the cannabis being provided. Hazekamp et al.,⁴ in response to public opinion that there was only a price but not a quality difference between pharmacy and coffee shop cannabis, performed their own study. Hazekamp et al.⁴ compared and tested the MC in a random sampling of pharmacies and cannabis from coffee shops. They found that not only was the quality of the cannabis significantly compromised, but the quantity of cannabis (i.e., the weight and percentage of active ingredients) purchased from the coffee shop had also been doctored.^1,4

The quality of the cannabis from the coffee shops, as tested in mycological analyses, was contaminated by bacteria, including: Escherichia coli, Cladosporium, and Aspergillus types. However, the pharmacy-dispensed cannabis had always the correct weight and had no bacteria or carcinogenic contaminants.^1,4 The costs of therapeutic agents are important for patients; however, safety of patients, especially those with compromised immune systems, must outweigh cost.

This example of the Netherlands has highlighted that, not only must a high standard be maintained for patients, but the public must also be educated on the associated safety protocols.¹ The Netherlands has provided the sole global example of a regulated and quality-ensured MC product at varying strengths dispensed in a pharmacy.^1,7

One of the concerns highlighted by pharmacists around the world is cannabis abuse; however, the Netherlands who have been dispensing MC since 2003 have found that the average daily consumption of MC (based on 90% of dispensed prescriptions) was stable over the years.³ Therefore, de Hoop et al.³ demonstrated that the concerns of overconsumption might be negligible. There was a lack of literature on pharmacists' concerns about MC, likely because it has already been accepted as part of the existing medical landscape. Pharmacists do appear to have advocated that MC should be dispensed in a pharmacy and not in a coffee shop environment to ensure quality and safety for patients.

Germany/Italy/Israel

Germany, Italy, and Israel have permitted MC (dried cannabis flowers) to be dispensed to patients in a pharmacy.⁸ Germany legalized the use of 14 different varieties of cannabis flowers for patients with severe debilitating diseases and no other treatment options (i.e., palliative patients) in March 2017.⁹ In Germany, these patients have been able to obtain MC at any pharmacy.²

Italy's MC is produced, cultivated, and distributed by the Italian army and is sold in all pharmacies under strict guidelines of consumption for only certain ailments, such as chronic pain where the MC is specified to only be consumed either orally (through an extract or in oil) or inhaled.¹⁰

Israel changed their policies in 2016 and now patients can obtain MC from pharmacies and not directly from the grower¹⁰; however, their policies continue to evolve.

These countries follow a similar methodology for the production and dispensing of MC, following the Netherlands model. There is a national government-controlled production and supply for MC; this has helped to ensure quality and safety controls.⁸ Nevertheless, there was a lack of literature on the attitudes of pharmacists, regarding MC in these countries.

Denmark/Finland/Poland/Switzerland

These four European countries dispensed MC (dried cannabis flowers) in a pharmacy; however, the cannabis is imported and it is only dispensed for certain medical conditions that have explicitly not responded to traditional means.⁸ For the pharmacies that wished to dispense MC, they must obtain a special license for the importation and preparation of each specific dosage.^8,11

MC in Denmark was only available at one pharmacy: Glostrup Pharmacy.¹² In Switzerland, there have been only two pharmacies that could prepare a MC tincture: Bahnhof pharmacy in Langnau and the Hänseler AG in Herisau.^10,13 Langnau is a 36-min drive to Bern and an hour and 40 min to Zurich. In Switzerland, unless it was in tincture form, it was illegal to use MC flowers for treatment. Nevertheless, it is likely that Switzerland's cannabis laws are in the process of changing to make MC legal, and thus increase the availability.¹⁴

Finland has allowed for the use of MC only under very specific conditions (i.e., pain) and it was only available at a small number of pharmacies.⁸ Poland, in 2017, legalized MC for certain conditions and was available to be dispensed at all pharmacies.^10,15 The Polish Pharmaceutical Chamber has stated that pharmacists will be trained on how to compound and dispense MC for a variety of conditions.¹⁶

Serbia

Serbia has not legalized MC, regardless of the pressure from neighboring Balkan states. However, Stojanović et al.¹⁷ investigated the knowledge of pharmacy students on MC, given the increase in societal pressure for MC legalization. Stojanović et al.¹⁷ administered the surveys to the final year pharmacy students at the University of Novi Sad (80 surveys). The survey questions focused on the students' knowledge of MC, the legalization process, side effects, and the pharmacy role in the dispensing MC. Stojanović et al.¹⁷ found that >90% of respondents felt that MC could have a therapeutic effect; however, approximately only 50% of respondents knew of those beneficial effects.¹⁷

The percentage of pharmacy students, who knew of the positive properties found by Stojanović et al.¹⁷ was similar to the findings of Moeller and Woods,¹⁸ who studied University of Kansas pharmacy students. Most of the University of Kansas respondents also struggled to correctly identify all ailments where MC was beneficial and were unable to appropriately identify potential side effects. In fact, many of the results found by Stojanović et al.¹⁷ were echoed in other studies of pharmacy students from the United States. Namely, more education is needed for these students to feel knowledgeable about dispensing and counseling on MC.

South America

Uruguay

The Uruguayan government, because of concerns about the distribution of illegal drugs and organized crime has adopted procannabis laws, regardless of their populace's negative opinion on cannabis. In fact, MC was not the main driver of this legislation, recreational cannabis was, and the policies are continuing to evolve.^1,19,20 About 61–66% of the Uruguayan population were anti-cannabis legislation, regardless of whether it was medical or recreational cannabis.^1,21 However, the reasoning behind the population not wanting to legalize cannabis had to do with the utilization of the pharmacy for selling cannabis (either medical or recreational).

The Uruguayan government has specified that only the cannabis flowers produced by two specific suppliers will be sold in the pharmacies. However, as of 2017, this program has not been put into effect.¹ According to Haberkorn²² only 50 of the 1200 total pharmacies in Uruguay have enrolled to dispense cannabis. There have been several reasons as to why Uruguayan pharmacists have voiced their opposition to dispensing cannabis: lack of government communication, cost-effectiveness, being pursued for unlawful activity, and losing business.^1,21,23

It was interesting that profitability or cost-effectiveness was listed as a key concern by the pharmacist, as this concern was not shared by pharmacists in other countries. However, it is likely that profitability was a concern as it has been made very clear that the government will decide on the price of the dispensed cannabis flowers.²¹ The Uruguayan government's goal is that if cannabis is dispensed in a pharmacy (with a 40 g/month limit) with a reasonable price, then individuals will use the government-mandated methods of obtaining cannabis and not the gray or black markets.^1,21,24

Cruz et al.²⁰ has suggested that there might have been more support for cannabis legislation, if the government had begun and focused only on MC for therapeutic reasons. As Cruz et al.²⁰ summarized, “The lack of support for the access to cannabis through pharmacy retail may compound an already problematic process of law implementation.”^{20(p. S433)}

The government has exercised caution with setting up a major cannabis commercialization system from seeds to dispensation. The Uruguayan pharmacist, who would be the one dispensing cannabis and counseling patients, has seemed to not want to dispense or sell cannabis at all. Thus, if the pharmacist does not want it, would they even dispense it?

Oceania

Australia

As of February 29, 2016, Australia passed an amendment to the 1967 Narcotic Drug Act regarding the growth and cultivation of cannabis, specifically MC. Before this amendment was enacted, it was illegal for MC to be used or scientifically researched in Australia.²⁵

Since 2016, questions have been raised on the safety, efficacy, and the method of dispensing MC. Isaac et al.²⁶ questioned 34 registered pharmacists of varying levels of experience, and who were employed in different work environments throughout Australia²⁶ on their opinion of MC.¹ Isaac et al.²⁶ identified that the majority of pharmacists wanted a regulated MC therapeutic agent as this would help with quality control and to “minimise any risk of harm to the patient associated with compounded forms of cannabis.”^{26(p. 9)} Of interest, most pharmacists interviewed by Isaac et al.²⁶ understood that there was a risk and reward with MC like there was with any drug.

This perspective was surprising, as it did not seem to be shared with pharmacists from other countries, such as the United States (as will be discussed later in this review). It is much safer for patients to obtain MC from a licensed pharmacist than from a black or gray market source, as was seen with The Netherlands.

Throughout the literature, Australian pharmacists have been clear that they want more education on MC but were overall supportive of dispensing MC.^1,26–28 In fact, Isaac et al.²⁶ compared the dispensing of MC with that of a needle exchange or provision of methadone. Some of the pharmacists did not have the same concerns about cannabis abuse (a concept that is readily discussed in the media and in other countries) because they felt that a large part of their role is to identify abuse and addiction, regardless of the drug.²⁶

In fact, one could make the global assumption that it is a part of the pharmacist role to stop abuse and addiction of a medication. The argument of possible abuse has lent itself more toward pharmacies dispensing MC than other facilities, as pharmacists have had the training to spot problems before they become issues.

A common theme throughout the literature, not just Australia, is that more information is needed to safely dispense MC, including: drug interactions, appropriate dosages, signs of toxicity, and effectiveness.^1,26,27,29 Martin and Bonomo²⁷ also discussed a common theme throughout this entire literature review, that it was unknown, at the time of publication, what were the appropriate starting dosages and possible toxic dosages. As well, it was also unknown how MC interacts with other drugs and the possible issue of variation within batches.

One approach to mitigate this safety and quality control issue would be to import the MC from the Netherlands, as The Netherlands Ministry of Health, Welfare and Sport closely regulates the growth and cultivation of MC, to ensure strict quality control, hence safety for patients.²⁸

Australian pharmacists seem to be more open to dispensing MC compared with other countries' pharmacists in this review.

North America

The United States

Cannabis, whether medical or recreational, is a Class 1 narcotic at the federal level, as viewed by Drug Enforcement Administration. Class 1 narcotics also encompass heroin, lysergic acid diethylamide, and other hallucinogenic amphetamines.³⁰ However, 33 states, Puerto Rico, Guam, and one district have authorized the use of MC regardless of the federal statutes.^31–33 As well, there have been 17 additional states that allowed for CBD oil only.³² This has been an interesting quandary for all American pharmacists, as they are currently in a gray area, where MC is allowed at a state level, but not federal. Which laws do they follow? Can you follow both?

The American Pharmacist Association has made some recommendations on MC, including that all cannabis products be clearly stated on every patient's profile. Another of their recommendations—which has been echoed by a variety of authors—was to standardize strength and strain (across the United States), thus making it easier to establish the side effects, interactions, therapeutic effects, and correct dosages.^34–39 In fact, the pharmacist role has already included discussing “alternative nonpharmacologic and pharmacologic therapy options.”^32,36^{(p. 349)} Overall, the pharmacist must have an open mind, otherwise the patient might be reluctant to speak to them about MC and then the patient will be placed in greater danger.^36,40

The American pharmacist has been placed in a unique position where they could face legal complications by counseling patients on MC owing to federal statutes. Of interest, in US states where cannabis laws have been enacted, there was, overall, a lower opioid analgesic overdose mortality rate compared with those states without cannabis legalization.⁴¹

According to the National Community Pharmacist Association, five US states have included a role for the pharmacist in the dispensing of MC: Arkansas, Connecticut, Minnesota, New York, and Pennsylvania as of 2017.⁴² In Arkansas, a pharmacist consultant is appointed and in Pennsylvania, a pharmacist or physician must be on-site in a dispensary.⁴² Connecticut, Minnesota, and New York have attempted to address the issue of patients not informing a pharmacist of cannabis use, by enacting laws to ensure that a pharmacist must dispense and counsel patients on MC usage.⁴⁰

In Connecticut, Minnesota, and New York, distribution centers have been the only place to get MC, but they must be dispensed by a trained health care professional (i.e., a pharmacist) at these locations.⁴³ Therefore, these pharmacists have had to be extremely knowledgeable to guide patients to which products were the best for their ailment(s) and their current medications. These three states took this novel dispersion model because a pharmacist has more knowledge than just a retailer.

Hwang et al.⁴³ focused specifically on Minnesotan pharmacists' knowledge and concerns about dispensing and counseling patients on MC. In Minnesota, only nonsmoked cannabis preparations are allowed (the only other state that specifies nonsmoked MC is New York). This included: oral liquids, oils, tablets, capsules, and vaporized extracts.⁴³ Globally, this was unique especially in comparison with European countries where edibles and smoking were not allowed.

As part of the Minnesota MC program, patients who used MC were registered and had to meet with a distribution center pharmacist on their treatment goals and which dosage and strain would be best for them. In fact, the patient would have had to meet consistently with this specific pharmacist for follow-ups and refills.⁴³ Connecticut and New York followed a similar model to that of Minnesota.

Two months before the implementation of the MC program, Hwang et al. administered a survey to all pharmacists in Minnesota (7,332) and had a 10% response rate (607 collected and fully completed).⁴³ Although their response rate was very low in terms of statistical significance, the absolute number was still high enough within this population to be investigated. They found some disconcerting results with regard to the knowledge base of pharmacists regarding MC.

For instance, not all pharmacists could correctly identify what were eligible dosage formats, as well, the results were mixed on what qualified as a correct condition to be eligible for MC.⁴³ Only 46% of pharmacists understood what the consulting duties about MC involved and only 29% would have been able to help patients make the right selection of strength and strain for their needs.⁴³

Even more troubling was the fact that only 62% of pharmacists could identify cannabis as a Schedule 1 substance at the federal level.⁴³ Most pharmacists felt that they had very little knowledge of MC with which to counsel patients. Nevertheless, these pharmacists wanted further education on MC pharmacotherapy, regulations, rules, strains, and strengths.⁴³ Given the unique role of the pharmacist in the American medical landscape, pharmacists need increased training and education to be able to appropriately counsel patients.

US pharmacy students

Within the literature, medical students' opinions, attitudes, and education toward MC have also been explored. The medical student's perspective was of key importance as it would be likely that these students will soon be dispensing MC throughout different states. But do pharmacy students possess the necessary education about MC, including the safety, efficacy, and legal ramifications?

Moeller and Woods¹⁸ anonymously surveyed the University of Kansas first-, second- and third-year pharmacy students' knowledge and attitudes to MC, specifically, to establish if further education was needed. Berlekamp et al.⁴⁴ focused on Ohio pharmacy students throughout six colleges in Ohio; and Caligiuri et al.³² focused on first-, second- and third-year pharmacy students in an unnamed private Midwestern university. Of importance, MC is not legal in Kansas, whereas it is legal in Ohio for certain conditions.

Moeller and Woods¹⁸ designed a survey to assess the knowledge of MC including, the potential uses (diseases and ailments); the students personal attitudes (medical and recreational); efficacy, safety, and potential drug interactions; and finally six closed-end questions about personal views that could impact their counseling or dispensing of MC.

Berlekamp et al.⁴⁴ designed a 19-question survey that assessed the students' knowledge of MC (including management and legalities), support of MC legislation, their confidence in counseling patients, and if there was a need for further education). However, in comparison with Moeller and Woods¹⁸ whose survey was handed out to all pharmacy students in one university, the Berlekamp et al.⁴⁴ survey was administered through email to all pharmacy students who wanted to participate. Consequently, Berlekamp et al.⁴⁴ had a lower response rate in comparison with the study of Moeller and Woods (2015) at the University of Kansas.

Caligiuri et al.³² administered a voluntary survey at one unnamed midwestern university, where the students had some introductory knowledge about the endocannabinoid system. Their survey focused on assessing the knowledge base and attitudes, specifically, qualifying conditions, negative side effects, and their associated confidence with dispensing and counseling on MC.³²

Moeller and Woods¹⁸ had a response rate of 311 completed surveys of a possible 360, or 86.4%. Berlekamp et al.⁴⁴ had a response rate of 319 surveys (whether fully completed or not) from a total of 1931 or more, simply stated as 16.5%. Because Caligiuri et al.³² was administered in-class, although it was voluntary, their response rate was 76% or 238 of a possible 315.

These authors^18,32,44 found that the majority of students did not have an accurate knowledge of the approved illnesses that MC could treat or were they knowledgeable about potential side effects. Moeller and Woods¹⁸ found that users of recreational cannabis were more knowledgeable about cannabis benefits. Nevertheless, the relationship between those students who have previously used cannabis to their understanding of MC was not explored in Ohio or in the private midwestern university. Caligiuri et al.³² and Moeller and Woods¹⁸ found that most respondents were in favor of MC being used a treatment and a symptom management option.

A knowledge gap has been identified within pharmacy curriculum on the use and potential benefit of MC. Abazia and Bridgeman³¹ stated that “…healthcare professional curricula have failed to keep pace with the evolving national landscape and widespread use of this [MC] therapy”.^{31(p. 1166)} It has appeared that much of the discussion on cannabis in the classroom, to date, has focused on its abuse potential. Some authors^18,31,32,45 have noted that MC needs to become a part of the pharmacy school curriculum, especially as it becomes a legalized therapeutic product.

In fact, Caligiuri et al.³² found that >90% of their student respondents wanted MC to be a larger part of the curriculum, with added focus on how to counsel patients. Of interest, Smithburger et al.⁴⁵ evaluated the pharmacy college curriculum in terms of MC inclusion. They sent out a survey to one designated person (as chosen through the American Association of the Colleges of Pharmacy member on the Curriculum Special Interest Group roster) at each university or college in the United States.⁴⁵

There were a total of 140 pharmacy programs and Smithburger had responses from 68; 42 respondents indicated that MC was already included, to some degree, in their school curriculum.⁴⁵ However, in no instances were the college courses, where MC was taught, identified. A common theme seen throughout the American literature, was that the pharmacist, regardless of whether still a student or already practicing, wanted more education and clarity on MC.

Canada

In 2001, Canada enacted the Marihuana Medical Access Regulations that allowed dried cannabis to be used for medical reasons.⁴⁶ Under this regulation, only authorized patients could obtain cannabis from either Health Canada, a designated grower, or grow their own. However because of safety and patient application concerns, in 2013 the Marihuana for Medical Purpose Regulations (MMPR) were enacted to regulate, through licensed producers, the production and distribution of medical cannabis.⁴⁶

As of October 2015, there are 26 authorized licensed producers in Canada, but there was still a lack of scientific knowledge on benefits, dosage, interactions, and risks. The licensed producers in Canada have offered >200 different strains/varieties of MC.⁴⁷ However, there has been a paucity information to guide a patient or a physician into picking the correct strain and strength.

Of interest, as MC will soon be dispensed in pharmacies, it will soon be a part of the pharmacist's role to counsel patients on correct strain and strength, especially with so many available variations. According to the Canadian Pharmacist Association,⁴⁸ pharmacists are uniquely poised to provide advice to patients on MC, as well as the dispensing and the safe management of taking MC.^47–49

The Conference Board of Canada⁵⁰ prepared a detailed analysis of patients' access to MC under a pharmacy-dispensing model versus a licensed producer model, in August 2016. The Conference Board of Canada⁵⁰ found that it was to the benefit of the populace to follow a pharmacy dispensing model, not only because it would be more cost-effective but also owing to pharmacists monitoring of patients, reducing misuse of MC, higher quality control, clear pricing, and easier accessibility for patients.⁵⁰

The Conference Board of Canada⁵⁰ also found that the pharmacy dispensing model would lead to a “uniform market” and that pharmacies would likely be able to obtain MC at a wholesale price. Finally, this report also established that if a pharmacy dispensing model was used, then it would likely lead to a decrease in cannabis misuse hospital visits.⁵⁰ Pharmacists have been trained to watch for signs of addiction and abuse to medications, MC would be no different. Furthermore, if a pharmacist is dispensing MC, then a doctor may be more likely to prescribe this product, as a well-respected health care professional is monitoring the usage and potential drug–drug interactions.

Pharmacists in Canada, like the rest of the world, already know how to dispense and manage controlled substances (i.e., opioids); thus, the pharmacist is likely the best choice for dispensing MC.^48,49

The Canadian Pharmacist Association⁴⁸ has several educational resources and courses that pharmacists have been able to utilize to gain more knowledge. However, Grootendorst and Ranjithan⁴⁷ highlighted several issues with pharmacists dispensing MC from the cost of drug, established gray markets, and logistics that would prevent MC from being dispensed easily or successfully in a pharmacy. Grootendorst and Ranjithan⁴⁷ also recognized that in Canada, patients can obtain their MC from outside the regulatory system, including online, dispensaries, or unauthorized places. Nevertheless, it has been the hope of the government that patients would utilize the pharmacist instead of other—more gray—markets, owing to their knowledge and foresight.

This has already been seen from a pharmacist counseling perspective, as the number of patients utilizing MC has increased from just over 100 patients in 2001 to 250,000 patients in 2017⁴⁷ and to >270,000 patients as of 2018.⁴⁹ For MC to be dispensed in a pharmacy, then it must be streamlined, because otherwise keeping all varieties and dosages available would be costly and expensive. A cost-effective approach is needed for the pharmacy, as the unique relationship between the pharmacist and the patient needs to be preserved.

Hospital pharmacists in Canada have also been surveyed for their opinion about MC. Mitchell et al. investigated hospital pharmacists' opinions on MC, specifically the safety, efficacy, and level of comfort when counseling patients and other health care providers about MC.⁵¹ Mitchell et al. used a 35-item online anonymous survey, available in French and English, and sent it out to all hospital pharmacists in January and February of 2015 and their response represented 13% of hospital pharmacists.⁵¹

Overall, Mitchell et al. found that approximately half of the surveyed hospital pharmacists felt that MC was safe and/or effective to use.⁵¹ Nevertheless, in total, only 17.2% of those surveyed felt knowledgeable about MC.⁵¹ Pharmacists in Ontario felt that they were knowledgeable about MC, whereas those pharmacists in Quebec felt the least knowledgeable.⁵¹ Many of the hospital pharmacists surveyed did not work in hospitals where there was an MC policy.⁵¹ This is indicative of where policy changes need to be applied, especially, as the government policy on MC has been changing and those changes directly affect the pharmacists.

The hospital pharmacist is in a unique quandary between a hospital with possibly no governance for MC and a government policy that stated they are required to dispense it.

Conclusion

This review has identified a knowledge and implementation gap for many countries that have legalized MC, as it was unknown how their pharmacists felt about counseling, dispensing, and monitoring. Given the key role of the pharmacist, the lack of literature on the role and attitudes, in terms of MC described in this review, has been surprising. Globally, there is also a significant lack of legal or regulatory body guidance. As Ware et al.⁵² stated, “Health care workers need to be able to discuss cannabis use with patients and to be able to accurately describe possible risks and benefits of cannabis use.”^{52(p. 215)}

Overall, within the literature reviewed here, although pharmacists are comfortable with providing patients with MC, they want more education to be able to dispense this therapeutic agent safely and effectively as possible.

Footnotes

Acknowledgments

The authors thank Joanna Malinowska for her help identifying relevant articles in Poland and translating them to English. Her help was invaluable.

Author Disclosure Statement

C.T. has acted as a consultant for MC producers (Tilray, Medreleaf, and Aurora) and MC clinics (Spartan Wellness and Canna Connect).

Funding Information

Funding for this article has been provided by the Sleep Wake Awareness Program.

Abbreviations Used

References

Thirlwell

. Pharmacists and medical cannabis: a global perspective. Med Cannabis Today. 2019; 4: 9–11.

Bifulco

, Pisanti

. Medicinal use of cannabis in Europe: the fact that more countries legalize the medicinal use of cannabis should not become an argument for unfettered and uncontrolled use. EMBO Rep. 2015; 16:130–132.

de Hoop

, Heerdink

, Hazekamp

. Medicinal cannabis on prescription in the Netherlands: statistics for 2003–2016. Cannabis Cannabinoid Res. 2018; 3:54–55.

Hazekamp

, Sijrier

, Verpoorte

. An evaluation of the quality of medicinal grade cannabis in the Netherlands. Cannabinoids. 2006; 1:1–9.

Knöss

, van de Velde

, Sandvos

, et al. Key elements of legal environments for medical use of cannabis in different countries. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2019; 62:855–860.

Ministry of

Health

, Welfare and Sport and the Institute for Responsible Medication

Use

. Medical Cannabis: information brochure for patients. Revised Version. The Hague: Netherlands, 2019.

Hazekamp

, Heerdink

. The prevalence and incidence of medicinal cannabis on prescription in The Netherlands. Eur J Clin Pharmacol. 2013; 69:1575–1580.

Krcevski-Skvarc

, Wells

, Häuser

. Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: a survey of the status in the chapters of the European Pain Federation. Eur J Pain. 2018; 22:440–454.

Häuser

, Fitzcharles

, Radbruch

, et al. Cannabinoids in pain management and palliative medicine: an overview of systematic reviews and prospective observational studies. Dtsch Ärztebl Int. 2017; 114:627.

10.

European Monitoring Center for Drugs and Drug Addiction. Medical use of cannabis and cannabinoids: questions and answers for policymaking. Publications Office of the European Union: Luxembourg, 2018.

11.

Health Products Regulatory Agency. Cannabis for medical use. A scientific review, 2017. Available at: http://health.gov.ie/wp-content/uploads/2017/02/HPRA-Report-FINAL.pdf Accessed September 1, 2019.

12.

Cannabis Denmark. Legislation for Patients in Denmark. Available at: https://www.cannabisdanmark.dk/english/legislation-for-patients/ Accessed September 2019 .

13.

Medical Cannabis Association Switzerland. Medical Cannabis. Available at: https://www.medcan.ch/de/recht/23-medizinisches-cannabis Accessed September 2019 .

14.

Switzerland Federal Office of Public Health. Médicaments à base de cannabis: modification de la loi. Available at: https://www.bag.admin.ch/bag/fr/home/medizin-und-forschung/heilmittel/med-anwend-cannabis/gesetzesaenderung-cannabisarzneimittel.html Accessed June 2020 .

15.

Sharman

. Poland legalizes Medical Cannabis. Independent. 2017. Available at: https://www.independent.co.uk/news/world/europe/poland-legalise-medical-marijuana-cannabis-pharmacy-a8037681.html Accessed September 5, 2019.

16.

The Pharmaceutical Journal. Medicinal cannabis made legal in Poland. Available at: https://www.pharmaceutical-journal.com/news-and-analysis/news/medicinal-cannabis-made-legal-in-poland/20203919.article Accessed November 2019 .

17.

Stojanović

, Tomas

, Paut-Kusturica

, et al. OJ. Pharmacy students' knowledge and attitudes regarding cannabis for medical purposes. Hosp Pharmacol Int Multidiscip J. 2017; 4:559–567.

18.

Moeller

, Woods

. Pharmacy students' knowledge and attitudes regarding medical marijuana. Am J Pharm Educ. 2015; 79.

19.

Aguilar

, Gutiérrez

, Sánchez

, et al. Medicinal cannabis policies and practices around the world. Int Drug Policy Consort. Briefing paper. 2018:1–32.

20.

Cruz

, Boidi

, Queirolo

. The status of support for cannabis regulation in Uruguay 4 years after reform: evidence from public opinion surveys. Drug Alcohol Rev. 2018; 37:S429–S434.

21.

Cerdá

, Kilmer

. Uruguay's middle-ground approach to cannabis legalization. Int J Drug Policy. 2017; 42:118.

22.

Haberkorn

. A majority of pharmacists in Uruguay don't want to sell pot, here's why. Cannabist. 2017. Available at: https://www.thecannabist.co/2016/07/06/uruguay-marijuana-pharmacies/57627/ Accessed July 23, 2019.

23.

Palmer

. Uruguayan pharmacists say no to marijuana. Council on Hemispheric

Affairs

. 2016. Available at: www.coha.org/uruguayan-pharmacists-say-no-to-marijuana/ Accessed August 2019 .

24.

Kilmer

, Kruithof

, Pardal

, et al. Multinational overview of cannabis production regimes. Rand Europe: Cambridge, UK, 2013.

25.

Australian Office of Drug Control. Legislation. Department of Health. Available at: https://www.odc.gov.au/legislation Accessed October 2019 .

26.

Isaac

, Saini

, Chaar

. The role of medicinal cannabis in clinical therapy: pharmacists' perspectives. PLoS One. 2016; 11:e0155113.

27.

Martin

, Bonomo

. Medicinal cannabis in Australia: the missing links. Med J Aust. 2016; 204:371–373.

28.

Mather

, Rauwendaal

, Moxham-Hall

, et al. (Re) introducing medicinal cannabis. Med J Aust. 2013; 199:759–761.

29.

Gardiner

, Singleton

, Sheridan

, et al. Health professional beliefs, knowledge, and concerns surrounding medicinal cannabis—a systematic review. PLoS One. 2019; 14:e0216556.

30.

Frazzetto

. Does marijuana have a future in pharmacopoeia? Although recent research backs the therapeutic benefits of cannabis, its adverse effects and the risk of addiction push against the legalization of the drug for medical use. EMBO Rep. 2003; 4:651–653.

31.

Abazia

, Bridgeman

. Reefer madness or real medicine? A plea for incorporating medicinal cannabis in pharmacy curricula. Curr Pharm Teach Learn. 2018; 10:1165–1167.

32.

Caligiuri

, Ulrich

, Welter

. Pharmacy student knowledge, confidence and attitudes toward medical cannabis and curricular coverage. Am J Pharm Educ, 2018; 82:6296.

33.

Berke

, Gould

. This map shows every US state where pot is legal. Times Union, 2019. Available at: https://www.businessinsider.com/legal-marijuana-states-2018-1 Accessed September 5, 2019.

34.

Borgelt

, Franson

. Considerations for hospital policies regarding medical cannabis use. Hosp Pharm, 2017; 52; 89.

35.

Frezza

. Medical marijuana: a drug without a medical model. Geo LJ, 2012; 101:1117.

36.

Mahvan

, Hilaire

, Mann

, et al. Marijuana use in the elderly: implications and considerations. Consult Pharm. 2017; 32:341–351.

37.

Russo

. Current therapeutic cannabis controversies and clinical trial design issues. Front Pharmacol. 2016; 7:309.

38.

Wilkinson

, D'Souza

. Problems with the medicalization of marijuana. JAMA. 2014; 311:2377–2378.

39.

Zarhin

, Negev

, Vulfsons

, et al. Medicalization of cannabis: what does it mean?. Int J Drug Policy. 2017; 49:54–57.

40.

Marcoux

, Holmes

, Vogenberg

. Regulatory and legislative disparities with cannabis present challenges to P&T committees and health care providers. Pharm Ther. 2019; 44:290.

41.

Bachhuber

, Saloner

, Cunningham

, et al. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999–2010. JAMA Intern Med. 2014; 174:1668–1673.

42.

National Community Pharmacists Association. State medical marijuana legislation and the pharmacist's role, 2017. Available at: www.ncpa.co/pdf/medical-marijuana-one-pager-aug-2017.pdf Accessed October 2019 .

43.

Hwang

, Arneson

, Peter

. Minnesota pharmacists and medical cannabis: a survey of knowledge, concerns, and interest prior to program launch. Pharm Ther. 2016; 41:716.

44.

Berlekamp

, Rao

, Patton

, et al. Surveys of pharmacy students and pharmacy educators regarding medical marijuana. Curr Pharm Teach Learn. 2019; 11:669–677.

45.

Smithburger

, Zemaitis

, Meyer

. Evaluation of medical marijuana topics in the PharmD curriculum: a national survey of schools and colleges of pharmacy. Curr Pharm Teach Learn. 2019; 11:1–9.

46.

Beaulieu

, Boulanger

, Desroches

, et al. Medical cannabis: considerations for the anesthesiologist and pain physician. Can J Anesth. 2016; 63:608–624.

47.

Grootendorst

, Ranjithan

. Pharmacists should counsel users of medical cannabis, but should they be dispensing it?. Can Pharm J. 2019; 152:10–13.

48.

Canadian Pharmacist Association. Issues spotlight: medical cannabis. Can Pharm J, 2018; 151:274.

49.

Dattani

, Mohr

. Pharmacists' role in cannabis dispensing and counselling. Can Pharm J. 2019; 152:14.

50.

The Conference Board of Canada. The cost of medical marijuana in Canada: a pharmacy dispensing model and the status quo. In: Paper presented to the Can Pharmacists Association, August 2016, Ottawa, Ontario.

51.

Mitchell

, Gould

, LeBlanc

, et al. Opinions of hospital pharmacists in Canada regarding marijuana for medical purposes. Can J Hosp Pharm. 2016; 69:122.

52.

Ware

, Doyle

, Woods

, et al. Cannabis use for chronic non-cancer pain: results of a prospective survey. Pain. 2003; 102:211–216.