Integrating the medical and cannabis systems: A mock case study.

To illustrate the challenges, let’s follow the path of one patient visiting you, her community pharmacist, for cannabis therapy. Mary is a 78-year-old woman living in a residential retirement residence with in-home nursing care provided by a private company. She heard from her neighbour that cannabis may be beneficial for sleep. She has atrial fibrillation and is on warfarin 3 mg daily and bisoprolol 2.5 mg daily. Her therapy has been stable for many years and she is largely asymptomatic.

As with any treatment consideration, the benefits and risks of cannabis must be considered and discussed with Mary. This also includes a number of related variables, such as relative concentration of cannabidiol (CBD) and tetrahydrocannabinol (THC), routes of administration, dosing and, of course, likelihood of sleep being improved and safety of the therapy (i.e., effect on her heart, falls risk, etc.). After speaking with Mary, as well as reviewing her medical history and laboratory values, you determine that the potential benefits outweigh the risks for oral cannabis therapy, although she will need to watch for blood pressure and heart rate changes as well as having her international normalized ratio (INR) monitored. Now the challenging part begins.

You select the recommended product/treatment; however, you recall that a specific authorization form is required instead of a standard prescription. You go to the producer’s website and locate the authorization form; however, the form requires prescribing in grams per day. After finding the conversion used by this manufacturer and converting the dosage, filling out the form, noting this on her file, faxing this form to the physician and giving a copy to Mary, you observe that the pharmacy is starting to back up. However, more time is still required as you write down the dose that you recommend on a prescription pad as well as a recommendation for INR monitoring that she can take to her physician’s visit later in the day. You counsel Mary on cannabis use and what to expect and remind her of the recommended monitoring.

A few hours later, you receive a faxed prescription from the physician for Mary for THC 2.5 mg and CBD 5 mg, both to be taken at bedtime. You call the office and explain that, unfortunately, the system for cannabis products is separate from the pharmaceutical system and that the physician will need to fill out the authorization that you sent over earlier and fax it to the producer.

A week later, Mary comes back to the pharmacy wondering if you have heard from the producer as she has not received anything. You call the physician and confirm that the authorization was sent in. You then look up the number and call the producer to see if her authorization has been processed. After waiting on hold, the producer informs you that yes, the authorization has been processed that day. You let Mary know this and explain that she will receive information in the mail, which she can use to log in online to order her product.

Mary also has a new prescription for zopiclone 3.75 mg, to be taken at bedtime as needed, which you fill, and remind her that this should not be used at the same time as cannabis products.

Two days later, your pharmacy gets a call from Mary asking where she can bring her cannabis prescription that she received from the producer. Your pharmacy assistant explains that this letter is not a prescription and that she will need to go online to order her product. Mary doesn’t have a computer but says that she can probably get assistance to order the product. A few hours later, you get a call from her daughter asking which product she should order and how Mary should take it as it is not written on the authorization (luckily you have entered this information into the comments section on Kroll!).

A week later, you receive a fax from Mary’s home care nurse. The nurse explains that he cannot administer Mary’s cannabis oil as he does not have a prescription for it. You fax the physician for a prescription-formatted recommendation so the nurse can administer the medication. The next day, your pharmacy gets a call from the facility nurse manager. The manager says that the nurses are not allowed to administer anything that is not labeled by a pharmacy and, unfortunately, the nurses are not currently permitted to administer cannabis products. Mary would need to self-administer this product, measuring out the dose herself. Mary has difficulty seeing small print and cannot see the clear gradations on the plastic syringe. She asks what you would recommend, and you suggest that she switch to capsules, although she will now need to purchase 2 separate products. You look it up online and confirm that this producer makes a 2.5 mg capsule of THC and a 5 mg capsule of CBD and recommend that Mary take 1 capsule of each an hour before bed. You write this down for her to give to her daughter.

The next month, you see Mary again and note that she is quite dizzy and unsteady on her feet. You ask the nursing staff to send over her medication profile and note that she still has zopiclone listed but not the self-administered THC and CBD capsules. She has the bottles with her and you note that she has accidentally purchased THC 5 mg capsules and CBD 2.5 mg capsules. You ask Mary, and she confirms that she has been taking 1 capsule of each as recommended. Unfortunately, cannabis does not appear on the provincial prescription system, and she is now taking a double dose of THC in addition to zopiclone.

In conclusion, as depicted in this scenario, there are a number of process issues affecting the prescribing of medical cannabis. The onerous and inefficient paperwork, the separation of information from the established medical system and the fact that, unlike all other prescription medications, cannabis is legally prohibited from having intended use or dosing information included on the product label all contribute to putting prescription cannabis users at risk. ■