As cannabis gains acceptance, debate grows over pharmacists’ role

First in a three-part series

At the 2015 APhA Annual Meeting & Exposition in San Diego, the topic of pharmacists’ role in the care of patients using cannabis was on a lot of attendees’ minds.

During the APhA House of Delegates’ packed final session, participants engaged in a lively debate that eventually led to the adoption of several APhA policy statements. One was a policy opposing pharmacist involvement in “furnishing cannabis and its various components for recreational use.” Another called for supporting pharmacist participation in “furnishing cannabis and its various components when scientific data supports the legitimate medical use of the products and delivery mechanisms.” However, that statement was met with some heated back and forth and was originally rejected, until a representative from the APhA Academy of Student Pharmacists opened it up for reconsideration, where it was adopted with a round of applause.

If the House of Delegates session was any indication (see sidebar for 2015 APhA policy statements on cannabis), pharmacists realize they have a role to play as cannabis becomes more widely accepted. But what is that role, and what should society and state legislatures be asking pharmacists to do?

Things are moving quickly

To date, 24 states and the District of Columbia have laws that legalize and regulate cannabis for medicinal purposes. Four states and the District of Columbia have legalized cannabis for nonmedical use. It’s likely that more states will move to adopt similar laws. In addition, Connecticut’s medical cannabis law requires an onsite pharmacist to dispense the drug, as does Minnesota’s medical cannabis law, although the language is not as detailed as Connecticut’s law.

Pharmacists agree that two barriers still need to be addressed before full participation can occur. Scientific research on the safety and efficacy of cannabis is still lacking, and federal and state laws are in conflict, leaving many pharmacists further confused.

This article is first in a three-part Pharmacy Today series examining these issues and more for pharmacists. The second article will focus on Connecticut, where pharmacists are required to dispense medical cannabis. The third article will spotlight Colorado, a state that has made the most progress on implementing its law legalizing cannabis for recreational use. Although marijuana is the more commonly known term, the proper scientific term, cannabis, will be used in this series.

Lack of evidence

“As a pharmacist, I feel like I don’t have all the right tools I need to be able to help patients when it comes to this topic,” Bithia Fikru, PharmD, MPA-HAS, PhD, Candidate and Research Analyst at the University of Minnesota, told Today.

Because the federal government classifies cannabis as a Schedule I drug, the medical community has been restricted from gaining access to it for research purposes. In addition, a lack of standardization, meaning cannabis can vary from one state to another, makes research even more difficult. Cannabis can have different levels of potency and affect diseases uniquely. Research points to the ability of cannabis to relieve certain clinical conditions, including glaucoma, nausea, AIDS-associated anorexia and wasting syndrome, chronic pain, inflammation, multiple sclerosis, and epilepsy.

According to the 2015 House of Delegates background paper on cannabis, pharmacists have raised concerns about managing patients who use “inhaled cannabis in disease states in which efficacy and safety have not been evaluated, restrictions on patients who are able to access inhaled cannabis, and the effect of inhaled cannabis on patient decision-making skills as well as their medication regimen.”

The University of Mississippi houses the only federally funded cannabis program in the country to supply forms of cannabis for research. Although the program has not conducted studies to address dosing and disease state directly, Mahmoud ElSohly, PhD, Research Professor at the University of Mississippi School of Pharmacy and Director of the University of Mississippi Marijuana Project, acknowledges that lack of guidance on dose, frequency, or duration of treatment is the problem with the use of the term “medical marijuana” or “medical cannabis.”

The House of Delegates background paper goes on to say that pharmacists are hesitant to jeopardize their careers by dispensing inhaled cannabis without large-scale trials on inhaled cannabis or guidance from FDA.

State vs. federal law

State laws that condone cannabis for medical uses are in direct conflict with federal law, where cannabis is not approved for medical use. In addition, states regulate professional practices, whereas the federal government regulates products in interstate commerce.

This discrepancy can have several consequences for practitioners, according to Stephen Schondelmeyer, PharmD, PhD, FAPhA, head of the Department of Pharmaceutical Care and Health Systems in the College of Pharmacy at the University of Minnesota.

“We have an interstate commerce law that conflicts with what professions can and cannot do,” he told Today.

“In following state laws, can they [pharmacists] be found in conflict with federal law? And if so, what is the consequence for their license? Do they have civil or criminal liability? Will a pharmacist’s DEA number be taken away?” asked Schondelmeyer.

In essence, the conflict is jurisdictional, relating to who sets the boundaries of what professions can and cannot do with drug products.

Schondelmeyer said it would also help to look to some model states for consistency in state laws pertaining to cannabis, and more importantly, he thinks it’s time for a federal evaluation on the issue, which would also lead to a regulated process for drug product purity and quality as well as marketing and advertising of cannabis.

In March, three U.S. senators introduced a bill that would legalize medical marijuana by reclassifying it from a Schedule I to Schedule II drug.

APhA policy on the role of the pharmacist in the care of patients using cannabis (2015)

  1. APhA supports regulatory changes to further facilitate clinical research related to the clinical efficacy and safety associated with the use of cannabis and its various components.
  2. APhA encourages health care provider education related to the clinical efficacy, safety, and management of patients using cannabis and its various components.
  3. APhA advocates that the pharmacist collect and document information in the pharmacy patient profile about patient use of cannabis and its various components and provide appropriate patient counseling.
  4. APhA supports pharmacist participation in furnishing cannabis and its various components when scientific data support the legitimate medical use of the products and delivery mechanisms, and federal, state, or territory laws or regulations permit pharmacists to furnish them.
  5. APhA opposes pharmacist involvement in furnishing cannabis and its various components for recreational use.

Source: Report of the 2015 APhA House of Delegates