In Connecticut, medical cannabis must be dispensed by pharmacists
Cannabis: Second in a three-part series
In 2012, when Gov. Dannel Malloy of Connecticut signed legislation legalizing medical cannabis, Connecticut pharmacists were presented with a new career opportunity.
In an attempt to better align medical cannabis with proper pharmaceutical regulation, Connecticut’s medical cannabis law requires that a board-certified pharmacist be onsite to dispense the product at a medical cannabis dispensary.
“I think having the pharmacist involved legitimizes this in a way,” Nick Tamborrino, PharmD, founder of Bluepoint Wellness, told Pharmacy Today.
Bluepoint is one of six dispensaries currently operating in Connecticut.
“We are monitoring patients the same way as if they were being treated with a prescription medication,” said Tamborrino.
In addition, four of the six dispensaries in Connecticut are owned by pharmacists who saw the law as an opportunity to exercise their entrepreneurial spirit.
Tamborrino was one of them. He earned his MBA after pharmacy school and says he’s always been an entrepreneur at heart.
“I was never a big advocate of marijuana. But as I studied it, it drew me in; and seeing it first-hand with patients is an amazing experience,” he said.
This article is second in a three-part Today series examining the role of pharmacists around cannabis. Although marijuana is the more commonly known term, the proper scientific term, cannabis, is being used in this series.
Inside a dispensary
Bluepoint Wellness sits next to a Planet Fitness gym in a new business complex off a main road in Branford, CT. Like all dispensaries, there’s heightened 24/7 security, with cameras surveying the parking lot and each room inside the facility. Bluepoint patients are seen by appointment only, and Tamborrino said volume can range from 30 to 40 patients per day. When a patient arrives at Bluepoint, they present identification and their medical marijuana certification to a receptionist behind a glass window before they are let into the waiting room area, which has a spa-like feel.
Only physicians can grant their patient a medical marijuana license. During the registration process, patients have to indicate their preferred dispensary. According to Connecticut law, they have to go through another registration process to change dispensaries.
Tamborrino said the first appointment between pharmacist and patient at Bluepoint is essentially a medication management consultation, where information is gathered about the patient, the disease state, and the medication history.
“We try to establish some treatment goals, and then we have follow-up appointments to make sure everything is working for them,” said Tamborrino.
Without much existing scientific evidence about medical cannabis, the process is mostly self-taught for pharmacists. Adjustments are made with delivery method, products, and dosing for each individual patient. Unlike most medical care, patients need to be engaged to give the pharmacist feedback about what’s working and what’s not. Tamborrino said most patients he sees need to be educated about the different properties of medical cannabis and the effects that go along with each strain.
In the waiting room area of Bluepoint Wellness, patients can see a menu board displayed on a giant flat screen TV with the products available, the percentages of tetrahydrocannabinol (THC) and cannabidiol (CBD)—which control the psychoactive effects of cannabis—as well as the properties, effects, and pricing.
“Most patients don’t know all of this initially, but once they start the program, they become educated,” said Tamborrino. “With the initial consult, I make sure they leave here knowing the differences, and if they don’t, sometimes I’ll give them two different strains and ask them to log the difference about how it affects them, and have them tell me about it during our next appointment.”
“Just like any other drug dispensing, pharmacists are the ones handling it and looking at the patient’s total drug history,” Margherita Giuliano, BSPharm, Executive Vice President of the Con-necticut Pharmacists Association (CPA), told Today.
She said incorporating pharmacists into the dispensing process also established a comfort level for some lawmakers who were initially on the fence about voting for the legislation.
Connecticut’s medical cannabis law says that patients can receive up to, but not exceed, 2.5 ounces of cannabis per 30-day period—all of which is tracked at the dispensary.
Under federal law, cannabis is a Schedule I drug, but Connecticut’s law reclassifies it as a Schedule II drug. Because of this change, medical cannabis goes through the same process for other controlled substances in Connecticut, meaning it’s tracked through the Connecticut Prescription Monitoring and Reporting System, which is a statewide database updated weekly with patients’ prescription data.
“With this system, the Department of Consumer Protection knows who is prescribing and dispensing, and to which patient,” said Giuliano.
The database also allows participants to include notes about the effect cannabis has on a patient’s symptoms and conditions and how it interacts with other drugs the patient might be taking.
Eleven medical conditions
The dispensaries in Connecticut are required to follow the same pharmacist-to-technician ratios as in pharmacy practices in the state, which is three technicians to one pharmacist. The law also states that only up to five pharmacists can work in a single dispensary.
Pharmacists working in Connecticut dispensaries are not allowed to tamper with the cannabis that comes prepackaged directly from growers in the state. Connecticut went from having one grower last year to now having four on the market today.
Angela D’Amico, an independent businesswoman, opened Compassionate Care Center of Connecticut, a medical cannabis dispensary in Bethel, CT, in September 2014. She said having more growers has driven down the price, which is good for patients because they pay out-of-pocket for medical cannabis.
Along with the Department of Consumer Protection, growers test and examine every cannabis strain in the products Connecticut dispensaries are authorizes to sell, which include flowers, edibles, vape oil compounds, and tinctures.
Giuliano said quality control for medical cannabis is the same as it would be for pharmaceutical testing and also is helping to standardize medical cannabis.
Information from growers about dosing on the packaging is also meant to help pharmacists more accurately dose cannabis to patients. In addition, Tamborrino said they have devices that make it easier to quantify a dose for a patient. For instance, Tamborrino uses a vaporizing device for cannabis oil that enables the pharmacist to tell the patient to take one to two inhalations every 4–6 hours.
However, dosing is still unknown for most cannabis delivery methods and can vary for each patient—a concept that is hard for most pharmacists to get used to.
“There is no set dose, but we are developing it,” Colleen Higgins, BSPharm, staff pharmacist at Compassionate Care Center of Connecticut, told Today.
Connecticut’s law authorizes medical cannabis to be used for the treatment of 11 medical conditions. These include cancer, glaucoma, positive status for HIV/AIDS, Parkinson disease, multiple sclerosis, damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity, epilepsy, cachexia, wasting syndrome, Crohn disease, and posttraumatic stress disorder. Four other conditions have recently been added.
Tamborrino said one of his goals is to be able to pinpoint a specific strain for a specific disease state or symptom. He believes this will be attainable soon with the research and data collection that’s already progressing in Connecticut.