2018 Sep 17th
CMA says doctors won't be needed in 'gatekeeper' role, while others say expert oversight still required
Aidan GearyCBC News
Some researchers, patient advocates and industry professionals say Canada needs to maintain a distinct medicinal cannabis system following legalization of marijuana for recreational use, despite the Canadian Medical Association's position that doctors should no longer be gatekeepers.
"It is simply a reality now that cannabis is part of the medical landscape," said James MacKillop, director of the Peter Boris Centre for Addictions Research and the Michael G. DeGroote Centre for Medicinal Cannabis Research at McMaster University in Hamilton.
"I think we need to address that reality head-on as opposed to sort of walking away from the reality at this point."
The Canadian Medical Association has said when pot becomes legal for recreational use on Oct. 17, two distinct systems for medicinal and recreational products will be unnecessary. The CMA says some of its members are uncomfortable prescribing cannabis due to a lack of high-quality research. Medical marijuana users require approval from a doctor before being allowed to order medical marijuana online from a government-licensed producer.
The CMA has made its position known in submissions to Health Canada, the House of Commons standing committee on health and the federal Task Force on Cannabis Legalization and Regulation since 2016.
"There's nothing to stop them from asking their doctor, 'might it work for this condition,' or 'do you have any idea about what doses I should use,' or these types of things," Dr. Jeff Blackmer, vice-president of medical professionalism for the association, told CBC Calgary earlier this month.
If the two systems are kept separate — which Health Canada has said will be the case following legalization — the association recommended in a 2017 submission a review of the legislation should be conducted within five years. Health Canada's website says that will take place.
"Health Canada recognizes the concerns of the CMA regarding the level of evidence on the risks and benefits of cannabis for medical purposes, as well as on dosage and potential interactions with other medications," a spokesperson for Health Canada said in an emailed statement. "Measures under the Cannabis Act aim to facilitate research with the goal of improving our knowledge in these and other areas."
In an emailed statement Thursday, a CMA spokesperson said physicians will continue to work with patients to provide the best care possible. However, she repeated the association's concerns about a lack of clinical research, guidance and regulatory oversight.
"Over the years, physicians have been put in a position of gatekeepers for a substance that has not undergone established regulatory review processes required for all other prescription medicines," the statement reads.
MacKillop believes doctors should continue to work with patients to make informed choices about their health.
"My position is not that we should retain a medical cannabis system because it's been proven over and over over again in these many different contexts — but actually because we really need to maintain surveillance and do more research and engage patients rather than permitting them to simply move over to the recreational products," he said.
Nurses Association backs separate systems
Medicinal cannabis has been legal in Canada since 2001. According to Health Canada statistics, more than 296,000 Canadians were registered to get cannabis for medical purposes by the end of March 2018.
During that month, nearly 3,500 doctors provided medical documentation for a registered client, and licensed producers made close to 133,000 shipments across the country. It was the eleventh consecutive month that licensed producers made more than 100,000 shipments.
Marijuana is used for a variety of conditions, with varying degrees of scientific support. For some, including anxiety and PTSD, researchers have said the hype outweighs the evidence. MacKillop and Jason Busse, his co-director at McMaster's cannabis research centre, said the evidence is stronger for others, including chronic, non-cancer pain, treatment-resistant seizures, muscle spasticity for those with multiple sclerosis and loss of appetite among patients who are receiving chemotherapy
Under the current system, patients get an authorization to use the drug from a physician or nurse practitioner and order their product online from producers licensed by Health Canada. They can write the health expense off on their taxes and some are allowed to produce cannabis on their own.
Karey Shuhendler, who is with the Canadian Nurses Association, said medical cannabis products can vary greatly from products designed for recreational use. Medicinal pot usually has a higher concentration of cannabidiol, which does not produce a high or intoxication, and a lower concentration of tetrahydrocannabinol, or THC, which does.
The nurses association, which represents more than 139,000 Canadian nurses, has advocated to maintain a separate medical system for years, she said. The association is concerned about access, she said, including worry that dismantling it could encourage producers to focus their efforts on recreational products.
"We think that it's foreseeable that without the protection of a separate stream for medical cannabis, the production of products will be based on consumer demand, which will be largely for what people call recreational purposes," she said.
"Protecting a medical stream helps to ensure that there's going to be product produced for medical purposes, and that access to those products won't be minimized and swayed toward a more commercially driven product demand."
Without a separate medical system, she worries patients won't choose to talk with their health-care provider about their cannabis use, including issues around efficacy, drug interactions and when, how and why to use it.
"Without that kind of clinical oversight, really, our perspective as an organization is that we're leaving patients to essentially self-medicate and figure it out on their own," she said.
Patient advocates speak out
James O'Hara, a medicinal cannabis user and president of Canadians For Fair Access to Medical Marijuana, said patients look to their physicians and pharmacists for confidence in their medical treatments, and they don't want to feel judged.
"There's a lot of emotion behind that. They really want to talk to their doctors, because bottom line they want their doctors to care and have an interest in their patients," he said. "They do, but patients feel that there's a bit of a dividing wall when it comes to medical cannabis."
Allan Rewak, the executive director of Cannabis Council of Canada, said his organization will work with the CMA and physicians to answer any questions it can.
"We believe that doctors have the skills and the knowledge to really help people understand the best treatment approaches for whatever condition they have," he said. "But the biggest challenge is this kind of perception of cannabis, and that creates deep fiscal impacts on patients who are seeing improvements in their lives."
Dravet Canada, an advocacy group for people with the intractable seizure-causing genetic disorder Dravet syndrome, said it's crucial for patients that cannabis is considered "actual medicine," including funding through health insurance, strict regulation of quality and a guaranteed supply to avoid disruptions to medication plans.
"For epilepsy control, you need specific components. Products must be tested and clearly labelled. The testing and labelling process must be verified," a spokesperson for the group said in an emailed statement.
Cannabis companies weigh in
Gary Symons, director of communications for Winnipeg-based cannabis producer and soon-to-be retailer Delta-9 Cannabis, said the company agrees with the CMA's call for more research, and understands critiques it's raised in the past about difficulty in ensuring precise dosage and quality.
But he said the company is working to bring in new technology to improve precision regarding dosage, and has a focus on research to understand it better. Maintaining a separate medical system, he said, will eventually foster that understanding within the medical profession.
"If there's no medical system, then there's no real impetus for physicians to learn about cannabinoid treatment, and cannabinoid treatment is actually a very important area," he said.
An emailed statement from National Access Cannabis said it also supports a separate medical system. Its own medical division is focused on best practice and patient care, the statement says.
"The recreational market caters to adult use and is not a replacement for medical prescriptions or the associated assessments and screening required to care for patients," the statement reads.
O'Hara said Canada's medical cannabis system isn't perfect, but he sees an opportunity for the country to be a leader on the world stage — and he wants physicians to be a part of it.
"All they have to do is step forwards instead of stepping backwards," O'Hara said. "That is, simply learn about it."