Riding the wave of change

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Pharmacists’ frontline role and clinical expertise makes them ideally placed to dispense medicinal cannabis and become a key partner in the patient journey

For decades cannabis, or marijuana as it’s commonly known, has been used illegally for medicinal purposes and as a recreational drug. Its reputation as an illicit substance along with evidence of negative side effects has certainly overshadowed appeals to recognise its therapeutic benefits.

However, rising interest in the use of cannabis for medicinal reasons has led to several changes in policy. In November 2016 legislative changes were introduced in Australia to allow the cultivation, prescribing and dispensing of medicinal cannabis for certain patients under specific access schemes.

Cannabis use and the current evidence

Prior to the November 2016 legislative changes, illicitly sourced cannabis was being used to treat a wide range of medical conditions. The Cannabis As Medicine Survey 2016, conducted by the University of Sydney immediately before the changes in legislation, showed that Australians who use illegal cannabis for medicinal reasons do so mainly to treat chronic pain, mental health, sleep issues and epilepsy.

The majority of respondents were smoking their cannabis, despite indicating they would prefer to use safer methods, such as oral or vapourised administration.

While participants stated that cannabis had positive results on their health conditions, a number of side effects were reported including increased appetite, drowsiness, eye irritation, lethargy and memory impairment.

Concern was also raised about the illegal status of their cannabis use, which impacted ease of access and the quality of the cannabis.

Not surprisingly, participants expressed a strong preferences for medicinal cannabis to be integrated into mainstream healthcare, and for products to meet quality and safety standards.

A UK Department of Health report said this year: “the fact we now have evidence of the therapeutic benefit of cannabis-based medicinal products for certain medical conditions and reasonable evidence of therapeutic benefit in several other medical conditions is a major leap forward”.

The National Academies of Sciences, Engineering, and Medicine’s 2017 report The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendation for Research concluded: “There is substantial evidence that cannabis or cannabinoids are effective:

  • for the treatment of chronic pain in adults (cannabis);
  • as antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids);
  • for improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids).

There is moderate evidence that cannabis or cannabinoids are effective for:

  • improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis (cannabinoids, primarily nabiximols).

There is limited evidence that cannabis or cannabinoids are effective for:

  • increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and oral cannabinoids);
  • improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids);
  • improving symptoms of Tourette syndrome (THC capsules);
  • improving anxiety symptoms, as assessed by a public speaking test, in individuals with social anxiety disorders (cannabidiol);
  • improving symptoms of post-traumatic stress disorder (nabilone; a single, small fair-quality trial)”.

The role of the pharmacist

Pharmacists are in an ideal position to address growing public interest in cannabis for therapeutic purposes, help de-stigmatise the use of medicinal cannabis and offer guidance on the evidence.

Kos Sclavos, clinical pharmacist, chairman of the Australian Pharmacy Profession (APP) and past national president of the Pharmacy Guild of Australia, sees medicinal cannabis as a core pharmacy offering. He comes from a ‘use it or lose it’ standpoint, calling on pharmacists to get involved early.

“Pharmacists need to be strategic. When you look at the development of pharmaceuticals, there’s a big focus on specialised medicines like biologics and biosimilars. You need to make sure your pharmacy is looking after all patients. Don’t send away a patient because you don’t want to deal with medicinal cannabis.

“Medicinal cannabis is not a first-line therapy; it will be prescribed as an adjunct to therapy. When prescribed, patients will be advised to continue taking their current medicines. That approach will help assess if the medicinal cannabis has had the desired therapeutic effect.

“It’s critical to have a full view of the patient’s medicines and to monitor them and that’s why a local pharmacist is well-placed to play a role in this area.

“Whether it’s for cancer pain, non-cancer pain or epilepsy, this is a long-term therapy. The pharmacist will need to counsel the patient, but probably the most important factor is the pharmacist’s role in titrating doses,” Mr Sclavos said.

“Dosing always starts low and changes slow; the pharmacist plays a key role in ongoing dose review and most doctors are happy to have the pharmacist in that role because they’re the ones dealing with the patient on a regular basis.

“Doctors also want to be able to refer to a pharmacist they know and trust. The doctor wants to know that their chosen pharmacy can facilitate supply; that they can handle the administration requirement and the logistics.

“Most medicinal cannabis products are cold chain. Sativex, which accounts for most scripts in Australia, has to be stored between 2°C and 8°C. Cold chain management is vital and given it’s already an essential component of pharmacy practice it makes sense that medicinal cannabis should be administered via the pharmacy route.

“Additionally, because medicinal cannabis is available by special access scheme, it’s not kept on the shelf. This special access teamed with the cold chain requirements are made much easier if the patient can access and re-order the cannabis from a pharmacy in their local vicinity.”

What pharmacists need to know

  • Medicinal cannabis can only be accessed through an ‘authorised prescriber’ or via a TGA Special Access Scheme application made by the patient’s doctor.
  • Medicinal cannabis should be considered only where conventional treatments have been tried and proven unsuccessful in managing the patient’s symptoms.
  • Medicinal cannabis is not considered a first-line therapy for any indication. When prescribed, patients will be advised to continue taking their current medicines.
  • The current state of evidence for its therapeutic use. See the TGA’s Guidance for the use of medicinal cannabis in Australia: Patient information.
  • State and territory regulatory requirements regarding the prescribing and dispensing of medicinal cannabis (these can be obtained through the individual Department of Health websites for each state).
  • According to the Australian Drug Foundation (ADA) the pharmaceutical cannabis products, approved by the TGA, include nabiximols (Sativex) and synthetic cannabinoids such as Dronabinol.
  • Unapproved medicinal cannabis products outside of the Special Access Scheme can be obtained via the Authorised Prescriber scheme.

On the frontline

Kos Sclavos says, “The pharmacist has a key role in giving factual information to patients about medicinal cannabis.

Kos Sclavos: “The challenge for pharmacists is that we need to get involved in these new therapeutic areas….”

“I know of several cases where the patient has sought advice from the pharmacist because they were too embarrassed to broach the subject with their doctor or they though the doctor had a predisposed belief that medicinal cannabis was of no use.”

Pharmacist Kevin Mullins from Capital Chemist Charnwood, ACT, adds, “Questions about medicinal cannabis have come mainly from non-cancer pain patients. These are people who are at the end of their tether using opioids.

“They are in chronic or full pain, experiencing constipation from using opioids and possibly dependent. Plus their pain is still not well managed. The idea that there’s something out there that might help them better manage their pain is very interesting. A few have the idea it’s a magic bullet that will solve all their problems and of course we do our best to manage those expectations.

“Making people aware of the process, who might be prescribing it, how they can go about accessing it, where information exists and providing information on the products is a vital role for pharmacy.”

Capital Chemist Charnwood has a few patients that have been through the ordering and supply of medicinal cannabis.

Kevin Mullins explains, “We registered the pharmacy on the Medicinal Cannabis Medicines Portal so that if a local doctor wants to prescribe the products we come up as a pharmacy that can access them.

“There’s also a pain specialist in Canberra who’s prescribing the Tilray CBD THC product and this is only available through Tilray themselves.

“It’s as simple as registering with them, setting up an account and then when a prescription comes in we can order directly through them.

He adds, “Prescribers have been good at giving us direction on how to access the products, which has been really helpful.

“The patients we’ve seen have received good positive health outcomes from medicinal cannabis,” he said.

“One of our patients was on high dose opioids, regular Panadeine Forte and had tried multiple nerve pain medications under a pain specialist with very little reduction in pain, not to mention the negative impact on their general health from taking all these medications.

“After three months of using medicinal cannabis their pain score dropped from 8 to a 2 or 3, which is massive”.

There was a high level of regular contact with prescribers, Mr Mullins explained.

“We’re frequently in contact with the prescriber regarding the dose, we perform a regular MedsCheck and we have a review process in place that monitors for side effects, keeps an eye on the level of pain and looks at how other medications might be playing a role.”

“There’s certainly a very big role for pharmacy in this area and our accessible nature makes it easy for patients who might be having issues to access help and advice.

“All the anecdotal evidence for medicinal cannabis is inspiring, but it makes me wonder how many people are missing out because of the beurocracy involved in prescribing and the barriers in accessing the products.

“Being prepared for that first script that walks through the door is vital. Just in the act of registering you pick up knowledge about what products are out there and what they’re used for. Even if you never get a prescription it’s worth finding out more as it’s such as fascinating medicine.

“I feel privileged to be able to deliver healthcare through this means. It feels like we’re on the cutting edge of something special; we’re riding the wave of change, which is very exciting,” says Mullins.

Kos Sclavos says, “The challenge for pharmacists is that we need to get involved in these new therapeutic areas. We know there’s extra paperwork, it’s difficult, there’s new accounts to open up, there’s more discussion and counselling needed with the patient because their doses need titrating, but this is an exciting new therapy area where the pharmacist’s role is highly valued.

“I implore pharmacists to get involved in this space. Don’t turn patients away who are seeking advice, support or product.

“In five years time medicinal cannabis is likely to be standard fodder for pharmacy, but if your response is “okay, I’ll wait five years.” My advice is that by then doctors will have already established networks around you – they won’t be going to your pharmacy.

“At every opportunity our American and Canadian cousins admit they made a mistake. They thought it was going to be a high-risk product and didn’t want to carry it. Now it’s a massive product almost exclusively sold through mail order, bypassing the traditional pharmacy model.

“In Australia we’re at the front end of what could potentially be a big industry. We need to be strategic. We must engage now to facilitate the dispensing of medicinal cannabis through community pharmacy.”

Useful resources

The Pharmacy Guild of Australia offers a ‘Medicinal Cannabis Readiness Course’. For more information or to register click here 

The University of Sydney’s Lambert Initiative for Cannabinoid Therapeutics is a useful source of news, up-to-date research and information. Click here

The Australian Drug Foundation provides relevant information for pharmacists and patients on the types of cannabis available and the current legislation. 

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