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Welcome to the AJP podcast,
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a podcast for pharmacists by pharmacists where we discuss current events,
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relevant topics, and emerging issues. I'm your host, Carlene McMaugh,
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and together with the AJP I'm bringing you the opinions and expertise of
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different pharmacists to discuss their views and insights on topics relevant to
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pharmacists.
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Please like and rate each episode and subscribe to the podcast so you don't miss
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an episode.
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So the first thing I'm going to ask is can I please ask you to do an
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introduction for yourself?
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Yes, absolutely. Who.
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Are you for the audience?
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Yeah, absolutely. So my name is Kylie Neville.
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I work for PDL, which is Pharmaceutical Defense Limited,
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and I've been with them only roughly coming up to three months.
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I'm a relatively new professional officer.
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I'm one of five professional officers with PDL.
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My background is predominantly in
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community pharmacy that I have also touched into hospital
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pharmacy as well, both private and also public hospitals.
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So definitely a great situation to be here at PDL because
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I'm able to use my decades of experience to
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help with pharmacists who might be in a situation of high risk
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or vulnerability, and they might be undergoing
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a regulatory matter that requires assistance from PDL.
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So yeah, that's the short and sweet of my background.
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Thank you.
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Can I please ask you what are some of the risks involved when pharmacists
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dispense medicinal cannabis?
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Absolutely, yes. So there are a few different risk areas.
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The great majority of medicinal cannabis products prescribed in Australia today
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actually fall under the category of being unapproved products,
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which means they don't appear on the ARTG,
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which is the Australian Register of Therapeutic Goods.
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So this means that you can't simply just go to a doctor,
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request a script and have it filled at the pharmacy as you would with an ARTG
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registered medicine. So
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these unapproved products still actually need to meet standards which
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aim to make sure the products have reliable cannabinoid content and are actually
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free of contaminants. So that's the first sort of thing to think about.
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So if we go right back to the starting ground and the first moment when we see
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or take in a script from the pharmacy at the counter,
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so there's times when the pharmacist doesn't know who the prescriber is
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and if that prescriber might be using,
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say the T-G-A-S-A-S pathway,
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which is one way for a prescriber to have approved product
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approval, pardon me, for their patient to obtain medicinal cannabis,
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or some prescribers have done a little bit more in terms of what they're
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able to do and they become what we call an approved prescriber.
So pharmacists
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don't always know this about a prescriber.
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There's no sort of telltale on whether or not a prescriber is an
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approved prescriber or they might be using the SAS pathway.
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So firstly,
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having access to the correct paperwork that companies a medicinal cannabis
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script such as the copy of the TGA approval,
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they say S approval is critical because that should be handed over to the
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pharmacist as they'll need that when they're dispensing the script to legally
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dispense the script.
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So that's probably my first point to think about is right from the beginning is
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when we're taking in that script,
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sometimes you also need that paperwork that TGA approval paperwork might be
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required when you're ordering a script from a supplier or a wholesaler,
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sorry, ordering a product from the wholesaler.
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Another risk area is when pharmacists encounter prescriptions that have been
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written for a category of medicinal cannabis products using a range
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of THC percentages instead of an exact percentage.
So
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for example, a script might be written for,
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say a dried flower in a range of 18 to 22%, for example.
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So this is problematic because a prescription for medicinal cannabis really
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needs to specify a precise strength to be valid.
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Adding onto this point,
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actually substitution for another product cannot occur even if the
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doctor has verbally told you to do that or even written it,
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it's actually not valid.
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So a new prescription is required if a different product is
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dispensed for a patient.
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So that's another sort of critical aspect there that we look at with risk.
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A further risk can occur
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when conveying dosing information to the patient. So for example,
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a patient's been told by their doctor to use a maximum one gram of dried
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flower daily as needed.
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So the patient may not have any knowledge of how much one gram is.
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This is a really different dose form to what pharmacists are more
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familiar with.
So most pharmacists know that a tablet contains X amount X
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milligrams of medication.
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So medicinal cannabis often involves a variable dosing when a patient might be
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using cannabis to treat a condition like maybe even,
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I'll just give an example of migraine, which can change in intensity,
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their symptoms change depending on the day or other lifestyle factors that come
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into the way they're dosing. And another risk,
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I thought of another one to talk about is there are times when a patient has
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received advice from their prescriber to dose with two or
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more,
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and sometimes we see quite commonly patients with six to
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eight or sometimes higher prescriptions for medicinal
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cannabis products. So as pharmacists,
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we're naturally wary of anything that is a schedule eight medicine,
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and we often feel overwhelmed in not knowing the exact way a patient will use
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their medications.
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So the therapeutic use of medicinal cannabis is not black and white and actually
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takes in shades of grey. So yeah,
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those are sort of my little summaries there of the main risk. Yeah.
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Thank you.
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What types of issues should a pharmacist be aware of when handling,
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storing and dispensing medicinal cannabis?
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Absolutely. That's a great question.
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Pharmacists always would want to keep in their mind that a large many of
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medicinal cannabis products are schedule eight and they should be treated
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as such.
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So it's wise for pharmacists to review the use of the medicinal cannabis
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with a patient as you would with any other medicine and counsel on the safe and
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appropriate use.
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If there are repeats on a medicinal cannabis script,
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those intervals should be adhere to.
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And although toxicity risk below when it comes to medicinal cannabis in
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comparison to say an opioid,
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there can still be many situations when the overuse of cannabis can lead to
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harm.
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Another thing is we want to remind patients about DHC and driving
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laws. That's essential.
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So that's an issue that a pharmacist should have in the back of their mind when
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they're speaking with a patient just to have that in their counseling
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aspects.
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I think pharmacists might see medicinal cannabis in a different light to
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say regular medications that we're familiar with.
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And this is a bit problematic because as with any Schedule eight medicine,
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if you are unsure who the prescriber is, it can pose a risk situation.
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Looking up a prescriber on Ahpra can often give you information like a starting
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point if it's somebody that you don't know who that prescriber is.
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So that's probably more talking about the issues to be aware of when it comes to
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dispensing.
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Thinking about your patient's history and in regard to where
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medicinal cannabis may fit in,
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sometimes you might have a full medication history of a patient,
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sometimes you are meeting that patient for the very first time.
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As with any other medicine that you'd be dispensing for the first time,
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there's a great benefit in knowing and understanding the therapeutic needs of
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that patient.
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So using say real time prescription monitoring can give valuable history
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to allow pharmacists to conduct a risk assessment for the patient before
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they use that and ongoing throughout their time when they're using that product
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as well. When it comes to storage of medicinal cannabis,
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which is another area where we have seen regulatory actions towards pharmacists,
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it's so important to remember medicinal cannabis products,
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which are Schedule eight,
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do require storage in a lock safe that meets those schedule eight requirements
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as per your state and territory legislation.
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If a medicine that's kept in the fridge such as an example would be
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like nabiximols, which is like the brand name Sativex,
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it's to be stored in a locked fridge that secured to the premises in the same
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way that say,
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a Schedule eight safe would need to be secured to the premises.
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So those are the sorts of issues.
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Just a brief little rundown on what to think about when you're handling
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and storing medicinal cannabis. And yeah,
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I hope that answers that question.
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Thank you.
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Can you also discuss for us the types of incidents that you're seeing being
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reported to PDL relating to medicinal cannabis?
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Absolutely, Carlene.
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So this is something that we're all passionate about at
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PDL because we don't want anyone to be reported
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or have any regulatory notification regarding this.
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So some of the things that we see most commonly is that pharmacists might feel
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tempted to substitute a product without authorization.
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So for example, if a script has been written for a cannabis flower,
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I'll give an example, which is say 20% and it's particular strain.
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It's a particular one that the doctor has prescribed,
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and that's what the doctor would like the patient to have,
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and you don't have it in stock and there's problems getting it in a timely
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fashion. The patient might, the patient may be giving you some pressure.
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I'm sure pharmacists listening to this will know how that feels to have
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someone applying some pressure to have it dispensed as soon as possible and to
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have it available.
It's something that we see,
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and I want to emphasize that it is essential that pharmacists stick to what is
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prescribed. Interestingly, even providing a lower percentage,
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so just say you had a 19% flower in stock
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and it doesn't meet, of course,
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the 20% what was written on the prescription that has actually caused
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issues providing a lower strength.
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It'd be the same as imagine if you had Oxycontin 15 milligrams in the safe and
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the doctor had prescribed 20 and you just didn't have the
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20 in stock and it out of stock or hard to get.
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We absolutely as pharmacists wouldn't ever just give a lower strength hoping
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that it would be fine.
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So even though there is a minimal difference between those percentages of say a
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20 and a 19%,
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it still doesn't adhere to what the prescriber has asked to do.
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The other incidents that we see are storage conditions keeping medicinal
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cannabis products out of the safe or not securely locked has definitely
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resulted in pharmacy owners receiving complaints.
Inspections
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can be random,
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so it's important to follow Schedule eight guidelines for storage.
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Definitely patients can often have unreal expectations
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around the supply of medicinal, medicinal cannabis products in a pharmacy,
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and it often takes longer than to order in than say,
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a straightforward order through a major wholesaler.
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I think it's important to highlight to many patients right at the very start
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that if there's a product prescribed,
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if they've had a product prescribed that might take some time to order in
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or whatever reason it's out of stock, that there will be delays.
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I think pharmacists by our willingness or wantingness to
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help people are often in a hurry to please so much that it can cause a
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misunderstanding of the time constraints and there is extra paperwork
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that's sometimes needed when ordering.
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So we will have complaints made against
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pharmacists from patients who are frustrated by the process.
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Another area where pharmacists are receiving complaints is when a patient
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exceeds their specified limits.
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So if a doctor's script has stated that
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they might be receiving X number of grams or they shouldn't exceed X
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number of grams per week or so,
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patients might push the pharmacist to supply sooner than the script is
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specified. So in the case of a Schedule eight medication,
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it's so important to follow those guidelines just with any other Schedule eight
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medicine. If a patient presented early,
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we would probably decline or at least speak out more information such as
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contacting the prescriber details or
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ask for advice.
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And probably the last other big thing that when I talk about
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incidents, another one that I look back and had a look at the historical
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information was the differences in state laws can present a challenge.
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In some instance though, for example,
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with our migratory workforce living and working in different states,
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for example, if you are say,
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a Queensland resident and you're traveling to New South Wales to live or work a
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New South Wales pharmacist can dispense a script from another date as long as
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the prescriber is Ahpra registered and the pharmacist has evidence that
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the doctor has approval from the TGA to prescribe.
Interestingly,
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if you were to travel to Western Australia,
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only WA-based medical practitioners can write a script for medicinal
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cannabis,
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and the script can only be dispensed at a western Australian pharmacy.
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So those are the sorts of major incidents that we sort of see as just
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being caught out by maybe differences in state laws or
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that's something that,
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and it's really hard to be across every state law and every piece of
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legislation, unless you are working in that state, you often don't.
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Some pharmacists wouldn't really, unless you maybe on a border town,
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if you're working in a border town, you might know those things,
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but most pharmacists won't know the legislation in other states,
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and people do move around and they work in different areas. So yeah.
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So those are some key aspects or key incidents that we see here at PDL.
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Thank you.
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What can pharmacists do to reduce risks when dispensing medicinal cannabis?
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Yeah, absolutely. Good question.
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So real time prescription monitoring is a way to gain insight
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into the frequency of a patient who's receiving,
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say, a medicinal cannabis product. If it's a Schedule eight product,
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of course schedule four products like CBD oils,
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we wouldn't really necessarily see those pop up at all on any sort of monitoring
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program.
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So in the case of a patient having multiple prescriptions going at the same
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time, which does happen,
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it helps if the pharmacist can calculate daily dose, total use, sorry,
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the total daily use or weekly total grams,
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which can be stated by the prescriber.
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So it's sometimes it's complex to work out if somebody is getting close
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to their limit of stated what the doctor has stated on the script.
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Also,
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real-time prescription monitoring allows you to see if the patient actually has
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multiple prescribers for medicinal cannabis, which can occur.
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So all medicinal cannabis products do require vigilance,
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and if you are dispensing schedule eight medication,
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it's great to follow.
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It's so important to follow those dispensing and storage requirements,
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and that goes a long way to reduce the risks that pharmacists face when they do
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handle medicinal cannabis products. Also, make sure,
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ensure you have good record keeping habit in your pharmacy store,
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your paperwork in a way that makes it easy to find should you need to find those
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records quickly. For example,
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if you were in an audit process,
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you'd want to be able to have those on hand pretty easily or in a safely
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filed database.
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So be aware that medicinal product cannabis products are highly sought after
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on the markets and are often at risk of being diverted.
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So keeping vigilant is everything when it comes to reducing risk,
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when dispensing medicinal cannabis products. Yes.
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And many pharmacists have not undertaken training in medicinal cannabis
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products,
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and as such often feel out of their depth when it comes to patient counseling.
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So what can be the reason for this and maybe some ideas on how patients can,
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pharmacists can better counsel their patients?
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Yeah, absolutely. This is a really pertinent point, so
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it's interesting. So there's really only two products,
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medicinal cannabis products on the ARTG that's Sativex and Epidiolex.
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So when pharmacists supply an approved medicinal
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cannabis product, namely those two products,
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they're very easy to find dosage guidelines, evidence-based information.
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So pharmacists feel really confident with counseling.
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In the case of unapproved medicinal cannabis products,
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which really account for most of the prescriptions we see in Australia,
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there is often insufficient evidence to say to a patient,
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this will assist you with pain or sleep or
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anxiety.
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And I think this makes pharmacists feel out of their depth when it comes to
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discussing medicinal cannabis products. Interestingly,
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I think as evidence grows for the therapeutic use of medicinal cannabis as a
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treatment, more information is developing. It's a really rapidly evolving space.
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It's highly useful to discuss medicinal cannabis treatments with the
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patient.
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And even if you don't have a complete full
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understanding of why this patient isn't using it, pardon me,
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why this patient is using it,
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I think engage with someone regarding their treatment,
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you'll find out so much from that patient and sharing
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00:20:22.860 --> 00:20:25.320
information, which is really valuable to learn,
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asking them about side effects or beneficial positive effects they're
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experiencing. Check in with the patient when they're in the pharmacy,
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when they're picking up perhaps their product or their repeat,
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discuss how their treatment's progressing or not progressing.
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Ask them how they're using the product because sometimes they might need a
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little tweak on how they're using the product or they're not getting the full
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benefit. So
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it's so important to be transparent with patients when having these
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conversations. It's interesting how just little things,
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so when it comes to medicinal cannabis dosage,
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sometimes ingesting it with say, a fatty meal,
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can actually enhance the effect.
And so if patients are
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sometimes taking it with a fatty meal, like for example,
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some cheese or something that's quite oily,
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00:21:21.430 --> 00:21:23.260
and then another time they might not,
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they'll actually see variances in the way that their body handles that
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medication or the effect that they're receiving from it. So
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I think it is important to engage with the patient, and a lot of
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you can find a lot of information out definitely on
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wholesalers websites or suppliers websites,
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or even going directly to the manufacturer's websites,
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even contacting them Sometimes of course,
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00:21:51.820 --> 00:21:56.620
that information is not easy to get just by click and a download.
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You may need to actually call the company and ask,
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00:22:00.370 --> 00:22:04.690
especially if that's a particular supplier that you'll be using or a particular
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brand. They're often very helpful to pharmacists and they'll supply you with
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information that's not readily available in a public arena.
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They'll be very happy to help a healthcare professional with information. So
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yeah, don't always trust some of the things you read on unofficial websites.
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Of course, just like anything,
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you might come across information that isn't particularly correct,
339
00:22:30.860 --> 00:22:31.990
or it might be misleading.
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So it's always good to be choosy about where you get your product information
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from.
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There are really great evidence-based resources and education out there for
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pharmacists. So for example, I'll throw some ones out there.
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The TGA have a medicinal cannabis landing page,
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which provides overviews for health professionals.
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There are guidelines available for using medicinal cannabis in say,
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epilepsy, multiple sclerosis,
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chronic non-cancer pain, palliative care,
349
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nausea and vomiting. There's some great resources there.
350
00:23:16.330 --> 00:23:19.060
Also, the Lambert Institute,
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00:23:19.090 --> 00:23:22.030
which is part of Sydney Uni,
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I think it's linked through their Sydney Uni website,
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has an amazing overview of medicinal cannabis treatments and trials with links
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to associated web services as well, websites, nights,
355
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and of course I can't leave off.
356
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It's the Australian Center for Cannabinoid Clinical Research and Excellence,
357
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which goes by the acronym acre, ACRE.
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They have a great number of research articles and information about clinical
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trials,
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and they've also developed the cannabis medicines prescribing
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guidance to assist prescribers,
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mostly aimed at medical practitioners to help them with
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00:24:05.360 --> 00:24:09.680
prescribing medicinal cannabis to patients for conditions which are perceived to
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have some benefit.
So it's a really rapidly evolving space.
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00:24:13.820 --> 00:24:18.470
R-A-C-G-P has a great website as well that's
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dedicated to information for prescribers,
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but also I think it's useful for pharmacists to gain an understanding of the
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processes behind prescribing a cannabis product,
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00:24:31.760 --> 00:24:35.900
the protocols that doctors might undertake when they're thinking about
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trialing it in a patient where the patient might've had
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no success in traditional treatments and is finally at the end of
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almost feeling at the end of their road and they're just reaching out for help.
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So I think GPs are in that situation where they need guidance,
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and so the R-S-C-G-P has a good site there.
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Yeah,
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I think definitely trusting those sources rather than just a
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review website sometimes, although they can be also good for just
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to get a feel for what's being talked about in the circles
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00:25:16.820 --> 00:25:19.820
of people using medicinal cannabis. But always,
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00:25:19.880 --> 00:25:24.230
I'd recommend every pharmacist use a trusted source to gain their
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education or information. Yeah,
382
00:25:28.870 --> 00:25:32.210
so I hope that was a long-winded answer there for that question.
383
00:25:32.690 --> 00:25:34.550
That was very helpful. Thank you.
384
00:25:34.880 --> 00:25:39.800
And where can pharmacists seek evidence-based resources and education about
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00:25:40.040 --> 00:25:42.080
medicinal cannabis to better equip themselves?
386
00:25:42.080 --> 00:25:46.220
Are there any other resources or evidence-based resources that you recommend?
387
00:25:48.380 --> 00:25:51.380
I think the ones that I was just mentioning there,
388
00:25:51.410 --> 00:25:52.820
they're probably my most trusted.
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00:25:54.470 --> 00:25:59.240
There are definitely overseas
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00:26:00.530 --> 00:26:03.770
maybe US or Canada websites that are, I mean,
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00:26:04.190 --> 00:26:08.930
I think we have enough Australian based websites that we can sort of use
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00:26:09.140 --> 00:26:12.410
those ones. So definitely the Lambert Initiative
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00:26:13.010 --> 00:26:17.360
for Cannabinoid Therapeutics
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00:26:18.380 --> 00:26:21.800
in New South Wales. There's also the John Hunter Hospital pharmacy department,
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00:26:21.920 --> 00:26:25.100
which is particularly useful for assisting
396
00:26:26.630 --> 00:26:30.440
to understand the latest evidence around medicinal cannabis and also
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00:26:30.530 --> 00:26:35.360
understanding the regulatory requirements for prescribing. But yeah,
398
00:26:35.450 --> 00:26:38.330
I mean the TGA are very useful too.
399
00:26:39.470 --> 00:26:43.560
So I think keeping eyes on all that literature as it comes out,
400
00:26:44.250 --> 00:26:47.970
even subscribing to updates.
401
00:26:47.970 --> 00:26:51.420
If you are someone that likes to have things delivered straight into your inbox,
402
00:26:52.320 --> 00:26:54.120
touch base with, say,
403
00:26:54.690 --> 00:26:59.670
some of these websites register to receive their updates
404
00:26:59.670 --> 00:27:00.750
or email updates,
405
00:27:00.780 --> 00:27:05.760
and you'll find that information is just sort of fed into your inbox.
If you're
406
00:27:05.760 --> 00:27:08.820
interested in that space and you want to further your knowledge and gain more
407
00:27:08.820 --> 00:27:13.710
confidence with new and emerging ways that prescribers are
408
00:27:13.710 --> 00:27:17.760
using medicinal cannabis. It's a very fast evolving space,
409
00:27:17.760 --> 00:27:21.780
and Australia is certainly embracing medicinal cannabis.
410
00:27:21.990 --> 00:27:26.370
When you look at where we've come from many back in, what was it,
411
00:27:26.430 --> 00:27:30.780
2019 it was,
412
00:27:30.990 --> 00:27:35.670
or even earlier than that, I think it was a small uptake of Australian patients,
413
00:27:35.680 --> 00:27:38.790
but now we see a massive growth in this area.
414
00:27:38.820 --> 00:27:43.650
It's something that pharmacists are seeing just so much
415
00:27:43.650 --> 00:27:48.090
more of and being aware of the risks and knowing how to handle
416
00:27:48.930 --> 00:27:53.640
the storage requirements and just keeping ourselves
417
00:27:53.820 --> 00:27:55.830
educated at the forefront so that we know
418
00:27:57.960 --> 00:28:01.980
that what's happening in that space is just changing so much.
419
00:28:01.980 --> 00:28:06.540
It's not something that's a set and forget. It's moving rapidly.
420
00:28:07.110 --> 00:28:08.460
So yeah,
421
00:28:10.050 --> 00:28:13.110
I think those are some really great websites to follow up.
422
00:28:13.110 --> 00:28:17.700
If anyone listening to this podcast wants to rewind and play
423
00:28:17.700 --> 00:28:18.780
back those names,
424
00:28:18.780 --> 00:28:23.490
they will be able to find those websites pretty easily and just be able to have
425
00:28:24.370 --> 00:28:26.910
a great range of evidence right at your fingertips.
426
00:28:28.290 --> 00:28:30.180
So brilliant. Thank you. Now,
427
00:28:30.180 --> 00:28:34.950
are there any questions that I haven't asked you that you would like to
428
00:28:35.700 --> 00:28:37.080
share your thoughts about?
429
00:28:39.690 --> 00:28:43.440
There's not too much. I mean, I think there's lots of things we could talk about
430
00:28:45.270 --> 00:28:50.040
outside of the area of risk that we talk about with medicinal
431
00:28:50.040 --> 00:28:52.830
cannabis. I mean, often,
432
00:28:53.700 --> 00:28:56.760
sometimes I'll speak with pharmacists who sort of say to me,
433
00:28:56.760 --> 00:28:58.440
how do I know what a normal dose is?
434
00:28:58.440 --> 00:29:02.430
Or what's a typical dose of CBD or THC?
435
00:29:02.440 --> 00:29:07.140
How would I know that what the doctor's written is actually within a guideline?
436
00:29:07.200 --> 00:29:10.950
And this is bit of a fuzzy area because
437
00:29:12.930 --> 00:29:16.470
when it comes to starting a patient's dose,
438
00:29:17.850 --> 00:29:22.650
pharmacists may not really feel confident in counseling. If it's a medicine,
439
00:29:22.650 --> 00:29:24.330
we know, we know our antibiotics,
440
00:29:24.330 --> 00:29:29.280
we know what the rough dosage limits
441
00:29:29.280 --> 00:29:33.810
are for a child or for an adult or we sort of know in our
442
00:29:33.810 --> 00:29:38.190
minds what we are looking at. But when you see a script for medicinal cannabis,
443
00:29:38.190 --> 00:29:42.820
then it's a mixed oil or it's a flower with this or that.
You're
444
00:29:42.820 --> 00:29:46.990
thinking, well, I don't even know what that means. How much are they taking?
445
00:29:46.990 --> 00:29:48.220
Or how do I warn them?
446
00:29:49.450 --> 00:29:54.280
Just keeping in mind that most of the prescribers are asking their patients to
447
00:29:54.280 --> 00:29:58.960
start on really low doses, almost subtherapeutic doses.
448
00:29:59.050 --> 00:30:02.830
So you might see DHC doses started as low as
449
00:30:03.340 --> 00:30:06.400
2.5 milligrams a day, or even lower than that,
450
00:30:07.450 --> 00:30:10.960
and CBD might be started around,
451
00:30:13.240 --> 00:30:18.100
well, I guess the recommended endpoint for CBD is the really broad range.
452
00:30:18.100 --> 00:30:21.190
We can go from 50 up to 1500 milligrams daily.
453
00:30:21.310 --> 00:30:24.550
That's the sort of dosage range With THC,
454
00:30:25.030 --> 00:30:26.380
it's typically the endpoint.
455
00:30:26.410 --> 00:30:30.190
You're sort of looking at that five to 20 milligrams total daily dose,
456
00:30:30.700 --> 00:30:35.050
but it's so important to start when patients are starting,
457
00:30:35.350 --> 00:30:40.060
always starting so low and increasing every couple of days When it comes to
458
00:30:40.990 --> 00:30:43.150
those slower onset oils,
459
00:30:44.770 --> 00:30:47.530
you want to be careful not to overload.
460
00:30:47.530 --> 00:30:52.330
The person's end cabin can avoid system and
461
00:30:52.510 --> 00:30:57.070
go too fast or too high if a slow gradual increase.
462
00:30:57.790 --> 00:30:59.020
And keeping, of course,
463
00:30:59.020 --> 00:31:03.010
patients are always encouraged to keep diaries about how they're feeling from
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00:31:03.010 --> 00:31:07.360
day to day, which is really part of their journey,
465
00:31:07.600 --> 00:31:11.620
documenting how they're feeling to get an assessment with their prescriber if
466
00:31:11.890 --> 00:31:13.630
they are receiving benefit or not.
467
00:31:15.670 --> 00:31:19.810
So drug to drug interactions is probably something we haven't touched on.
468
00:31:19.990 --> 00:31:24.430
That's another risk area. There is potential for interactions.
469
00:31:25.630 --> 00:31:29.770
CBD is an inhibitor of the cytochrome P four 50 enzymes,
470
00:31:29.890 --> 00:31:33.310
especially three A four, and CYP two, C1 nine.
471
00:31:33.700 --> 00:31:35.590
So if used in quite high doses,
472
00:31:35.590 --> 00:31:38.740
there are potential interactions with other medications,
473
00:31:39.490 --> 00:31:41.590
especially say for example,
474
00:31:41.980 --> 00:31:46.270
anti-epileptics or there might be medications with a narrow therapeutic window.
475
00:31:46.300 --> 00:31:49.090
That's something to really keep in the back of your mind as well.
476
00:31:49.120 --> 00:31:52.420
It's pretty rare that there is, but in high doses,
477
00:31:52.420 --> 00:31:57.250
there's always a chance where there can be inhibition of enzymes.
478
00:31:59.440 --> 00:32:03.940
Contraindications always, when it comes to THC,
479
00:32:03.940 --> 00:32:08.890
we're always on edge about patients with a history of angina or
480
00:32:08.920 --> 00:32:13.870
myocardial infarction or a personal or family history of schizophrenia or
481
00:32:13.870 --> 00:32:16.660
psychotic related disorders. That's something that
482
00:32:18.970 --> 00:32:21.280
pharmacists may have a good history.
483
00:32:21.280 --> 00:32:25.450
You might have a history of someone's medications on your dispense system and
484
00:32:25.450 --> 00:32:27.280
you can see, oh, hang on.
485
00:32:27.610 --> 00:32:30.670
They didn't perhaps disclose that to their prescriber,
486
00:32:30.790 --> 00:32:34.300
and maybe the prescriber is a different prescriber to their family GP or,
487
00:32:34.750 --> 00:32:39.650
so those sorts of things are definitely part of our risk in
488
00:32:39.740 --> 00:32:44.540
the space of pharmacy where we're always on the
489
00:32:44.540 --> 00:32:48.650
lookout for those sorts of things. So I think,
490
00:32:48.650 --> 00:32:51.650
I feel like I could just talk forever about this.
491
00:32:53.690 --> 00:32:57.470
I probably have to draw the line somewhere. Actually.
492
00:32:57.590 --> 00:33:01.040
Let's talk about side effects really quickly. So side effects, of course,
493
00:33:02.210 --> 00:33:04.100
I'm deviating away from the risk topic.
494
00:33:04.110 --> 00:33:08.840
I was essentially trying to aim for because I'm representing PDL, of course,
495
00:33:09.920 --> 00:33:12.470
side effects when it comes to CBD,
496
00:33:12.560 --> 00:33:15.470
which is the part of course of
497
00:33:17.210 --> 00:33:20.000
the non-psychoactive component. Look,
498
00:33:20.000 --> 00:33:24.980
I think the most commonly reported side
499
00:33:24.980 --> 00:33:26.870
effects are things like acute diarrhea.
500
00:33:27.980 --> 00:33:32.780
I think mostly the toxicity of that is it's
501
00:33:32.790 --> 00:33:37.130
very hard to achieve anything that's too dangerous apart from looking at that
502
00:33:37.460 --> 00:33:42.320
aspect of drug to drug interactions that we were talking about earlier. However,
503
00:33:42.320 --> 00:33:46.040
there are definitely more side effects when it comes to THC.
504
00:33:46.790 --> 00:33:51.200
There are things such as acute dizziness, cognitive impairment,
505
00:33:52.100 --> 00:33:56.600
dry mouth nausea. There are rare psychosis,
506
00:33:58.400 --> 00:34:00.290
potential drug-to-drug interactions,
507
00:34:00.890 --> 00:34:05.360
and of course where long-term high THC use is involved.
508
00:34:05.960 --> 00:34:08.060
This can lead to cannabis use disorder,
509
00:34:08.070 --> 00:34:12.650
which is situation that is quite
510
00:34:12.650 --> 00:34:17.450
serious.
Look medicinal cannabis is generally well tolerated when
511
00:34:17.450 --> 00:34:18.830
appropriate doses are used.
512
00:34:19.730 --> 00:34:23.060
So I think it's only when, of course,
513
00:34:23.070 --> 00:34:24.890
if it's mixed with a street cannabis,
514
00:34:26.630 --> 00:34:29.720
everything starts to get quite complex then.
515
00:34:31.070 --> 00:34:34.580
But if you've got a patient who's adhering to the recommended amount
516
00:34:36.050 --> 00:34:40.460
and is willing to have a treatment journey where
517
00:34:41.480 --> 00:34:44.720
no one's really sure if it's going to with an
518
00:34:45.860 --> 00:34:49.490
unregistered non T-R-G-A-R-T-G product,
519
00:34:49.970 --> 00:34:53.630
you don't always know if it's going to assist that person.
520
00:34:54.560 --> 00:34:59.450
But it's definitely an exciting space to observe and hopefully
521
00:34:59.450 --> 00:35:02.900
patients will achieve some therapeutic outcome.
522
00:35:02.930 --> 00:35:06.980
It may not be the entire outcome that they were hoping for at the beginning,
523
00:35:06.980 --> 00:35:10.370
but the benefits can be there,
524
00:35:11.780 --> 00:35:14.990
and if done safely, it can be a really life-changing event.
525
00:35:14.990 --> 00:35:19.490
For a lot of patients. I've heard some very positive stories. I mean,
526
00:35:19.490 --> 00:35:23.570
there's also patients out there who have tried medicinal cannabis and actually
527
00:35:23.570 --> 00:35:26.540
achieved almost no positive outcomes,
528
00:35:27.290 --> 00:35:30.980
not necessarily any negative outcomes, but just for some reason or another,
529
00:35:30.980 --> 00:35:32.630
it just wasn't for them.
530
00:35:33.200 --> 00:35:37.250
So keeping an open mind about medicinal cannabis is really important,
531
00:35:38.370 --> 00:35:40.530
and to recognize that for what it is,
532
00:35:40.530 --> 00:35:43.740
it's an emerging treatment area,
533
00:35:44.190 --> 00:35:48.180
lots of unknowns and with lots of unknowns. There's always risk.
534
00:35:48.990 --> 00:35:53.640
As we know as pharmacists, there's risk ready to appear around every corner.
535
00:35:56.130 --> 00:35:58.800
So hope that gave a good overview there.
536
00:35:59.580 --> 00:36:02.370
Thank you. That was amazing. Thank you so much.
537
00:36:02.820 --> 00:36:04.860
You're very welcome. Thanks for having me on the show.
538
00:36:04.860 --> 00:36:07.380
I really enjoyed chatting, and yes,
539
00:36:07.380 --> 00:36:12.360
I hope anyone out there who's wanting to reach out, of course,
540
00:36:12.360 --> 00:36:14.910
does reach out through PDL.
541
00:36:14.910 --> 00:36:19.020
You're always welcome as PDL members to touch base with any of the professional
542
00:36:19.030 --> 00:36:23.730
officers to discuss concerns or worries regarding medicinal cannabis in your
543
00:36:23.730 --> 00:36:27.240
workplace. So thank you again for having me on.
544
00:36:28.200 --> 00:36:29.400
Thank you. Thank.
545
00:36:29.400 --> 00:36:30.270
You so much.
546
00:36:31.470 --> 00:36:34.410
We hope you've enjoyed this episode of the AJP podcast.
547
00:36:34.620 --> 00:36:37.980
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548
00:36:38.190 --> 00:36:43.080
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549
00:36:43.080 --> 00:36:43.913
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550
00:36:44.370 --> 00:36:47.550
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