Now that more states are legalizing cannabis for medical and recreational use, pharmacists must step up to educate and counsel customers on safe use
Although pharmacists who dispense cannabis are now counseling patients about medical marijuana use, “This really was not a position for many pharmacists over a decade ago, but as more and more states have legalized [can- nabis], it’s a growing area of need,” explained Paul Peak, vice president of clinical pharmacy at Sedgwick Claims Management Services in Memphis, Tennessee.“ Certain states now require pharmacists to be involved with the dispensing process, which I think is right; they are a great clinical resource.” Danielle Fixen, PharmD, assistant professor at the CU Skaggs School of Pharmacy and Pharmaceutical Sciences, in Aurora, Colorado, noted that the role of a pharmacist varies depending on the state, but that pharmacists can perform drug-interaction checks and educate patients on potential side effects they may experience.“ Some states have pharmacists within the medical marijuana dispensary while others do not,” she said. “Given the multiple drug interactions with cannabis, it is important to evaluate [its] safety...in patients.”
As more clinical literature is published, it’s vital that all pharmacists better understand the potential benefits and risks of a substance that is being used more frequently—even if only recreationally: the percentage of Americans who consume cannabis is now greater than the percentage who smoke cigarettes, according to recent data from Statista.
A Historical Review
Physicians in the United States have been treating patients with marijuana since the 19th century. But after cannabis was criminalized in the United States in 1937,1 medical professionals were no longer allowed to prescribe it or learn about it.2 However, public opinion is changing.
“The California Pharmacists Association now supports pharmacists dis- tributing marijuana for medical use,” said Pegah Panahi, PharmD, a pharmacist with the Physician’s Cannabinoid Council. “Some states, like New York and Connecticut, allow pharmacists to dispense marijuana.”
Any state that permits medical marijuana requires a medical professional to be involved in the patient’s cannabis use. Some dispensaries hire pharmacists to oversee patients, and courses on cannabis are now being taught in some pharmacy programs, notably the University of Southern California and the University of Colorado.
As with all other therapies, the pharmacist’s main priority is patient safety. Pharmacists have the expertise to read and analyze certificates of analysis and review cannabis products for potency and efficacy. They can also assess a patient’s current medication regimen to avoid possible drug interactions.
“Pharmacists are experts on the impact and interaction of medications,” Panahi added, noting that it is especially important for elderly patients dabbling medical cannabis use to remain in close contact with a pharmacist “as they are more likely to experience negative side effects from tetrahydro-cannabinol (THC).”
Pharmacists can also lend credibility to the cannabis space through patient consultation and medical expertise, as well as guide patients who are cannabis curious through their options—without stigma. But despite the benefits they offer, many pharmacists have encountered roadblocks, and most cannot dispense or recommend cannabis as a treatment without putting their job or license at risk owing to federal policy.
A Forward-Looking Idea
In 1997, when Anthony Minniti, PharmD, and his sister, Marian K. Morton, RPh, purchased the then 66 year-old Bell Pharmacy in Camden, New Jersey, they found a bottle of cannabis and learned that the pharmacy had been dispensing cannabis in the 1930s before it became illegal.
As acceptance of cannabis grew and New Jersey legalized it for medical use in 2010,3 Minniti decided to bring it back by planning a marijuana distillery on the building’s second floor and seeking a special pharmacy permit for it.
“My rationale was that if New Jersey declared [cannabis] a medication it deserved to be in the pharmacy; why wouldn’t it be?” he said. “My overarching goal is to create a blueprint for other forward-thinking members of the...profession to utilize and tailor to their individual practices and states. We’re now in the homestretch... waiting for our approval from the New Jersey Cannabis Regulatory Commission.”
Minniti says he believes that pharmacists need to play a role in cannabis delivery and as such should thoroughly understand who it would work for, why, and how best to use it.
Pharmacists who are well educated on cannabis can—and for various reasons should—play a critical role in the clinical care required when dispensing medical marijuana.
“Pharmacists are specifically trained...to provide patient counseling for medications, and that is exactly what we need more of as it relates to cannabis,” Peak said. “Never has there been so much confusion about a med- ication [or] drug available to a majority of the public and therefore it is critical that clinicians who understand the potential benefits, side effects, and interactions are engaged in providing support to patients.”
After all, there is still much that is unknown about the potential risks and benefits of taking cannabis for certain conditions; pharmacists, though, know how the body works and understand how drugs affect the body.“ It is important to understand the endocannabinoid system, which works to regulate and control a number of our normal bodily functions,” Peak said, explaining that the endocannabinoid system affects our “memory, hunger, [and] sleep as well as our inflammatory responses.” Understanding this system means understanding how substances works on the body, “whether we are talking about THC, CBD [cannabidiol], or both.”
The current research and iterature on the subject can be confusing at best and contradictory at worst, which is why many pharmacy schools have started to include more intensive coursework on cannabis in recent years. “There is a lot of new research to keep up with, and pharmacists are trained in how to read and understand these studies,” Peak said.“Even though the latest headline may say, ‘Cannabis helps alleviate symptom X,’ a pharmacist can read the original study and interpret and analyze methodology to see if the conclusions...have real value and are validated.”
Pharmacists can also help with dosing and standardization, the latter being one of the biggest concerns within the medical marijuana industry.
“FDA-approved medications are approved based on specific doses and dosage forms, whereas cannabis is still federally illegal and therefore there are no specific doses set or defined,” Peak noted. “Pharmacists can be critical players in advocating for consistency” across doses, as well as counseling patients on safety and potential adverse effects associated with a new formulation. A patient who switches from a tincture to a capsule would benefit from the expertise of a trained cannabis pharmacist who knows how the THC in these formulations are metabolized by the body.
As is the case with any medication, it is important for pharmacists to learn as much about the patient and their medical history as possible, including why they are being treated with cannabis, what other medications they’re taking, comorbidities, and the expectations or concerns they may have about using cannabis.
It’s also essential for pharmacists to do their homework to understand the various formulations available, their respective onset and duration of action, and ratios of THC and CBD. “A large majority of practicing pharmacists did not get the in-depth training on cannabis that this unfamiliar environment will require,” Peak pointed out.
When patients come to Panahi for medical cannabis, she begins the conversation by asking them about their health goals and explaining how cannabis interacts with the body. “I also make sure to note the other medi- cations and supplements they are taking, as some medications such as blood thinners can cause negative interactions,” she said. “Most patients looking for cannabis have tried all other options and need help and sympathy. It is important to ask patients if they have a history with marijuana to determine proper dosing and minimize side effects, especially in the elderly.”
Risks/benefit discussions are important, as are those about time to benefit. “If a patient has been trying a therapy for a month and does not notice a difference, it may be time to try something different. Some formulations of cannabis begin working immediately, while others may take a few hours,” Fixen said. “This is very important for patients to know, especially if the side effect poses a risk of sedation or drowsiness. If a side effect can alter alertness, it may be best for the patient to take [it] at bedtime or...when they do not need to leave their home.”
As with any other prescription medication, pharmacists should help patients feel comfortable with medical marijuana. It is important to explain as clearly as possible how to take the dose, what to expect from it, and any known or potential adverse effects or interactions.
Laws and Regulations
The federal government continues to classify marijuana as a Schedule I controlled substance—the same category as heroin, LSD, and meth. Schedule I substances have no currently accepted medical use and may not be prescribed, administered, or dispensed for such use. Therefore, under federal law, no one, including pharmacists, can legally dispense marijuana as a medical treatment—even in states that have passed medical marijuana legislation.
Panahi believes legalization will not only benefit people who use medical CBD and THC but will also remove barriers to researching cannabis treatments. “Many of my patients are anxious or wary about entering a conventional dispensary due to the...stigma around marijuana,” she said. “Allowing cannabis to be dispensed in a medical setting would increase the safety of patients and increase the accessibility of cannabis treatments.”
1. Bridgeman MB, Abazia DT. Medicinal Cannabis: History, pharmavology, and implications for the acute care setting. PT. 2017;42(3):180-188.