A few years ago, we published part 1 of this blog series All About Cannabis Administration – Part 1 , introducing two of the most common ways of using medical cannabis: inhalation and ingestion. Since then, cannabinoid medicine has continued to evolve rapidly. New formulations have become available, and our understanding of cannabinoid pharmacology has grown considerably. As a result, patients, researchers, and clinicians have increasingly explored alternative routes of administration.

Today, patients have access to a much wider range of options, including oromucosal sprays, topical products, transdermal patches, and suppositories. Each route has unique advantages and limitations, and understanding these differences can help patients and healthcare providers make more evidence-informed treatment decisions.

WHY DOES ADMINISTRATION ROUTE MATTER?

Choosing how cannabinoids enter the body is just as important as choosing which cannabinoid to use. The route of administration influences how quickly the medication works, how long the effects last, how much reaches the bloodstream (bioavailability), and the likelihood of specific side effects.

Cannabinoids like delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are highly lipophilic, dissolving easily in fat but poorly in water. This is why medical cannabis products are often oil-based and better absorbed when taken with fatty foods. While this property allows cannabinoids to cross fatty cell membranes efficiently, it hinders their passage through water-rich environments such as saliva, mucus, or deeper skin layers. Formulations may include absorption enhancers, such as ethanol, medium-chain triglycerides (MCTs), or surfactants, to improve transfer across biological barriers and raise bioavailability.

Orally ingested cannabis undergoes hepatic first-pass metabolism: after absorption in the gut, blood carrying the drug passes through the liver before reaching the rest of the body. During this initial pass, part of the drug is metabolized, reducing the remaining amount of drug reaching the rest of the body. This contributes to the delayed and more variable effects of oral cannabis products. In the liver, delta-9-THC is also converted into 11-hydroxy-THC (11-OH-THC), an active metabolite that produces stronger and longer-lasting psychoactive effects than THC itself (1). This is why edibles can feel more intoxicating (“feeling high”) and last longer than inhaled cannabis, even at similar doses.

Alternative routes of administration—including oromucosal, transdermal, and rectal/vaginal—partially or completely bypass the first-pass metabolism. Because less THC is converted into 11-OH-THC, these routes can offer a faster onset of action, more predictable absorption, and a lower relative risk of unwanted intoxication compared to orally ingested THC. However, the degree to which these benefits appear depends considerably on the formulation used and individual factors such as genetics, body composition, and a person’s sensitivity or tolerance to THC (2).

OROMUCOSAL ADMINISTRATION

Although both oral and oromucosal products begin in the mouth, they follow very different paths. Oromucosal formulations – sprays, strips, or lozenges – are mostly absorbed directly through the mucous membranes (under the tongue or inside the cheeks), allowing cannabinoids to partially bypass first-pass metabolism and reach the bloodstream more directly. In theory, this translates into a more predictable effect and a faster onset of action.

The oromucosal route has gained particular importance in medical cannabis care because it is the route used by nabiximols (Sativex®), a standardized pharmaceutical product that has generated one of the strongest bodies of evidence in cannabinoid medicine (3). Because it is a licensed pharmaceutical product with a standardized THC:CBD formulation and dosing regimen, it has been evaluated in numerous randomized controlled trials, particularly for multiple sclerosis-related spasticity and neuropathic pain (4).

Controlled pharmacokinetic studies comparing oral THC to oromucosal Sativex found a trend toward greater THC bioavailability and a lower 11-OH-THC-to-THC ratio with the oromucosal spray, consistent with partial avoidance of first-pass metabolism (5). Its ethanol-based formulation allows rapid absorption through the oral mucosa, although some patients may experience local irritation or mouth discomfort. Sativex® is not covered by government-based prescription plan (RAMQ in Quebec), but some private insurers may offer coverage under specific criteria.

TOPICAL AND TRANSDERMAL ADMINISTRATION

These two terms are often used interchangeably, but they describe different therapeutic approaches.

Topical products are designed to act locally within the skin and underlying tissues. Creams, gels, lotions, and oils are commonly used to target localized symptoms such as pain and a variety of dermatological conditions. Without significant absorption into the bloodstream, they carry little to no risk of intoxication. A placebo-controlled clinical trial reported that topical CBD oil significantly reduced pain and other symptoms in patients with peripheral neuropathy, with minimal side effects (6). These findings are consistent with our clinical experience; our clinical staff and patients have observed positive effects with the use of topical products for localized pain.

Transdermal patches, adhesive strips applied to the skin, are specifically formulated to deliver cannabinoids across the skin barrier and into the bloodstream, providing longer-lasting effects throughout the body. This distinction matters because the skin is naturally designed to keep substances out, so transdermal formulations require specialized technologies — such as chemical permeation enhancers or microneedle systems — to help cannabinoids cross this barrier (7) Although preclinical studies demonstrate the anti-inflammatory properties of cannabinoids that may benefit certain skin conditions, clinical evidence for the use of cannabinoids in dermatology remains limited, underscoring the need for further research (8).

RECTAL AND VAGINAL ADMINISTRATION

Suppositories are solid preparations designed to melt at body temperature and deliver medication via the rectal or vaginal route. They are typically made from fatty bases — such as cocoa butter, shea butter, or coconut oil — which suit the lipophilic nature of cannabinoids.

Cannabis suppositories have attracted growing interest from both patients and clinicians in recent years. Although clinical data remain scarce, patients living with conditions such as chronic pelvic pain, endometriosis, and dyspareunia are increasingly seeking out this route, and it is being prescribed more often in clinical practice.

Suppositories are thought to offer higher local bioavailability within the pelvis while reducing how much of the cannabinoids circulate throughout the body compared with the same dose administered orally or by inhalation. Because this route partially avoids first-pass metabolism, it produces less 11-OH-THC and may result in lower concentrations of this metabolite reaching the brain. In theory, this may reduce the likelihood of THC-associated psychoactive effects while maintaining local therapeutic benefits. Real-world evidence suggests they may improve pelvic pain and menstrual discomfort while being generally well tolerated (9).

While some studies exist for the rectal route (10), none have yet been published for the vaginal route, despite considerable patient interest. In a survey of persons taking cannabis for perimenopause and post menopause, 78% expressed interest in cannabis-based vaginal products, most commonly to address vaginal atrophy, dryness, and localized pain — needs that current products on the market do not adequately serve (11).

COULD EYE DROPS BECOME A FUTURE OPTION?

Researchers have been exploring ocular administration of cannabinoids for decades, particularly for glaucoma, but also for other ophthalmologic conditions such as dry eye disease and diabetic retinopathy. Cannabinoids—particularly THC—may reduce intraocular pressure (IOP) while also exerting anti-inflammatory and neuroprotective effects (12). The main challenge has been developing formulations capable of delivering cannabinoids effectively to ocular tissues while avoiding the systemic exposure and psychoactive effects associated with conventional routes of administration. To address these limitations, researchers are investigating advanced drug-delivery technologies to improve ocular bioavailability (13). Though this method sounds promising, cannabinoid-based ocular products are not available on the market.

LOOKING AHEAD

The legalization of recreational cannabis in Canada has accelerated innovation in cannabis formulations, expanding the range of therapeutic options available to patients. As this article has shown, each formulation and route of administration offers unique advantages that may better suit different symptoms, lifestyles, and treatment goals. While patients and clinicians have readily embraced these new products, further research is needed to improve their cost-effectiveness and to support policy changes that expand access and reduce the persistent stigma surrounding medical cannabis.

At Santé Cannabis, research and patient care go hand in hand. For more than a decade, our clinical research program has generated real-world evidence and clinical trials and helped advance cannabinoid-based care. Every patient who participates in research contributes to closing important knowledge gaps and moving the field toward safer, more effective, and more personalized treatments. Whether you’re just beginning your medical cannabis journey or exploring new treatment options, our multidisciplinary team is here to help you find the approach that best fits your needs.

Author: Luiza Marouelli, Clinical Educator at Santé Cannabis.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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Don’t miss the first part of this series

Discover the main routes of administration for medical cannabis.

Discover the first part

REFERENCES

1. Lemberger L, Martz R, Rodda B, Forney R, Rowe H. Comparative pharmacology of Δ9-tetrahydrocannabinol and its metabolite, 11-hydroxy-Δ9-tetrahydrocannabinol. J Clin Invest. 1973;52(10):2411–2417. 

2. Olivero MM, Colom J, Gual A. Psychoactive constituents of cannabis and their clinical implications: a systematic review. Constituyentes psicoactivos del cannabis y sus implicaciones clínicas: una revisión sistemática. Adicciones. 2018;30(2):140-151. Published 2018 Apr 15. doi:10.20882/adicciones.858 

3. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015. 

4. Novotna A, Mares J, Ratcliffe S, et al. A randomized, double-blind, placebo-controlled, parallel-group, enriched-design study of nabiximols (Sativex®), as add-on therapy, in subjects with refractory spasticity caused by multiple sclerosis. European Journal of Neurology. 2011. 

5. Karschner EL, Darwin WD, Goodwin RS, Wright S, Huestis MA. Plasma cannabinoid pharmacokinetics following controlled oral Δ9-tetrahydrocannabinol and oromucosal cannabis extract administration. Clin Chem. 2011;57(1):66–75. 

6. Xu DH, Cullen BD, Tang M, Fang Y. The effectiveness of topical cannabidiol oil in symptomatic relief of peripheral neuropathy of the lower extremities. Curr Pharm Biotechnol. 2020;21(5):390–402. 

7. Torabi A, Madsen FB, Skov AL. Permeation-enhancing strategies for transdermal delivery of cannabinoids. Cannabis Cannabinoid Res. 2024. 

8. Hashim PW, Cohen JL, Pompei DT, Goldenberg G. Topical cannabinoids in dermatology. Cutis. 2017;100(1):50-52. 

9. Dahlgren, M.K., Smith, R.T., Kosereisoglu, D. et al. A survey-based, quasi-experimental study assessing a high-cannabidiol suppository for menstrual-related pain and discomfort. npj Womens Health 2, 29 (2024). 

10. ElSohly MA, Gul W, Walker LA. Pharmacokinetics and tolerability of Δ9-THC-hemisuccinate in a suppository formulation as an alternative to capsules for the systemic delivery of Δ9-THC. Med Cannabis Cannabinoids. 2018;1(1):44–53.

11. Dahlgren MK, El-Abboud C, Lambros AM, Sagar KA, Smith RT, Gruber SA. A survey of medical cannabis use during perimenopause and postmenopause. Menopause. 2022;29(9):1028–1036. 

12. Tomida I, Azuara-Blanco A, House H, Flint M, Pertwee RG, Robson PJ. Effect of sublingual application of cannabinoids on intraocular pressure: a pilot study. J Glaucoma. 2006;15(5):349–353. 

13. Saraiva SM, Martín-Banderas L, Durán-Lobato M. Cannabinoid-based ocular therapies and formulations. Pharmaceutics. 2023;15(4):1077. 

No gatekeeping here, we share our skills and knowledge acquired from 10 years of experience in medical cannabis care.

Santé Cannabis has been at the forefront of medical cannabis consultation and research in Québec since 2014. With over 7500 physicians and nurse practitioners having referred more than 20,000 patients, our multidisciplinary team comprises family physicians, specialists in chronic pain, oncology, palliative care, gastroenterology, endocrinology, psychiatry, pediatrics, and nurses with expertise in cannabis medicine. Beyond patient care, we are dedicated to educating healthcare professionals, researchers, and policymakers through both online and onsite training programs.

Over the last 10 years, we saw growing interest from the Quebec patient community for medical cannabis treatments and very few doctors were open to prescribing it. Often due to a lack of knowledge about this treatment, poor scientific evidence being available, and ongoing stigma.

A 2018-2019 survey of medical students in Quebec revealed that cannabis-related topics were minimally covered in their curricula, leading to low comfort levels among them. The majority felt unprepared to address cannabis-related issues in their future practices, highlighting a need for enhanced medical education on cannabis in Quebec’s medical schools.

Addressing the Gap in Medical Cannabis Education

As strong advocates for patient rights and medical cannabis access, we needed to address the gap in medical cannabis education. In 2019, we launched the Prescriber Training Program for healthcare professionals. Initially created for Quebec physicians, interested in learning more about clinical guidelines for medical cannabis and developing individualized treatment plans, it sparked interest from Canadian and international physicians.

With the legalization of recreational cannabis in 2018 came changes and challenges for Quebec’s medical cannabis landscape. Santé Cannabis is always adapting to the evolving industry and staying on the frontline to provide the best care to the community. Some negative points of this legalization were medical cannabis patients turning to self-medicating and accessing their medicine through recreational outlets like the SQDC. While some of the positives are less stigmatization around cannabis and more interest in training from healthcare professionals, guidance from trained healthcare practitioners remains essential to safe access.

Importance of Specialized Training

As Dr. Michael Dworkind, Medical Director of Santé Cannabis and Associate Professor of Family Medicine at McGill University, emphasizes, “It is our duty as physicians to understand the available treatment options for our patients, and medical cannabis treatments have emerged as an important clinical tool.” This sentiment underscores the necessity for healthcare professionals to engage in specialized training to effectively meet patient needs.

With the launch of our online boutique in 2024, a platform created to provide healthcare professionals direct access to a wealth of educational and training resources, we bridge the educational gap and facilitate medical cannabis education.

Through our practical education materials, we aim to empower general practitioners, specialists and, nurse practitioners and enable them to deliver the best care possible. These learning tools are accessible from anywhere at any time and adaptive to your needs and your calendar.

Additionally, we offer in-person training opportunities to help professionals enhance their skills and knowledge.

Together, let’s explore all the possibilities!

Virtual and In-Person Training

Prescriber Training Program

Recognizing the growing demand for medical cannabis education, Santé Cannabis offers a transformative training initiative for Québec healthcare professionals. The Prescriber Training Program, meticulously designed by clinicians, provides a practical approach to medical cannabis education. Developed from our years of clinical care and research we have based on real-world data and the latest research on medical cannabis treatments.

The complete Prescriber program package comprises 10 self-learning modules. In these modules, you will learn about Cannabis as a medical treatment, Patient assessment, and Prescribing. You will find treatment evidence for specific conditions and symptoms, allowing physicians to customize learning based on their professional needs. The virtual program can be followed at your own pace, however, if someone wants to focus on one subject, selected modules can be purchased separately.

For reference module 3 The Prescription Guide covers initial and follow-up treatment protocols for each indication and treatment objective, as well as product format details and drug interaction information.

The Prescriber Package also includes: a Clinical toolkit, and a starter kit of clinic forms, available for customization to your practice, including our referral form, patient evaluation, follow-up form, treatment plan form, and authorization form (Medical Document).

Viewing access to an educational video and presentation, about determining the appropriate medical cannabis treatment, also available for purchase separately.

Personal Mentorship Sessions: Group or 1 on 1 sessions to address all of yours and your teams’ training questions.

Shared Care

This service allows your medical team to request support from our nursing team on a patient-by-patient basis. Available Monday to Friday and includes direct (our nurse to your patient) or indirect (our nurse to your clinical team member) support to develop treatment plans and dosing schedules, source product recommendations, insurance coverage questions or any other needs.

The program was designed for Quebec clinics and practitioners as it includes regulatory information and guidance specific to the Quebec healthcare system. However, the medical cannabis content can be adapted and integrated into your local practice.

“I turned to Santé Cannabis in order to train myself and be able to respond correctly to demand. It gives me the opportunity to prescribe cannabis and also to follow up with my patients properly.  I’ve noticed that a deeper relationship of mutual trust has developed because they don’t feel judged.” – Dr.Jerome Lopez

The course will teach you all the essentials of medical cannabis-based treatments and care, and you’ll leave with the knowledge you need to prescribe with confidence.

“They clearly put a ton of effort into setting up this training program, which demonstrates their commitment to advancing the field of medical cannabis for the health care profession. As well, Dr. Dworkind specially tailored certain aspects of my rotation to me based on my interest in palliative care and chronic pain management, as he has expertise in this area after his long clinical career. ” -Dr.Lorne Wiseblatt

Ask the Expert Sessions

One might wonder what is an “Ask the Expert” session? These 1-1 sessions are the perfect opportunity to get answers to all your questions about medical cannabis as well as to review and discuss complex patient files. They can be done virtually or by phone with one of our physicians or nurses.

In-person Training

We offer onsite preceptorships for doctors, nurse practitioners, pharmacists, nurses or clinic directors that want to learn in a clinical setting. During their preceptorship, they will observe initial and follow-up patient consultations and see our model of care in action.

They can participate in patient file reviews and attend patient education sessions led by a nurse.

The trainees may debate cases and collaborate on patient care decisions and personalized treatment plans. Our team will adapt to the trainees’ needs and their schedule, whether they can commit to a full day or a half day, we will make the most of their time spent in our practice.

“Thanks to their expertise, I feel fully equipped to support my patients in the safe and effective use of medical cannabis. Thank you to Santé Cannabis for their commitment to the training of healthcare professionals and the accessibility of this therapy in Quebec.”  – Dr. G. Lemire, Global MD – Saguenay, completed our prescriber training program and onsite preceptorship and will be integrating a medical cannabis consultation service into her practice.

Educational Tools and Videos

To make our training program more accessible, we have broken down the program into 10 self-learning modules. You can choose the modules you want specific to your field of practice. The self-learning modules Sleep Disturbances and Post Traumatic Stress Disorder are gaining in popularity and meet a growing demand to support these patient populations suffering from uncontrolled symptoms. Other modules like Neurologic Indications or Gastrointestinal Indications can provide valuable insight and evidence-based data about these disorders.

Our educational videos are a fun way to learn, presented by a Santé Cannabis physician or nurse, they are a simple and effective way to understand the fundamentals of providing medical cannabis care in a clinical setting.

Introduction to medical cannabis covers the following concepts: medical cannabis status, the endocannabinoid system, main Phyto cannabinoids and chemovars, indications and relative contra-indications, treatment options and titration, adverse effects and drug interactions, main regulations as well as patient education.

The Santé Cannabis Model of Care; through our peer-reviewed model of care, we’ve achieved standardized patient care. Get to know the secret of our inner workings and our success as a free clinic.

The 5 Common Myths about medical cannabis and the supporting evidence to debunk them:

• The only way to take medical cannabis is to smoke it
• Medical cannabis is harmless and impossible to overdose
• There are no drug interactions with medical cannabis
• Medical cannabis causes addiction and makes you high
• CBD can be converted to THC

Clinical Tools

Our clinical materials will get you to a place where you are ready to prescribe to your community of patients. With our customizable clinic forms, you get to integrate this treatment seamlessly into your practice.

• The Patient Evaluation Form can provide targeted data collection for healthcare professionals and allow you to organize their symptoms more effectively.
• The Patient Treatment Plan Form is a clear and simple formulated document explaining the patient’s medical cannabis treatment containing valuable information like the name of the licensed seller, the name of products, dosage instructions and titration protocol and relevant precautions.
• The Patient Follow-up Form allows you to monitor a patient’s health and make adjustments to their treatment as required.

With the right tools, you can achieve your prescriber goals.

International Offering

International practitioners too can benefit from our trainings, by adapting the Prescriber Training Program, signing up for a preceptorship or a session with a mentor and using the International Prescriber Guidebook. We will help you build your confidence in patient screening and assessment for medical cannabis treatment.

“Santé Cannabis provided me with the most comprehensive training that I have ever received.  The doctors and nurses welcomed me and made me feel part of the team.  I am excited to take my knowledge home and to start prescribing confidently in my practice.” -Dr. Paula Martinez, MD (Neurology), Bogota, Colombia

The International Prescriber Guidebook is a complete and practical training resource for medical cannabis prescription and education, applicable across Canada and international jurisdictions.

It features:

• Active Therapeutic Compounds
• Methods of Administration
• Patient Evaluation and Prescribing Instructions
• Detailed Treatment Protocols and Product Selection by Indication
• Dosing Instructions
• Titration tables
• Follow-up and Monitoring
• Frequently Asked Questions
• Options for Prescriber Support

The guidebook is a valuable asset for international prescribers to navigate medical cannabis care with clarity and certainty.

Our Commitment

Why does medical cannabis education remain so important?

Under the Cannabis Act, the current recreational market has threatened the viability of the medical cannabis access program. This treatment option needs to stay available and be considered as a complementary and adjuvant treatment when conventional medications fail. It can support medication substitution including opioids, benzos, etc, and even improve the quality of life of countless patients.

Santé Cannabis remains steadfast in its commitment to empowering healthcare professionals with the knowledge and tools needed to integrate medical cannabis into patient care safely and effectively.

Through clinical research and real-world data, together we can bring progress to medical cannabis care.

The landscape of medical cannabis is rapidly evolving, and staying informed is crucial for healthcare providers aiming to offer comprehensive patient care. Santé Cannabis’s training materials serve as a valuable resource, equipping professionals with the knowledge and skills required to navigate this field confidently.

We know you can find your medical cannabis community of practice with us.

Author:
Alexia Bellemare

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As part of this historic step, the federal government committed to conducting a review of the Cannabis Act within five years. This was to include a review of the medical cannabis framework in Canada.

It’s important to note that in Canada, medical cannabis is accessible only via a federal program where authorized patients can purchase products from federally licensed companies under specific requirements. Medical cannabis is not available in pharmacies and must be shipped by mail order to patients’ homes or residences.

When cannabis was legalized for non-medical or ‘recreational’ use in 2018, licensed storefronts sprang up all across Canada. These stores now total over 3,800 which represents a very significant growth rate in just 5 years.

In contrast, implementation of the Cannabis Act brought no significant access changes to medical cannabis. The mail order system, in place since 2013, remains the only option for patients and caregivers to access regulated cannabis products for medical use.

While adult Canadians may choose to purchase cannabis from recreational stores and utilize those products for therapeutic purposes, such products are not eligible for insurance coverage, medical expense tax credits.

The complexity of this one aspect of accessing medical cannabis demonstrates the barriers faced by Canadian patients today.

THE NEED FOR RESEARCH ON PATIENT EXPERIENCES

To inform the Cannabis Act review, and to ensure the needs of Canadians who access medical cannabis, or may benefit from it are well understood, our research team joined forces with collaborators to develop a nation-wide study, the Medical Cannabis Access Survey (MCAS). The study was launched in March 2022 to provide an opportunity for Canadians with lived experience of accessing medical cannabis to share their experiences, challenges and suggestions regarding future improvements to the medical cannabis framework in Canada.

Eligible participants included Canadian residents aged 16 years and older, who were currently, previously, or considering taking cannabis for medical purposes.

The survey asked about their current medical cannabis use, purpose, and reasons for taking medical cannabis, their authorization and access experiences, insurance coverage and costs associated with medical cannabis, and changes experienced since legalization of non-medical cannabis in 2018.

A total of 5,744 individuals from across Canada (62% woman) completed the survey, making it one of the largest ever done from the perspective of Canadians accessing cannabis for medical purposes.

Overall, 5,433 participants (95%) reported currently taking medical cannabis and 54% of these individuals held current medical authorization.Here we share the main findings of this study.

USE OF MEDICAL CANNABIS

Most of the participants had a lengthy history of taking medical cannabis and reported taking it every day for such health conditions as chronic pain, anxiety, and sleep issues.

With the growing medical and non-medical cannabis market in Canada, respondents currently taking medical cannabis reported utilizing a variety of cannabis products, with dried flower and oil being the most frequently reported.

In addition, participants with medical authorization were more likely to take oils and capsules than those without (68% vs. 44% and 35% vs 21% respectively). This finding highlights the potential importance of medical authorization in educating and directing individuals towards alternative and complementary medical cannabis products.

Estimating how much medical cannabis product they consumed on average each day, including the amount of tetrahydrocannabinol (THC) and cannabidiol (CBD), was difficult for most individuals to report.

The uncertainty surrounding dose and THC and CBD levels raises several concerns from a safety and harm reduction perspective. Furthermore, it’s possible that many individuals are not taking an optimal dose for their individual needs and may not achieve potential benefits.

Understanding the efficacy and side effects of medical cannabis in the absence of dosing information creates challenges for healthcare practitioners. So those care providers who are attempting to engage in shared treatment decision making with individuals may also experience significant challenges. In addition, documenting the efficacy of different doses of medical cannabis and THC and CBD levels across health conditions provides valuable clinical data for healthcare practitioners working in such a nascent field as medical cannabis, and offers an important starting point for future clinical trial research. In the context of harm reduction, the lack of dose and THC and CBD level information prevents healthcare practitioners from understanding the thresholds at which severe side effects may arise for certain individuals.

CHANGES SINCE LEGALISATION

Not surprisingly, considering the proliferation of cannabis stores, the most significant shift in medical cannabis since the legalization of non-medical cannabis was where individuals obtained their medical cannabis products.

Regulated sales points such as recreational stores, licensed sellers and growing at home has become more popular compared to unregulated sources such as dealers and family/friends.

More than half of individuals with authorization indicated accessing medical cannabis at a legal recreational store, where it is prohibited to provide medical advice about cannabis.

Even more striking was the fact that over 20% of individuals using medical cannabis before 2018 made the decision to no longer access it through the medical cannabis access program at all, highlighting the perceived and experienced barriers.

Legalization also brought a perceived change in attitudes towards medical cannabis, with respondents reporting feeling more comfortable discussing and suggesting medical cannabis to others, except for their employers. Given the continued reports of discrimination experienced by workers who take medical cannabis, restrictive workplace and human resources policies related to medical cannabis, and the continued public education campaign that emphasizes the harms of cannabis, this hesitancy to disclose to employers is understandable.

RETAINING THE MEDICAL PROGRAM

Despite the challenges experienced by participants in accessing the medical cannabis system and their use of the recreational market to obtain medical cannabis, nearly 57% of individuals with medical authorization agreed that there was a need to retain the medical cannabis program as separate from the recreational cannabis market. Policies exclusive to the medical cannabis framework that were most relevant to these individuals included being able to claim medical cannabis on federal tax forms (47%), receiving compassionate pricing (36%), and possession limits (29%).

Individuals identified numerous improvements that can be made to the medical cannabis program in Canada, including:

• reduction of costs by eliminating applicable taxes,
• introduction of access via community-based pharmacies,
• protections for use in public and private spaces,
• review of THC limits for edible products for therapeutic use, and
• an increased focus on medical cannabis research and education.

These study findings highlight the complex landscape of medical cannabis, access challenges and unmet needs among the patient community, supporting the importance of locating patients at the heart of consultations.

NEXT STEPS

The Cannabis Act review is still underway, and stakeholders can contact Health Canada and the Expert Panel at legreview-examenleg@hc-sc.gc.ca to give their feedback on what they would like to see changed.

Once again, we would like to thank the participants who took the time to share their experiences and take part in this research, as well as the patient advocacy groups who circulated the study.

The full report is available here.

How to cite the report: Balneaves, L.G., Brown, A., Green, M., et al. (2023). Medical cannabis access and experiences in Canada. Retrieved from: medicalcannabissurvey.ca.

We’re always happy to hear from you

Do the results of this study match your experience? Email us to let us know what you think.

Contact us

It is with great regret and a heavy heart that we must announce the suspension of a large part of our services for financial reasons.

As of Monday, September 5th, we must unfortunately suspend initial appointments for all new patients. We must also suspend our training activities for health professionals and patients. Therefore, all announced fall events are cancelled. We will however continue to ensure the renewal of medical cannabis authorizations for existing patients.

We want to assure you that we will be here for our current patients. Our phones and emails will be open, however, we will have fewer staff to support them. Your doctors are here to provide continued care. Follow-up appointments will be a little different, but we are fighting to bring back our full level of care.

Here are ways that you can help:

• Make a contribution to our cause

• Share our campaign with your friends and family, or share on social media

• Continue with us – Moving to the recreational cannabis stream hurts our cause

• Send us a testimonial that you would be willing to share in our public campaigns – Rest assured, we won’t disclose any identifying information. 

•  Be patient with us during this difficult time, we will need more time to return your calls and your emails, we’re here for you but we are under-resourced

You might be wondering how this happened- Santé Cannabis has been a mainstay of medical cannabis access in Quebec since 2014. 

We’ve been struggling with the same question. Medical cannabis is not a priority for our government, for our healthcare industry, and we’ve tried everything we can to maintain our service, but we’re at our breaking point.

We’ve been slammed by the COVID-19 pandemic and increasing costs. And we now operate in the shadow of a recreational cannabis market entirely disconnected from its roots in medicine and patient advocacy. We now lack the resources required to continue providing our essential medical service. The RAMQ billings and educational grants we receive do not cover the costs of the care that we provide, and we must restructure in order to survive. We also receive no additional public funding in a province that profited $65 Million from recreational cannabis sales last year.

To date, none of these public funds are earmarked for medical cannabis research or improving medical cannabis access in Quebec. Many people will wonder, why do we still need medical cannabis clinics now that cannabis is sold legally?

There are many, many reasons:

• Patients using cannabis for medical purposes require care and education that cannot be provided by cannabis store clerks
• Physicians, nurse practitioners and pharmacists identify potential risk factors and drug interactions that require monitoring
• Vulnerable populations require personalized professional support to ensure they use cannabis safely and appropriately
• Cannabis purchased on the recreational market cannot be declared as a medical expense on income tax
• Medical cannabis authorizations provide protection to individuals who depend on it to work, to live and to care for their families
• Children and young persons can only access cannabis for medical purposes, and require personalized professional support
• Some patients receive reimbursement for their medical cannabis purchases, such as through Veterans Affairs Canada, CSST, SAAQ, and health insurance spending accounts. 
• Patients who grow their own cannabis require medical authorization, especially in Quebec where home cultivation is otherwise prohibited
• Specific Higher potency products for medical use are not available at the SQDC and can only be accessed via medical authorization

Once more, here are the ways you can help:

We are about to launch a media campaign to let the public know of this situation. We’ve protected our patients from these financial difficulties until now and avoided voicing them publicly. We are now at a point where we can no longer stay silent. As patients, you can help shed light on the importance of patient access to reliable information, educated medical evaluations and proper follow-ups. If any of the reasons for medical cannabis clinics to exist apply to you and you want to share your experience, send us your testimonial at info@santecannabis.ca.

We have also launched a donation campaign that we invite you to share with your connexions. We believe in our mission. We hope this situation is temporary, and thank you for your patience and support.

– Dr. Dworkind

Donate here

*Please note that this blog dates back to 2022. We restarted initial appointments for new patients in November 2022 and are still taking new patients.

No one said recovering would be easy; they said it would be worth it.  

Whilst sitting here wondering how I am going to take nearly 12 years of chronic health struggles and formulate it into a short blog post, I reflect on a 16-year-old: scared, confused, immature and unprepared adolescent. I bring myself back to the day I got the call from the Montreal Children’s Hospital Gastroenterology (GI) department to give me my first appointment, initiating the testing process for inflammatory bowel disease. It seems like so long ago, yet it’s still so fresh in my memory.  

As a medical cannabis patient and medical cannabis clinic employee, I hope my story can help anyone to see a glimmer of light at the end of even the darkest of tunnels. I currently see my daily fight to maintain balance and good health as a blessing and a strength, but as a teenager just starting to experience life, it felt like an absolute curse and weakness.  

The summer I turned 16, I went to see my gynecologist for my usual 6-month follow-up. Even though I was on birth control, I was constantly spotting between periods. Given my family history of Inflammatory Bowel Disease and Irritable Bowel Syndrome, and an additional concern of constant diarrhea for the last 3 months, worry grew that I may be battling an autoimmune disease. My doctor put in a request for me to be seen by the Montreal children’s hospital’s GI department, where I was diagnosed with Crohn’s disease.  

Within a month of my diagnosis and commencing treatments, I experienced an adverse reaction to the medication my doctors had prescribed to control my disease. It left me with pancreatitis – this was the beginning of my living nightmare.  

Due to ongoing complications, I was hospitalized for months at a time, and I was given opioids to control my pain, benzodiazepines for anxiety, and corticosteroids for the inflammation my disease caused. As time passed each hospitalization got longer and my time at home in between got shorter.  

Over time, I started to notice a shift in my moods. I thought I was only mildly depressed because of the cards I had just been dealt. I figured it was normal considering everything I had gone through in a short amount of time. I was watching my adolescence being ripped away from me. I began to feel like a prisoner in my own body. I went from being an outgoing and sociable teenager to being a reserved and isolated young adult. I was terrified.   

Shortly after being told that my pain from multiple flare-ups left me with chronic nerve damage to my intestines and pancreas, I began to realize that the pain I had was both physical and psychological, which in turn brought on severe anxiety. I started to seek unhealthy coping mechanisms.  

Subconsciously, I turned to opioids that doctors prescribed for my physical pain to alleviate my mental pain as well. I did not want to feel anything, I wanted to be numb. From that point on, there was not a day that went by that I did not misuse morphine, Dilaudid, codeine, fentanyl, or Ativan to escape the fact I was chronically ill and depressed.   

I was being followed in cognitive behavioural therapy and talk therapy for 6 months after my Crohn’s diagnosis. I learned I could tell my therapist whatever she wanted to hear just so my specialists would be happy and leave me be. After each session, I would go home and drown my feelings in whatever opioid I had at my disposal.   

Sleeping and avoiding reality became easier than dealing with my issues.  I had lost everything dear to me: school, friends, romantic partners, self-confidence, and, most of all, self-worth. I was doing absolutely nothing to help myself. I had secretly set a goal to do everything in my power not to see my 25th birthday. At this point, I was chronically depressed and had become a danger to myself.   

My cannabis journey began roughly 2 months later. I went into the ER as usually, thinking I was having another flare-up, but the nausea, vomiting, irritability, cold sweats and increased pain that I was experiencing was not disease related; it was withdrawal. I was hospitalized again, but this time was different. The chronic pain doctors and my care team agreed that I was physically dependent on Dilaudid. They proposed a 20-day in –hospital detox. At 17, I felt like I was being treated like a severe drug addict – little did I know, that was exactly the road I was heading down.  

My older brother came to visit me one day and was appalled with the approach the hospital was taking. Yes, on the one hand, they were doing right by getting me off the opioid causing more harm than good; but on the other hand, I had nothing in the short-term to control the constant pain that I was in. He decided to bring me outside and shared a joint with me. After smoking, my pain diminished, and I was able to finally eat something without vomiting. Since I was a minor my doctors were legally unable to recommend me using cannabis, but if it meant that I would use less opioids, they were not completely opposed to it. The doctors found less habit-forming derivatives of opioids for me to use during pain flare-ups; but with the help of cannabis, I did not need to use as large of doses as I used to.   

After my bowel resection at 20 years old, I recall that my family doctor noticed I was very depressed and needed help. He referred me to the best psychiatrist I’ve ever met. For the first time since getting diagnosed, I felt like I could make considerable progress. I felt like I could open up and be vulnerable with this doctor. I felt like finally someone other than my gastroenterologist genuinely believed in me and did not think I was just a drug seeker, that there was more to my substance abuse than the desire to get high. Despite that, it still took me 6 months to actually let her into some of the deepest, darkest parts of me.     

During one of my countless hospitalizations, I was assigned to the family medicine unit. Dr. Jean Zigby was following me. He was aware that I was trying to reduce my intake of opioids and substitute them with cannabis, but I had no guidance, little cannabis knowledge, nor did I have a clue what was in the cannabis I was consuming. Dr. Zigby changed all that and at 22, I was introduced to Santé Cannabis  

From there, I was blessed with a structured, positive, and organized care team. Confidently, I was able to find healthy approaches to put into practice and regain some balance in my life. I was able to gradually reduce my opioid use for anything other than pain management during my Crohn’s flare-ups. I no longer needed my benzodiazepines, not even for severe anxiety attacks. I was finally taking care of myself, and things began to look up for me. The one thing I did not expect was for the “rollercoaster” I called my life to sporadically have such horrific lows.     

After 7 years of being sick, I had hit rock bottom, attempted to overdose, and to commit suicide multiple times. It took me countless hospitalizations, substance abuse issues and 6 different mental health professionals for me to take my mental and physical health disorders seriously. I had a romantic partner at the time who gave me an ultimatum: it was drugs or her – and clearly, I chose her. I have been on a constant journey of recovery since.   

Due to a long-term use of steroids, I was diagnosed at 23 with ankylosing spondylitis in my sacroiliac joint, as well as rheumatoid arthritis. I was constantly waking up with swollen joints and pain in my lower back, hands, and knees. After being in constant pain for months, I had gone to the emergency room where they had done scans and blood tests. And sure enough, I had a new chronic autoimmune disease that I needed to deal with.  

I was already sober and well into recovery at this point. My medical cannabis care team and I had found a proper THC-rich cannabis regime for my neuropathic pain. Unfortunately, following my care team’s suggestion to add a CBD oil regime to control my ongoing inflammation was too costly for me, as I did not have an income at the time. I had no choice but to start methotrexate, which is a disease-modifying anti-rheumatic drug (and a cancer treatment at higher doses) with debilitating side effects. However, I was able to control my arthritis with it, to a point where I could keep a steady employment.  

Eventually, I was able to afford CBD oil, which in turn helped control the inflammation caused by arthritis. It almost seemed too good to be true, but following a strict ratio of THC:CBD, ALL my chronic health conditions were now under control. I was able to stop 98% of the medications I was prescribed.   

However, with my life headed in the right direction, a part of me still felt unhappy. There was still that little voice in my head, determined to think that I was going to fail, reminding me about the promise I made to myself that I would not see my 25th birthday. I hated the person I saw in the mirror daily. The only emotion I was able to feel was self-hatred. I overthought everything and anything, and I developed chronic social anxiety – I could no longer be in large groups or crowds of people.  

Instead of using drugs, I was now using romantic relationships and close friends to fill the empty hole deep within where self-love used to lie. I simply transferred addictions. I had not completely dealt with my trauma of the last 9 years. I was barely functioning. I hurt people and got hurt. I always had a superhero complex, but by the time I was 24, it was out of control. I thought I could deal with my “baggage” once a week in therapy without applying therapy tools to my daily life. My days revolved around my career and my partner; I was living and breathing for two things and none of them was me. I ended up burning myself out and nearly relapsing.  

I was a week away from the 2-year mark of my sobriety, 4 months away from my 25th birthday and I was once again ready to end it all. I had to take a sick leave from work and broke up with my then-partner when everything was getting hard. I had a plan to end my misery and give up on myself. The day I planned it, to overdose and close my eyes for good, somehow, with my hand full of pills, reality hit me. I realized how far I had come and could see my worth for the very first time in my life. Instead of relapsing and giving up, I decided it was time to go to rehab.  

I finally focused on myself and was able to get back to work. I took therapy seriously and was able to find new ways to appreciate the life I fought so hard for. I surrounded myself with positive and supportive people. I got through the darkness and celebrated my 25th birthday in June 2019.   

By sharing my story, I wanted to show you that anything is possible with a positive support system, a proper care team, and an individualized treatment plan. You can be dealt the worst cards imaginable, but it is the approach you choose to take that can lead to success or failure. I ventured down both roads and believe me when I say: once you learn to love yourself and embrace everything about yourself, you can overcome any obstacle.   

I found the positive before it was too late. I found my purpose and found my place in the world. No matter how dark the road gets for me, I can always manage to find a way to bring a glimmer of hope to the obstacle I am facing. I grew tired of letting my illnesses, my disorders and my struggles define my life, and learned to live with them.  

When I concentrated on caring for myself and dealing with my trauma, I could prevail through the darkness. I could not find the light in my darkness, so I became the light.  

Author: Rebecca Fogel, Patient Care Coordinator, Santé Cannabis   

Rebecca Fogel has worn many hats for Santé Cannabis since October 2017. She works as a Medical Office Assistant, Patient care coordinator and Patient advocate. She leads patient events and support groups, is passionate about public speaking, and is dedicated to providing medical cannabis patients a place to speak freely and to be heard. 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

(Rosa) lives in a retirement home. She seemed earnest about having dominion over her “secret”. On that day, she had maintenance workers attending her floor and an orderly was due to help her get dressed. She withholds her cannabis bottles from prying eyes, only to be laid open to view behind an old Brillo soap box.  

She says she would be represented dramatically by other dwellers as ‘’a habitual user of drugs ” if they knew. Her peers are still very observant of the common perceptions and other existing states. She has learned the intimacy of the daily in-and-out of caregivers and so, she dispenses her CBD oil in due course.   

Half a year later, I sensed she became more defiant, a contemporary moving ahead against the waves of the current stream. She explained. She made a definitive undertaking, testing the water so to speak. During an afternoon tea, she quoted to her fellow guests a news coverage about the benefits of medical cannabis. The feedback hit a schism, as expected. Personal opinions and so-called ‘’common sense “ dinged off each other like kids to broccoli. But amidst all that dissonance, (Rosa) was reassured that those who were in goodwill were assertive about appealing for medical cannabis. She felt not alone. Although encouraged, she isn’t ready to display her CBD bottles openly just yet.  

Little steps toward changing public perception. One (Rosa) at a time. 

Author: Pheng Lim, LPN 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Seeing that welcoming face first when patients come into the clinic will set the tone for their entire visit.   

Helping is the true nature of an MOA, this could not be truer at a medical cannabis clinic that conducts studies. The research component of our clinic requires special attention to detail in the tasks at hand and providing further assistance to patients and their caregivers. Being a medical cannabis advocate for our research but also for patient access becomes second nature to a Santé Cannabis MOA.   

We asked our team of medical office assistants to share with us their feelings and experiences of working at Santé Cannabis. Let’s look at their work diary:  

“My story at Santé Cannabis began as a patient and over time I was able to manage my illness to a point I could maintain employment. I wanted to give back to a community that gave me so much. Each patient I met needed their own individual support and I felt as if I could be this person to provide that for them.  

We are the first intervention if a patient is overwhelmed with emotions. I remember a past encounter with a patient that left a powerful impression when she told me ‘Today you saved a life, I hope you realize this. I cannot thank you enough for talking me off the ledge today. You are an amazing human being.’ 

We are the first voice of reason when a patient calls because they have lost hope in our medical system. As an MOA, we have a vital role to play in a patient’s care from the moment the clinic receives their referral.   

Not many people realize that the MOA is the glue that holds the clinic together.    

Being an MOA for the last 4 years has brought me so much joy and fulfillment, I am beyond grateful for the opportunity Santé Cannabis gave me.”  

– Rebecca Fogel, MOA 

“Seeing our patients satisfied and confident when leaving the clinic with new information and the ability to pass this information on to others that may be suffering is probably the best part of my job. 

I recently received a phone call from a patient, and the amount of joy, relief, and gratefulness that was coming through the phone was truly inspiring. They felt their treatment had helped them so much and they wanted to express the difference it made in their life. It was what I was here for; to hear that it helped someone to that extent was absolutely rewarding.  

Seeing what our patients have gone through has really opened my heart with much more compassion. The best part is that when the treatment really works for them. This gives me more motivation to push and reach my goals and help the people that need access to medical cannabis.”   

–Tamara, MOA 

“Working at a clinic whose goals are to improve access, educate, and treat patients, and taking part in those projects makes me feel like my time and efforts are worthwhile when compared to previous jobs. It has been eye opening to see the extent that patients must go to be able to acquire medical cannabis. The regulations, laws and policies put forth by our government when it comes to prescribing medical cannabis can really make it hard for patients to get the care they need. It’s not easy, and it needs to be improved.  

There is one anecdote that marked me was when booking an initial appointment for a palliative cancer patient. The patient told me they were about to undergo immunotherapy. Studies have shown immunotherapy treatment is not as effective when taking cannabis: medically or recreationally. In that moment, it hit me how important it is to educate people about the effects cannabis has on the body. Previously unaware of the risks, this patient could have gone to the SQDC and put their health and cancer treatment at risk.”  

– Shant, MOA and Research Assistant 

“I came to Santé Cannabis for a new beginning. My family doctor and I had a conversation about a new clinic that was opening neighboring his practice, and so I applied without hesitation. I knew nothing about cannabis. Since I was a little girl, I have always been there for others. I like to feel useful and no matter how small the help I can provide, I can still make a difference in people’s lives.  

In the early days working during Dr. Watier’s clinic, I asked him to follow a patient with autism, which he accepted. I’m impressed to see how much this young man’s life has changed with his cannabis treatment as well as the life of his parents. He is still a patient with us today.”  

– Manon, MOA 

“I take pleasure and pride in being the first line of contact for people who request our services. Being the first person who ensures each individual feels acknowledged and attended to with the utmost dignity, empathy and compassion is a responsibility that is integral to this position and that I greatly value.  In my work, a moment that always grounds me is the shared conversations with patients during phone calls. Their openness to be vulnerable and to discuss their personal struggles, their view on life and contemplation about the afterlife are always subjects of reflection and empathy that make me appreciate those moments.”

– Jessica, MOA 

“Santé Cannabis allows me to use my skills and experience to contribute to a worthy cause. I am also lucky to work among an incredible team of professionals in a field that’s always striving for improvement and building a standard for patient care, research, and education.  

One of my fondest memories, since I work here; was amid the pandemic; we had all been working from home for months – a difficult time for many – and we were preparing for our virtual Christmas party. I was helping organize our staff events and had to come into the office (a rarity at the time) to assemble care packages that were to be sent out to all the employees. Besides the fact that the packages were particularly generous, it was great to feel part of an organization that truly operated like a family caring for its members during tough times.”  

– David, Clinic Coordinator 

We also asked one of our founders and the manager of our nursing team to write a few words about our team of MOAs whom they work closely with and rely on to complete a successful clinic day. 

“I’m happy to recognize the work that our medical office assistants do on a daily basis.  You should be proud of what you do every day!  

 You are the first contact with the patient. You are there to assist them, to guide them through their journey, to ease their concerns, to respond to their needs. It is because of you that we can provide services to patients.  With your empathy, your kindness, and your listening, you contribute to improve their experience in the process of relieving their symptoms.   

You help both the patients and your colleagues during the course of care.  

It is not uncommon for me to hear patients say, ‘The staff is very welcoming’, ‘I felt taken care of as soon as I arrived’, ‘I had a lot of help from the medical office assistants while filling out the questionnaires’.  

The nurses are proud to work with you.”

 – Naomie Parrot, Nurse Manager 

“This initiative to recognize our team of MOAs is invaluable to building community.   

We are an organization that embraces all the workers as important contributors to the success of its operation. This is at all levels of our mandate: clinical, research, education, and advocacy.  

Our powerfully talented group of MOAs are contributing through their commitment to our vision of relieving the suffering of patients with chronic pain and other diseases that medical cannabis can treat.  

This positive interdependence is appreciated by everyone involved and leads to greater job satisfaction and dedication.  

We all need each other to get the job done.  

I am so grateful to have our MOA team, and to be able to rely on them for the smooth and efficient work that we achieve. ”  

 - Dr.Michael. A. Dworkind, Medical Director and Co-Founder.  

Whether their motivation is to educate, advocate or spread awareness on the importance of medical cannabis treatments and access, we know the empathy of our MOAs help build the patient’s trust. This trust is often the beginning to a long-term relationship. 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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If you imagine someone smoking a joint, you’re not wrong, but that’s not the only method of administration, nor the most recommended.

In the early years of medical cannabis legalization, patients mostly smoked their medical cannabis, as it was the only legal option at the time. Since then, other methods of administration (and associated medical formulations) gained recognition and wider acceptance both from patients and prescribers.

Administration of cannabinoid-based medicines can go through several routes: inhaled (in the lungs), oral (swallowed), oromucosal (through the mouth’s mucosa), transdermal (through the skin), ocular, rectal, etc.

If you want to learn how that works and debunk some myths, tag along in this dive into medical cannabis administration.

CLEARING THE SMOKE ON INHALED ADMINISTRATION

Cannabinoid inhalation produces a fast onset of effects, which can begin within seconds after inhalation; effects peak within 3 to 15 min (depending on authors) and last approximately 2 to 4 hours. [1-3]

With this method of administration, the body absorbs a high proportion of active cannabinoids that can then exert their effects on their site of action. This high bioavailability ranges from 10 to 35%, and sometimes up to 56%. The inhalation method (smoked vs. vapourized) and technique influence bioavailability, where technique may vary on depth of inhalation, puff duration, and breath hold. [1, 2, 4, 5]

Prescribers often consider smoking cannabis as an inadequate method to administer a medication due to the harmful combustion by-products. [6-8] Vapourization appears as a safer, smokeless administration method producing much less harmful by-products than smoking; [3, 9, 10] the latter is possibly less efficient since it could destroy from 30% to 50% of its cannabinoid content. [6] Vapourization also minimizes throat and lung irritation and can lead to higher cannabinoid blood concentrations as compared to smoking. [3, 6, 11]

BUT WHAT’S VAPOURIZATION?

Cannabis vapourization consists in creating a vapour with cannabinoids (and other desirable elements like terpenes) without burning the plant material.

The current terms used to describe vapourization overlap and makes it somewhat complicated. Two types of vapourization exist:

• Dried Cannabis Vapourization;
• Cannabis Extracts / Concentrate Vapourization (also called “vaping”, or “dabbing” in the case of concentrates).

ARE ALL VAPOURIZERS THE SAME?

Each vapourization method requires a specific type of vapourizer device, which is not necessarily compatible with the other vapourization type. However, those devices fit under the generic name “vapourizer”.

• Dried cannabis vapourizers, also called “dry-herb vapourizer”, use a lower heat (170 to 230˚C) than the one created by burning and smoking cannabis (500-600˚C), and thus creates less harmful by-products [3, 6].
• Cannabis Extract Vapourizers, also called vape pens or e-cigarettes, are portable electronic devices that require cartridges (or vape cartridge, vape carts, refill pods, etc.).
• Cannabis Concentrate Vapourizers can be 2 things: either a “dabbing rig”, a specialized water filtration device with a heating element [12], or a compact electronic device (also called dab pen, wax pen) with a small oven to heat concentrates. Depending on the device, cannabis extracts or concentrate vapourizers can operate at higher temperatures (up to around 500˚C). Since concentrates contain very little to no vegetal matter apart from cannabinoids and terpenes, it’s hypothesized that their vapourization at higher temperatures cause less harmful by-products than dried cannabis combustion.

Cannabis concentrates come in a wide selection, such as rosin, live resin, shatter, full-melt hashish, etc. 

Some prescribers prefer recommending dried cannabis vapourization over vaping, as Health Canada approved some dried cannabis vapourizers as Class II medical devices (like the Volcano Medic and other devices from the brand Storz & Bickel) [13]. Veterans Affairs and some private insurances may reimburse such medical devices.

Vaping of unregulated cannabis products also caused worry in 2019, when Health Canada issued a warning concerning potential pulmonary illness associated with vapourization products (with cartridges) [14]. Vitamin E acetate, an additive present in illegal THC vaping products, is strongly associated with e-cigarette (or vaping) associated lung injury [15]. Health Canada strictly regulates the manufacturing of medical cannabis vaping products and prohibits potentially harmful solvents.

Note that in Quebec, it is illegal to smoke or vapourize cannabis in a public place without a prescription, whether indoor or outdoor [16].

For several patients, smoking or vapourizing cannabis is not the best option. The second most common administration is through the oral route (ingested).

ORAL ADMINISTRATION

Compared to inhaled administration, which acts fast and for a relatively short period, oral administration takes a while to produce effects and they last longer. Ingested (swallowed) cannabinoid products take effect after a delay of 1 to 3 hours, and the effects last for about 6 to 8 hours, or longer depending on dose, fasted state, and other individual factors [3].

The different times of action between inhaled and oral administration are explained by the distinct absorption speeds. Where inhaled cannabinoids go into the lungs and quickly reach blood circulation, ingested cannabinoids get absorbed in the intestine and metabolized (transformed) by the liver, only then reaching blood circulation. This absorption is slow and variable; the bioavailability ranges from as low as 6% and up to 30% [5, 17].

*A note that the liver converts THC (specifically, delta-9-THC) into an active and potent metabolite (11-Hydroxy-THC) [18, 19], which can contribute to heightened side effects.

Some absorption factors we can’t control, like individual rates of metabolism (some being much faster than others) and sex-related absorption differences; a factor we can control is food intake [5, 20]. Cannabinoids have a high affinity with lipids (fats), and studies found that the absorption of THC and CBD increases (up to 5-fold for CBD) when taken with a high-fat meal [20, 21].

Oral administration includes several medical cannabis products: 

• Oils, made of cannabis extracts and diluted with a carrier oil;
• Capsules, containing a precise dose of cannabis extract diluted with a carrier oil;
• Oral sprays, that deliver tiny drops of cannabis oil;
• Lozenges, sublingual strips, and edibles.

“Edibles” refers to food and beverages that contain cannabis and/or cannabis extracts. While edibles make an appealing administration method for recreational purposes, not all prescribers agree that edibles are an adequate dosing method for medical purposes. Advocates argue that a wider selection of ingested product ameliorate patient access and can better meet their individual needs.

COMPLEMENTARY METHODS

As discussed in our Chronic Pain post series (Chronic Pain – Part 1, Chronic Pain – Part 2), both oral and inhaled administration can serve in some treatment plans:

• Oral administration can serve when a treatment requires day-long pain relief, for example, because of its long-lasting effects [3] and the accurate dosing of ingested products [22]. Administration frequency then varies according to pain frequency, from once daily to two or three times a day [22].
• Inhalation administration can be helpful to quickly relieve breakthrough pain [9, 10], with its onset of effects within minutes of inhalation [1-3]. Administration frequency is usually as needed.

However, in some cases a fast onset of effect is needed, but administration through the lungs won’t do because of a medical condition (like chronic obstructive pulmonary disease); in other cases, spot application could be a more direct method of administration, compared to the oral administration that produces effects on the whole body. In such cases, other methods of administration can prove useful.

Stay tuned for Part 2 of this blog post, where we’ll go over oromucosal sprays, topicals, suppositories, and more!

Author: Charlotte Bastin

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Ready to discover the other methods of administration?

Read part 2 of this blog!

 
All About Cannabis Administration – Part 2

You would like an assessment for a medical cannabis treatment?

Meet with a Santé Cannabis doctor or nurse practitioner today!

 
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Our boutique equips healthcare professionals with the tools and knowledge to confidently recommend and prescribe cannabinoid-based treatments.

 
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REFERENCES:

1. Sharma, P., P. Murthy, and M.M.S. Bharath, Chemistry, Metabolism, and Toxicology of Cannabis: Clinical Implications. Iranian Journal of Psychiatry, 2012. 7(4): p. 149-156.
2. Grotenhermen, F., Pharmacokinetics and pharmacodynamics of cannabinoids. Clinical pharmacokinetics, 2003. 42(4): p. 327–360.
3. MacCallum, C.A. and E.B. Russo, Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 2018. 49: p. 12-19.
4. Vučković, S., et al., Cannabinoids and Pain: New Insights From Old Molecules. Frontiers in Pharmacology, 2018. 9: p. 1259.
5. Bruni, N., et al., Cannabinoid Delivery Systems for Pain and Inflammation Treatment. Molecules : A Journal of Synthetic Chemistry and Natural Product Chemistry, 2018. 23(10).
6. Pomahacova, B., F. Van der Kooy, and R. Verpoorte, Cannabis smoke condensate III: the cannabinoid content of vaporised Cannabis sativa. Inhal Toxicol, 2009. 21(13): p. 1108-12.
7. Notcutt, W.G., Clinical Use of Cannabinoids for Symptom Control in Multiple Sclerosis. Neurotherapeutics, 2015. 12(4): p. 769-777.
8. Zajicek, J., et al., Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial. The Lancet, 2003. 362(9395): p. 1517-1526.
9. Bhaskar, A., et al., Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. Journal of Cannabis Research, 2021. 3(1): p. 22.
10. MacCallum, C.A., L.A. Lo, and M. Boivin, “Is medical cannabis safe for my patients?” A practical review of cannabis safety considerations. European Journal of Internal Medicine, 2021.
11. Spindle, T.R., et al., Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Network Open, 2018. 1(7): p. e184841-e184841.
12. Hädener, M., et al., A preliminary investigation of lung availability of cannabinoids by smoking marijuana or dabbing BHO and decarboxylation rate of THC- and CBD-acids. Forensic Sci Int, 2019. 295: p. 207-212.
13. Health Canada and Government of Canada, Medical Devices Active Licence Listing. 2019.
14. Health Canada and Government of Canada, Information Update – Health Canada warns of potential risk of pulmonary illness associated with vaping products. 2019.
15. Public Health Agency of Canada, Vaping-associated lung illness. aem, 2020.
16. Gouvernement du Québec, The legislation on cannabis. Regulation of cannabis in Québec, 2020.
17. Lucas, C.J., P. Galettis, and J. Schneider, The pharmacokinetics and the pharmacodynamics of cannabinoids. British Journal of Clinical Pharmacology, 2018. 84(11): p. 2477-2482.
18. Lemberger, L., et al., Comparative pharmacology of Delta9-tetrahydrocannabinol and its metabolite, 11-OH-Delta9-tetrahydrocannabinol. J Clin Invest, 1973. 52(10): p. 2411-7.
19. Goullé, J.P., E. Saussereau, and C. Lacroix, Pharmacocinétique du delta-9-tétrahydrocannabinol (THC). Annales Pharmaceutiques Françaises, 2008. 66(4): p. 232-244.
20. Lunn, S., et al., Human Pharmacokinetic Parameters of Orally Administered Δ9-Tetrahydrocannabinol Capsules Are Altered by Fed Versus Fasted Conditions and Sex Differences. Cannabis and Cannabinoid Research, 2019. 4(4): p. 255-264.
21. Taylor, L., et al., A Phase I, Randomized, Double-Blind, Placebo-Controlled, Single Ascending Dose, Multiple Dose, and Food Effect Trial of the Safety, Tolerability and Pharmacokinetics of Highly Purified Cannabidiol in Healthy Subjects. CNS Drugs, 2018. 32(11): p. 1053-1067.
22. MacCallum, C.A., et al., Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain. Front Pharmacol, 2021. 12: p. 633168.

I often get patients wondering in the same manner. There is still much reprehension about cannabis. Our society is unceasingly finding fault with it, no matter how its status has evolved. The public has yet to fully and intuitively confirm its moral direction. Cannabis perception is changing at a very slow pace. 

Even the method of administration is very much compatible to its malignant opinion. ‘’ I don’t want to smoke cannabis. I’m not a druggy.’’ one of our patients did say. The current terminology, slangs precisely, is still and probably throwing people off. Many of our patients do not want to be taking weed or puffing on a spliff. Our treatment plans are based on scientific data, and accordingly we make sure to use the appropriate terms to the purpose. 

Our esteemed doctors do not prescribe marijuana. They recommend inhaling dried cannabis for breakthrough pain. I would gently remind a patient when he or she uses such words as “pot” or “ganja”. The old proverbial ‘’to-may-to/to-mah-to’’ would ring out. So, what is the difference? Really? 

I believe words and how we understand them are very consequential moving forward. I remember back in the 1990’s, the semantics affecting the scope of the term ‘’death tax’’ eventually became the ‘’estate or inheritance tax’’ in the US? Basically, politicians and advocates tried to kill the bill by putting stress on how it harmed family farms and small businesses. They knowingly coined the term ‘’death tax’’ to get the public to consider their cause. Dying has more impact and meaning in the collective conscience. 

I think the transition toward a proper nomenclature in medical cannabis practice must be imposed, applied and supported by all parties involved. Indica dried cannabis, THC-rich, 3-4 inhalations at bedtime or as needed does serves as better example of a positive and trustworthy interpretation than 3-4 puffs of weed before going to bed. 

– Pheng Lim, LPN 

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