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.

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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.

There will be many articles published highlighting the highs and lows of the last two years. We have a healthcare and research  perspective as a dedicated medical cannabis clinic and research leader since 2014, and similarly have seen highs and lows for our patients and practitioners.

Importantly, before legalization, it was common thought that medical cannabis clinics were not long for the world, that  legalization would remove the need for dedicated medical support for patients. Having worked alongside patients for years, we knew that this would not be the case, and in fact, we have seen an increase in referrals from doctors and self-referrals from patients, stimulated by legalization. With better access to cannabis information, people are seeking support from trained healthcare professionals to make informed choices that can improve their health and wellbeing.

Our increased demand for service, and increasing number of appointments year over year indicate that the need for medical support and patient education from a dedicated healthcare team is not going away any time soon.

WHAT HAS GONE WELL

Less stigma Patients report feeling more comfortable speaking with the healthcare teams, their families and friends about medical cannabis. We’ve observed an increase in interest in educational patient events and our training programs from doctors, nurses and pharmacists.

Reduced ethical burden. Cannabis legalization has helped to provide a clearer role for healthcare professionals and reduce the ethical burden we faced in previous years where doctors were the gatekeepers to legal access. Now, within a legal cannabis framework, we can focus specifically on the patient’s eligibility for medical cannabis treatments and can discontinue treatment if the goals or the conditions of our medical program aren’t met without the concern for legal issues if patients continue to consume on their own.

Diversity of product formulations and methods of administration have provided more options for patients and doctors. In the last two years, cannabis extracts, oromucosal sprays, vapourizer pens and topical products, have become available, meaning patients are more likely to find a treatment regime that works for them.

Updated guidelines for prescription of medical cannabis from the Collège des médecins du Québec. The important emphasis on quality of care and documentation remains, however research is no longer mandatory and decisions such as follow-up frequency of stable patients are left to physician discretion. Santé Cannabis is still very committed to medical cannabis research and all patients assessed and followed at the clinic are enrolled in our Real-World Data study upon their consent. However as this is no longer a mandatory requirement, it reduces barriers for patients and physicians.

WHAT CAN BE IMPROVED

More public education required. Publically-funded and developed training for healthcare professionals is essential. There is still a lot of confusion between medical and nonmedical rules, especially in Quebec.

Commitment to healthcare professional training. Our public healthcare system is a pride of Canada, but the government responsibility for training of our doctors, nurses, pharmacists and healthcare support staff seems to be completely overlooked during the first two years of legalization. The fact that pharmacists still don’t have a defined role in Canada’s medical cannabis program is Canada’s most shameful deficiency.

Improved access points for patients Access has not really changed for patients in the last two years, they still cannot fill medical cannabis prescriptions at pharmacies or retail locations. While SQDC locations continue to expand across the province, and same-day home delivery is available in Montreal for non-medical consumers, patients must still order online or by phone directly from the licensed seller and wait 2-3 business days for delivery.

The cost of medical cannabis remains prohibitive to the majority of patients who could benefit. Legalization introduced an additional excise tax, in addition to the sales taxes already applied. Some improvement has been made with private insurance, however it remains limited and universal cost coverage is still far away.

The introduction of the Cannabis Research License, a license that must be obtained from Health Canada for all research that handles onsite cannabis or cannabis products, has delayed research projects and increased burden on clinical researchers. This barrier causes challenges with project planning and funding. Without improvements, Canada is at risk to lose its global leadership position for research and innovation of cannabis products and cannabinoid-based medicines.

Changes to product packaging with the implementation of the Cannabis Act have created unnecessary burden on patients, healthcare professionals and the licensed producers and manufacturers. After twenty years of medical cannabis in Canada, it is frustrating that policy decisions are still being made without putting patients’ needs first.

On the 2nd Anniversary of Legalization

We are proud to be practicing medicine and completing research in a province and country that has made such impressive gains in cannabis, medical and otherwise, over the past two years. Legalization was something we advocated for since we opened our doors in 2014, and we celebrate this anniversary each year, knowing how many strong people worked tirelessly to make it happen. There is still a lot of work to do, and we excitedly look towards the next two years and beyond. 

For more perspectives on the 2nd year anniversary of legalization, read here.

In August 2010, nabiximols -trade name Sativex- became the first natural cannabis-based medication to be fully approved by Health Canada for a specific indication. An adjunctive treatment for spasticity in multiple sclerosis, the drug has over the years gained approval from regulatory bodies in France, Germany, the U.K. and several other countries.

Recent studies suggest a wide acceptance of medical cannabis within the MS patient community. Yet still today, the large majority of M.S. patients who use medical cannabis continue to favor oils, sprays and other medical cannabis products over nabiximols. 

Why do so many multiple sclerosis patients and their healthcare providers still rely on unapproved medical cannabis treatments when a natural pharmaceutical cannabinoid is available?

The answer lies in a combination of factors, particularly economic barriers to access and the importance of personalized, adaptable treatments. 

Multiple Sclerosis and Spasticity

Multiple Sclerosis is characterized by demyelination, a process that sees cells involved in neuro-inflammation mistake the myelin sheath covering the nerves for a foreign antigen and attack it. While the myelin sheath can be repaired, the attacks nonetheless leave scars, the accumulation of which cause a wide range of symptoms. 

Approximately 50% of MS patients experience some pain associated with the disease.

Most frequent MS symptoms include neuropathic pain, spasticity, bladder dysfunction, and fatigue. Spasticity is thought to affect about 80% of M.S. patients, with symptoms ranging from light muscle tightness to painful involuntary spasms and contractions. 

Baclofen, a muscle relaxant and anti-spastic medication, is often prescribed to treat spasticity but research suggest as many as 25-30% of M.S. patients do not respond to the drug. 

For these patients, nabiximols could be a potential option. 

Nabiximols and Treatment Resistant Spasticity

Nabiximols is an oromucosal spray that consists primarily of a controlled dosage of THC and CBD extract from the cannabis plant. It is usually the first cannabis treatment option Santé Cannabis physicians consider for M.S. patients with treatment resistant spasticity.

But nabiximols isn’t covered by provincial health insurance plans in Canada, and is only covered by a handful of private health insurers. With the monthly cost of treatments ranging anywhere from 226$ to 903$, the drug is rarely an affordable option for patients. To counter this barrier to access, Santé Cannabis has developed effective alternatives using medical cannabis sprays and oils to treat spasticity in M.S.

TO FIND OUT MORE ABOUT TREATMENT RECOMMENDATIONS FOR SPASTICITY IN MULTIPLE SCLEROSIS, SIGN UP TO OUR PRESCRIBER TRAINING PORTAL

Testing Different Ratios: The Importance of A Personalized Approach

Nabiximols is a product with a balanced ratio of THC to CBD (2.7mg to 2.5 mg). At Santé Cannabis, the majority of treatments are initiated with products that have balanced THC:CBD ratios, particularly if patients are inexperienced with cannabis as CBD is thought to lessen some of the psychoactive effects of THC. 

But medical cannabis requires a highly-personalized approach to be effective. While balanced THC:CBD products may be effective for many, they aren’t necessarily the optimal ratio for every patient. 

Indeed, some patients may benefit from an increase in CBD or THC levels. The use of medical cannabis oils allows patients to test different ratios to find the right combination that meets their therapeutic goals, something that isn’t possible with pharmaceutical cannabinoids.

The Need for More Research

A 2019 review of 27 different studies on spasticity in adult patients with a range of conditions, including 21 studies on multiple sclerosis patients, demonstrated support for the trial of cannabinoids as a treatment for spasticity or pain in patients with M.S, 

This review “found evidence that THC and THC:CBD products may reduce spasticity or concluded that it generally favoured cannabinoids to treat spasticity based on the results of individual studies or trends towards significant effects.” (Nielsen et al. 2019)

Discrepancies in the scales used to assess the effectiveness of treatments have at times made comparing findings from different studies difficult. Although the Ashworth scale has been used to measure the efficacy of treatments on spasticity, researchers have over recent years suggested the 88-item Multiple Sclerosis Spasticity Scale (MSSS-88) as a more accurate approach. (Nielsen et al 2019) (Fu et al. 2018)

Carefully conducted, high-quality studies that focus specifically on the activity of different cannabis compounds are still required to further expand understanding of the benefits of cannabinoids for M.S. patients.

For more information about the potential of medical cannabis treatments for MS symptoms and improved quality of life, reach out to us. 

Veterans Affairs spokesperson Marc Lescoutre told the Globe and Mail on Friday that “consideration will be given to whether coverage should be extended,” as part of an effort to keep the marijuana program as “up to date” as possible.” Veterans Affairs has been reimbursing the cost of medical cannabis products in dried flower form for military veterans and former RCMP officers since 2008. More than 10,000 veterans submitted requests for the reimbursement of their medical cannabis over the last year. The ministry offers $8.50 for every gram of dried cannabis purchased.

Adult use of reusable and disposable cannabis vape pens was legalized across Canada in the fall of 2019, although provincial governments in Quebec and Newfoundland have banned their sale. Patients in Quebec and Newfoundland who have a medical authorization for cannabis however can still purchase them from Licensed Producers.

Click here to read the article on the Globe and Mail’s website.