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.

You would like an assessment for a medical cannabis treatment?

Meet with a Santé Cannabis doctor or nurse practitioner today!

Book an appointment

Want to learn more? Train with us!

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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. 

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!

 
Book an appointment

Want to learn more? Train with us!

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

 
Visit our boutique

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.

Leading Patient Service, Clinical Care Standards and Clinical Research Data Collection in Cannabinoid-Based Medicines

By Erin Prosk, President and Co-Founder of Santé Cannabis

As the President and Co-founder of Santé Cannabis, an organization at the forefront of medical cannabis clinical practice and research since 2014, I could not be more proud of what we have accomplished and the advancements that we have made to establish evidence-based practices in medical cannabis care.

The last decade has been both challenging and deeply rewarding and as Canadian leaders, we have a responsibility to share our experience, to support medical cannabis programs worldwide to build on our strong foundation to accelerate safe, supported access to cannabinoid-based medicines worldwide.

To that goal, I am excited to share that a detailed description of the Santé Cannabis clinical practice model has been published in the journal Complementary Therapies in Medicine. Our entire Santé Cannabis team has contributed to this achievement, the article is the first peer-reviewed publication describing a dedicated medical cannabis clinic.

This publication shares our clinic development experience and evolution of our clinic model and practice since 2014. It serves as a reference for physicians and allied healthcare professionals who are developing their own dedicated medical cannabis practice with details such as clinical organization, healthcare team, annual clinic data as well a discussion of the strengths, weaknesses and future directions of the clinic model.

Prosk E, Arboleda M, Rapin L, El Hage C, Dworkind M. The model of care at a leading medical cannabis clinic in Canada. Complementary Therapies in Medicine. 2021; 60.

Dedicated medical cannabis clinics have become an essential service delivery model in global jurisdictions such as Canada, Australia, the United Kingdom, Colombia and other Latin American countries and across several state jurisdictions in the US. The emergence of dedicated clinics is due to still-remaining critical gaps between patient needs and the traditional healthcare system. Medical cannabis assessment, prescription and follow-up remains service provided by a limited number of physicians, with the majority citing lack of training, limited amount of high-quality research, complex regulatory frameworks and lack of clinical guidelines for medical cannabis products.

As the primary point of access for the majority of the 300 000 registered medical cannabis patients in Canada, dedicated clinics have provided a critical source of evidence-based information, personalized medical support and treatment recommendations and ongoing follow-up. Several initiatives are underway in Canada to increase knowledge, including several that are described in the article.

Santé Cannabis assesses almost all of its patients on referral from their primary care physician or specialist, supporting patients to discuss the referral with their treating physician in order to integrate their care. Following a patient’s initial visit at Santé Cannabis, our team provides a consultation report to the referring physician. By this initiative, the clinic has introduced medical cannabis treatments to more than 5000 physicians since we opened our doors in 2014. Such commitments provide required integration between medical cannabis clinics and the “traditional” healthcare services and improve patient outcomes by sharing information between the healthcare team. The consultation reports support knowledge transfer between healthcare professionals and continued learning for the referring physicians as they continue to follow the patients in their care.

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

Similarly, this article breaks down practices at a medical cannabis clinic that are often viewed as a black box. Concerns have been raised about why these clinics exist and questions of the care provided; dedicated service is often required to meet patient and medical community needs within a complex regulatory system and lack of professional training for healthcare professionals.

As there have been to date no peer-reviewed publications describing a medical cannabis clinic model, the development of an article was critical to share practices. With limited resources, it is not always possible to maintain such advocacy. At minimum, practice standards must adhere to regulatory guidelines and clinics must operate in transparently, encouraging communication with regulators while raising any challenges to providing safe, effective patient care. Patients and partners of the medical cannabis clinic must be aware of its practices and of any funding relationships that may present a conflict of interest. Such relationships can be difficult to navigate, especially in emergent medical cannabis industries and collaboration with experience medical cannabis clinics is recommended.

Despite 20 years of legal access to medical cannabis in Canada, the majority of patients still rely on dedicated medical cannabis clinics as the availability of training opportunities on cannabinoid-based medicines remain limited and outside the standard medical curriculum at Canadian institutions.

Santé Cannabis is a unique medical cannabis clinic as its purpose and leadership extends beyond direct patient care. Operating as a clinical research site since 2015, Santé Cannabis emerged as Canada’s first Contract Research Organization dedicated to medical cannabis in 2018 and has since continued to expand its services to support the development of high-quality research. Santé Cannabis is also dedicated to training healthcare professionals and supporting the development of leading medical cannabis clinics worldwide.

As a still unapproved medical treatment, consideration of medical cannabis often emerges at the end of a long patient journey. Patient needs are high and long-standing stigma demands a responsive support service and dedicated patient education. This delivery is resource-intensive, especially when few details are available to clinic operators. This article introduces several available resources developed to support efficient, high-quality care and tested by our Santé Cannabis team.

Getting started with a medical cannabis practice introduces several challenges and little guidance is available from experienced clinicians and operators. Physicians and allied healthcare professionals who are developing a dedicated medical cannabis practice will benefit from the sharing of years of experience outlined in this article from our Santé Cannabis team, including the development of an operational plan that integrates objectives and community needs with available resources.

When well-developed, medical cannabis clinics provide an unparalleled opportunity for the collection of Real-World-Data and even the recruitment and operation of clinical trials. Whether clinical research is a priority initiative on clinic launch or in later years, considered planning is critical to ensure efficient collection of high-quality data.

The significant global evolution of regulatory frameworks in recent years indicates the validation of an essential treatment option for patients, one that patient advocates, physicians and supporting healthcare professionals for access to cannabinoid-based medicines have been pushing for decades.

It is clear that medical cannabis access will continue to expand worldwide, and with that the need to establish clinical practice standards to support patients and medical communities. Effective service delivery will only be possible with increased international collaboration between healthcare professionals to exchange knowledge, share experience and optimize resource development in the coming years.

Look to Santé Cannabis for this collaboration and to find innovative, practical training opportunities for international physicians and healthcare professionals and access personalized consultation from our expert team.

To discuss your project and find out if Santé Cannabis might accelerate your development, please contact us. From one innovative team to another, we’re looking forward to hearing from you.

Author

Erin Prosk

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

On World MS day (May 30th), we’re exploring the latest on Multiple Sclerosis and cannabinoid-based medicines (CBM). 

As clinicians and researchers, we’re sharing our takeaways for healthcare professionals, up-to-date literature on MS and CBMs, information from our clinics and the perspective from one of our active patient advocates.  

What is Multiple Sclerosis (MS)?

Multiple Sclerosis is an autoimmune and neurodegenerative disease affecting the spinal cord and the brain, which can lead to a variety of symptoms depending on what exact part of the central nervous system is affected. An autoimmune disease is a disease in which the immune system attacks healthy parts of the body. 

In MS, cells involved in neuro-inflammation mistake myelin (the protective barrier around neurons) for a foreign antigen and attack it repeatedly. As the myelin sheath can be repaired but not seamlessly, the accumulation of scars in multiple areas causes a wide range of symptoms. 

Most frequent symptoms include spasticity, pain, tremor, impaired balance and coordination, gait difficulties, fatigue, depression, bowel and bladder dysfunction, cognitive impairment, sensory impairment. No two cases are exactly alike, and different people will experience different symptoms in different severities. 

MS is separated into four subtypes according to the disease progression including the frequency of relapses (attacks): clinically isolated syndrome (CIS), relapsing-remitting (RRMS), secondary progressive (SPMS) and primary progressive (PPMS). 

Multiple sclerosis is one of the most common neurological diseases affecting 2.8 million people worldwide. Multiple sclerosis can occur at any age, however is typically diagnosed in individuals aged 20 to 49 years old. It is most frequently seen in women compared to men. 

Canada has one of the highest rates of MS with an estimated prevalence of 250 per 100,000 inhabitants. 

Top 9 takeaways for clinicians from the clinicians at Santé Cannabis:

1. In Quebec, medical cannabis should be considered only after first-line treatments are deemed ineffective. After attempting other treatments, you may want to discuss cannabinoid-based medicines  with your patient. If you don’t know where to start, you can sign up for our Prescriber Training Program for educational resources and access to a medical hotline. 
2. There is conclusive scientific evidence that supports the use of medical cannabis for MS related spasticity. (GW Pharma Ltd 2012)
3. Delta-9-Tetrahydrocannabinol (THC) is the cannabinoid identified in studies as being beneficial for spasticity in MS patients. Clinically, we typically see that THC can help with spasticity and MS related pain. However, cannabidiol (CBD) can help some patients with spasticity or pain. CBD has the advantage of not having many side effects and does not include the typical “euphoric” side effect associated with cannabis. 
4. THC has more side effects than CBD, including euphoria and the feeling of being “high”. However, it is possible to take THC medically without having side effects or being high: the key is starting at very low doses and titrating up very slowly.
5. The different treatment plans for the various MS-related symptoms are described in the educational material we offer within our Prescriber Training Program. 
6. Because of the very low amount of cannabinoid receptors in the medulla, it is impossible to die from a cannabis overdose (World Health Organization). However, accidents can be associated with impaired faculties due to cannabis side effects.  
7. Cannabis has contraindications like many other medications, it is important to know the contraindications and to assess patients prior to initiating a cannabinoid-based medicines treatment.
8. Capsules are concentrated oil placed in a capsule at specific doses and can replace cannabis oil for an ingested method of administration (long acting). This can make it a preferred method for certain patients.
9. Patients with multiple sclerosis often have trouble sleeping, cannabis at bedtime may help with sleep without worrying as much about side effects consequences (Zajicek et al. 2003; Schabas et al., 2019). 

“As a nurse myself, I know how important it is to seek out and research treatment options for the patients I see. As healthcare professionals we all have the responsibility to keep ourselves well informed for the sake of our patients’ safety and quality of life and this includes educating ourselves on cannabinoid-based medicines.” 

-Andrée Charbonneau, RN, Nurse coordinator

Current available treatments

There is currently no cure for MS however several pharmaceutical treatments exist to control inflammation, manage relapses and concomitant MS symptoms. Disease-modifying therapies alter the course of the disease; they are generally effective for RRMS and early treatment may  be helpful to prevent long-term disability. Symptomatic therapies are used to alleviate specific symptoms, notably neuropathic pain may be treated with antidepressants, antiepileptics and opioids and spasticity may be treated with muscle relaxants. 

General lifestyle recommendations such as exercise and balanced nutrition may also benefit patients.

Cannabinoid-based Medicines in MS 

Research on MS and cannabinoids started over fifteen years ago with a large randomized, placebo-controlled trial on 630 patients with stable multiple sclerosis and muscle spasticity (Zajicek et al. 2003, 2005). Patients were randomized to placebo, oral cannabis extract (THC:CBD), or delta-9-THC, starting with a daily dose of 5 mg to a maximum dose of 25 mg/day of active medication for a total duration of 15 weeks. 

The objective of the study was to ascertain the efficacy of cannabis extract or delta-9-THC for the treatment of spasticity and other MS symptoms. The findings indicated a reduction in patients’ perceptions of the effect of spasticity.  An unexpected secondary outcome result was a reduction of hospital admissions for relapses in both cannabis extract and delta-9-THC groups. Authors mentioned that trial patients had a slowly progressing MS, and since there are cannabinoid receptors on immune system cells, the reduced relapse rate in such an autoimmune condition is a finding that would benefit from further investigation.

Spasticity, pain, bladder dysfunction

Since then, the potential efficacy of cannabinoid-based medicines has been investigated mostly for spasticity, pain and bladder dysfunction symptoms (read more about MS spasticity and cannabinoid treatments here). Cannabinoids, and the endocannabinoid system, have been demonstrated to play a role in reducing spasticity in animal models (Chiurchiù et al. 2018; Baker et al. 2001; Nielsen et al. 2018; Zettl et al. 2016). Delta-9-Tetrahydrocannabinol (THC) appears to be effective in reducing spasticity in animal models and humans (Nielsen et al. 2018).

Systematic Reviews 

Two recent systematic reviews provide details: 

Nielsen and colleagues (2019) reviewed 27 studies and examined spasticity in adult patients with a range of conditions including multiple sclerosis (21 studies). 

• The reviewed studies examined the effect of THC, CBD, THC:CBD formulations, synthetic cannabinoids dronabinol and nabilone, inhaled (smoked) cannabis, and oral cannabinoid extracts. 
• Results were inconsistent between studies identified in the review, with many reporting positive effects on some but not all measures of spasticity and with most positive effects based on patient-rated measures rather than clinician-rated measures.

Nielsen and colleagues (2018), in their review of 11 reviews (32 studies) on MS symptoms and cannabis/cannabinoids, concluded that reviews identified evidence that would support trials of cannabinoids for the treatment of spasticity in patients with MS.

Torres-Moreno and colleagues (2018) reviewed 17 randomized clinical trials to assess the

efficacy and tolerability of cannabinoid-based medicines compared to placebo for symptom

(spasticity, pain, and bladder dysfunction) treatment in patients with MS. 

• The studied experimental interventions were oral cannabis extract; oromucosal cannabis extract/nabiximols; oral dronabinol; and oral nabilone evaluated as an adjunctive treatment to gabapentin (anticonvulsant). 
• Results for the pain symptom showed statistically significant differences in favor of cannabis extract, nabilone, and dronabinol. 
• There were statistically significant differences in favor of cannabis extract and dronabinol vs placebo for bladder dysfunction. 
• Nevertheless, most of the reported therapeutic effects for both symptoms were small. 

Overall, studies demonstrate cannabinoids have therapeutic properties useful for the treatment of some symptoms in MS. Cannabinoid-based medicines, whether plant-based or synthetic appear to improve patients’ perception of spasticity, pain and bladder dysfunction symptoms. Yet this perceived effectiveness is not clearly demonstrated in objective clinicians-based measures. This is both a downside, as it limits the supporting evidence for cannabinoid-based medicines, and an interesting indicator, as patients may be more sensitive to symptom improvement than clinician measuring tools.

Expectations for clinicians

Clinicians should have realistic expectations about cannabinoids’ efficacy, as the therapeutic effects may be small. There are other applications/MS symptoms in which cannabinoids could help (disease-modifying properties, bladder function), but the supporting evidence is mixed.

Research on MS and CBM is a good example of where we can go when we pursue rigorous studies; after several randomized clinical trials the oromucosal formulation of nabiximols was approved in Canada for the indication of spasms in this disease. (GW Pharma Ltd 2012). However, a recent notice from Health Canada stated nabiximols is no longer recognized as neuropathic pain management therapy in MS due to lack of evidence.

As is the case with most medical indications, research on CBMs and MS must continue to further these findings. There are currently very few (two) recruiting phase III clinical trials on multiple sclerosis and cannabinoid-based medicines. 

At Santé Cannabis, our clinicians use the ongoing research findings to provide treatment recommendations for their patients with MS. 

MS at Santé Cannabis

From our most recent database review of 1,275 patients between July 2020 and March 2021, 34 (2.7%) patients had a primary diagnosis of MS, and were aged from 23 to 68 years old (average 49 years). 25 of them (73.5%) identified as women. 

Of these patients with MS, 70% (24 patients) came to Sante Cannabis to evaluate CBM treatment for pain and 15% for spasticity. The others (5 patients) came for sleep disorders, headaches, numbness in legs and muscle rigidity. All patients also experienced secondary symptoms including sleep disturbances (19%), fatigue (18%), anxiety (14%), spasticity (14%), depression (10%), migraines and headaches (6%), stress (4%), nutrition-related issues (3%),  and muscle stiffness (3%). This multiple symptom presentation corroborates the wide spectrum of MS profiles in individuals and confirms patients are looking to alleviate multiple symptoms simultaneously. 

With regards to cannabis use history, most patients were not cannabis-naive: 50% had tried cannabis as a self-attempted medical treatment, 26.5% had tried it recreationally and 14.7% had never tried it.

Almost all patients were authorized with at least one ingested oil extract. 65% of patients were prescribed balanced CBD-THC, as while the literature suggests using THC to manage some MS symptoms, CBD can help to offset some of the side effects of THC.

With the use of our real-world data, our clinic is dedicated to offer better patient care through better science.  

“I have been living with multiple sclerosis for 42 years now. I took all kinds of medications and little by little my doses had to increase and I ended up with very high doses of several medications. I had many side effects and sometimes I felt like a zombie. I was still in a lot of pain and yet I was on the highest doses. That’s when my neurologist told me about a very serious study on medical cannabis and suggested that I participate. So I took a chance despite my apprehensions about cannabis in general… Eventually, …, I was able to both reduce my medication and control my pain. I feel fortunate that my neurologist sent me in this direction. ” Read more from Joanne, a patient at Santé Cannabis here

The combination of formal healthcare professional training and high-quality research is key to increasing the selection of treatments for MS and providing the best patient care.

Join us as we work towards the highest quality treatment for people with multiple sclerosis. Santé Cannabis is committed to advancing the knowledge on MS and CBM, and as such, we offer research services to companies and institutions interested in developing clinical studies. 

For clinicians currently treating people with MS who are interested in adding medical cannabis to their practice, our Preceptorships are available for any local and international physicians. For prescribers in Quebec we also offer a free Training Program more about CBM, and how to prescribe it.

Author

Dr. Lucile Rapin

with special thanks to the Clinical Education Team

Resources

https://mssociety.ca/

https://mssociety.ca/hot-topics/cannabis

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

Most of us have experienced the healthcare system, in times of darkness, stress, confusion, and often, in those dark places we find nurses as a beacon of light. At Santé Cannabis, our nurses are a primary point in our model of care. They’re the first medical professional our patients see, and the ones who stay by their sides through their treatment plans.

Medical cannabis is a journey, and for many patients, it’s one filled with unknowns and pitfalls, and our nurses are expert navigators. Our nurses listen. They get asked the tough, scary and embarrassing questions. They educate. They guide. They advocate. We wouldn’t be anywhere without them.

This year’s National Nursing Week’s theme is “We Answer The Call”, which speaks to the deep calling and commitment that our nurses have for their role in patient care. But during COVID many of these calls are literal – from patients from across Quebec, who are looking to access a treatment from someone who understands, cares and holds the highest level of expertise. Our nurses have shown incredible tenacity and spirit as they shifted from our clinics and into their homes as we began telemedicine last March, and soon back to the clinic. 

Our nurses at Santé Cannabis are a dedicated and diverse group of individuals that are driven by our purpose to positively impact the health of our community. Their compassion and dedication to see improvements in their patient’s lives is demonstrated by the positive feedback that is received from our patients and through the increasing demand of our services. 

Santé Cannabis would like to thank our nurses for their exceptional work and continued dedication to our purpose, not only for this week but every day.

Meet some of our nursing team

Naomie Parrot, Nurse Coordinator

I work at Santé Cannabis to have a unique experience as a nurse in a private practice. I feel valued at work and am challenged every day; with a team that is stimulating and we feel very close to each other. The most significant and rewarding part of my job is accompanying patients in the relief of their symptoms and improving their quality of life. 

We adapt treatment plans to be specific to each patient, and provide them with comprehensive education about medical cannabis as well as support for their treatment. We teach about the different molecules (THC/CBD), indications, side effects, precautions/contraindications as well as titration and administration of the product, allowing patients to be guided in their journey.

I enjoy the progress I’ve made at Santé Cannabis over the years, from nurse, to team lead to coordinator. I found flexibility and a balanced lifestyle working in private practice rather than the hospital. 

I’d also like to introduce Gigi, a little 4lb toy poodle, who arrived at my house during Covid. Telecommuting, I now have a new co-worker who fills my days with even more happiness. She makes a few surprise appearances in some meetings and gives us a good laugh!

Derek English, Research Nurse

I’m passionate about helping people, chronic pain and medical cannabis. I come from a background in orthopaedic surgery where I had experience treating people with all kinds of pain conditions, which helped be more understanding, patient and compassionate. I dealt with many frustrated patients who were not getting what they needed out of the healthcare system and I began to understand that traditional medicine isn’t always the answer for everyone. 

Since joining Sante Cannabis I’ve been fortunate to have many meaningful and amazing experiences, but being able to contribute to many of our patients having a more active life, increasing their overall health-related quality of life has revitalized my enthusiasm for nursing.

Since COVID, I’ve been keeping busy with all sorts of exciting new hobbies, from making yogurt in with the instant pot, and diving into the world of art via blogs, smarthistory youtube channel, and art apps and developing my interest drawing animation.

Tania Pellegrino, Educator/Team Lead

It’s meaningful to me to make an impact in our patients’ wellbeing. I believe that cannabis is a complementary medicine that helps a lot of people suffering from different medical issues. The legalization of cannabis in October of 2018 was really a milestone for us, giving medical cannabis much more credibility and interest. At that point the clinic also got involved in more meaningful research, which allowed us to hire many more employees. It’s been incredible to see this transition and growth.

I’ve always enjoyed making impactful bonds with clients and prior to graduating from nursing I worked in telecommunications in sales for 10 years where I got to make many connections with clients. I continue to make those bonds, with both the clients and the team I work with daily. My team is a great pleasure, and I appreciate the flexibility in our schedules and working from home during the pandemic. 

I’d like to introduce Sophie, my 2 and a half year old French Bulldog. She is great because she is playful, energetic and silly. In addition to everything that makes her great, she unfortunately suffers from anxiety. She is totally dreading my return to the office and staying alone all day – I’ll miss her too, but will be happy to see our clients again in person. 

Isabelle Fournier, Nursing Assistant/Educator

I work at Santé Cannabis to help people. For many, we are the last resort and we often hear from our patients that we have given them back a quality of life that they no longer thought possible. I really enjoy the respect and support within the entire medical team, and think our patients do as well.   

I’ve had many important experiences, but one that stands out for me is a pediatric case, where we were able to work towards the family’s health goals. One day I received a call from the father of the child who explained with tears in his eyes the difference he had experienced. 

I feel I am uniquely qualified to work at Sante Cannabis, as I experienced a work injury that has given me permanent limitations. I live with constant pain, insomnia and anxiety, and so can relate to many of our patients on a personal level. I’ve appreciated the ability to work from home over COVID, and to be able to meet with our patients on telemedicine, as for many of them travelling can be a barrier. I hope that post-COVID the government will continue to fund telemedicine visits, as has been a positive for our patients, many of whom have told me about reduced anxiety with their visits. 

Words of appreciation 

Vi Dam, RN, Director of Clinical Education

I am so happy to be celebrating our nursing team this week! Nurses and auxiliary nurses at Santé Cannabis play such a vital role in our operations and their actions stretch across all departments, they are really our essential workers! For me, particularly this past year with the pandemic, they have really embodied totally and absolutely what it is to be a nurse. 

I cannot express the immense appreciation I have for our nursing team; and for nursing coordinators who take on so much and have marked themselves as true leaders. They showed professionalism and adaptability when we needed to switch to virtual consultations. It was not an easy task, and they were a true support for our physician colleagues as well as for our patients. 

We put in them our trust and rely on their empathy, compassion and skills as advocates and communicators for our patients and for medical cannabis as a treatment. I couldn’t be prouder of the team we have put together. Happy Nursing Week 2021!

Erin Prosk, President

We wanted to take time to emphasize our respect and appreciation for the individual and team contribution that our nurses make to Santé Cannabis and to the thousands of patients who have benefited from the care, compassion and informed education that they provide. Our nurse team is the backbone of Santé Cannabis, from each individual patient consultation to the critical role that they play in the medical community to support the thousands of referring doctors and nurses across Quebec who trust our team. I can say emphatically that I am in awe of your work on a daily basis.

Please know that from myself and our entire team, we have this appreciation in all weeks, not just this one. Wishing you a great week!

Michael Dworkind, MD, Medical Director

I know that it goes without saying that I appreciate our nursing team immensely, on this week and every week, every day and sometimes every minute for all of the support and expertise that they provide to me and the other doctors to provide excellent care to our patients. I feel so privileged to work in their company and with such passion together towards our important purpose. 

I hope each nurse feels proud of their contribution and their medical cannabis leadership for all nurses and auxiliary nurses across Quebec.

Thank you to all our nurses from all of us. 

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

In Quebec, whether one is for or against its therapeutic use, medical cannabis is now one more tool in the modern pharmacopoeia. We believe that it is now essential to recognize the multidisciplinarity of the stakeholders involved in medical cannabis treatments, whether it is in relation to authorization, services and care provided to patients or in relation to research. More importantly, we want to bring these stakeholders together to discuss the integration of this additional tool into clinical practice in Quebec. 

This conference aimed to provide a better understanding of some of the challenges surrounding medical cannabis and to offer resources, including our training program, to overcome these challenges and increase general medical cannabis knowledge. 

We hold this event every year because we believe that medical cannabis is an essential service that must be free of stigma and integrated into medical practice. By hosting we hope to bring together the diverse perspectives of our presenters and audience to encourage innovative medical cannabis patient care, and do so by expanding on the learning beyond each participant’s specialization.

Highlights from the talks:

If you weren’t able to attend we’re excited to share some of the highlights that our staff shared from each of the talks. 

Lack of knowledge of the endocannabinoid system: An important obstacle to overcome

Vi Dam, RN, MSc

Ms. Dam’s presentation was highlighted by a patient testimony that was very powerful and touched other presenters as well as attendees. It showed how complex and difficult it is for patients to find the right treatment and highlighted the lack of healthcare professional training and support for patients for whom conventional treatments do not work. It reminded us why we do what we do and how essential our services are. 

Testimony of a specialized nurse practitioner

Isabelle Têtu, IPS, MSc

Ms. Têtu has noted the number of patients asking about medical cannabis in her clinical practice is increasing, but inadequate training for healthcare professionals have left many professionals unable to support their patients with the answers to the questions they have. 

PANEL: Integrating medical cannabis into your clinical practice: From novice to experienced physicians

Dr. Naïla Debache, MD, Dr. Jérôme Lopez, MD and Dr. Viviane Hoduc MD

All three of these inspiring doctors took different paths leading them to integrate medical cannabis to their routine practice. At first, it was a frustrating trial-and-error, learn-as-you-go method to learn about medical cannabis, and we are proud that Santé Cannabis was the resource that helped them overcome this challenge through our clinical experience. 

“Cannabis is illegal in France, and I arrived here with apprehensions […] I started learning about it, thinking that I would maybe have patients using cannabis for recreational purposes. I wanted to be ready to meet problems related to this. So I collected information, in the end mostly about medical cannabis.” (our translation) – Dr Lopez

He expanded about how his training and investigation changed his mind, and he now considers medical cannabis as part of his routine practice.

Cannabinoid Titration and Opioid Tapering in Patients with Chronic Pain – a consensus-based algorithm

Dr. Jordi Perez-Martinez

Dr. Perez’s presentation was very interesting and pertinent for clinical practice, especially considering the current opioid crisis. He presented an algorithm for cannabinoid titration and opioid tapering in patients with chronic pain that has been built as many chronic pain specialists reached a consensus.This algorithm brings hope that more algorithms and clinical guidelines can be developed, even without a conclusive medical cannabis consensus in the general medical community. 

About the important question, “are there age limits with this algorithm?”:

“We always start with the notion that the use of THC in young patients with a developing brain is probably not a good candidate. But we can’t forget that these are patients who are already taking opiates and we know that opiates have a negative effect on cognitive development.” Dr. Perez-Martinez

There remains a need for rigorous research, and a broader consensus must be reached before medical cannabis for pain management will be implemented everywhere. 

Workshop: Should cannabinoid-based treatments be maintained in the medical field?

Dr. Charles Sun

Cannabis is a unique medicine, as there are currently two access points to this substance: for medical purposes through the medical cannabis program, and for non-medical use through the retail points of the SQDC. Dr. Sun asked the audience about their opinions on maintaining two separate programs, and what might be reasons for or against.

 We were pleasantly surprised to see that almost every person who responded said they believe that a seperate medical cannabis program should exist outside of the non-medical program. Dr. Sun asked them to expand on their reasoning and the answers collected from the different questions provided food for thought:

• A large number of responders agreed that some of the disadvantages of the medical cannabis program are related to the complexity of the system and prescription process. Indeed, the medical cannabis program is far from perfect, but hopefully these disadvantages can be minimized in the future as the regulations evolve.
• There was a great consensus on the importance of patient medical assessment by healthcare professionals prior to medical cannabis treatment, in order to limit potential harms: 96% of responders chose this reason concerning the need for a seperate medical cannabis program.

Panel: medical cannabis use and management issues in different healthcare facilities in Quebec: the pharmacist’s perspective

Sarah Girard, pharmD M.Sc., Philippe Arbour, BPharm MSc and Andrée Néron, BPharm DPH FOP

The panel composed of three pharmacists was extremely interesting as they shared their challenges with medical cannabis in their practices. They are trying to work within a system where they are traditionally seen as experts on the medicine, but find themselves at a loss when asked by their patients and colleagues about cannabis treatments. 

A particular friction point they brought forward was how difficult and tedious it is to obtain complete patient drug information, as medical cannabis is not included in the usual drug list that patients bring. Furthermore, patients do not always think of informing their pharmacist that they take cannabis, be it for medical or non-medical purposes – highlighting the need for pharmacists to update their questionnaires to include cannabis as well as recreational substances like alcohol.

Legal Issues and Patient Education

Max Silverman, LL. B and Naomie Parrot, RN, BSc

For medical cannabis patients, not only do they have to concern themselves with the understanding of their medication, but also with understanding complex laws surrounding cannabis. Our nurse Naomie Parrot covered some of the medical side of education, while Mr. Silverman, a lawyer engaged in litigation for human rights, covered some of the current legal consequences for medical cannabis patients, highlighting some of the regulations that are incomplete or missing. 

For example, there are contradicting and unclear laws between federal and provincial levels as to workplace accommodations. An employee cannot be terminated for using medical cannabis, yet the same employee could be terminated because of medical cannabis side-effects impacting their ability to accomplish their work. It is an issue that is especially worrying if the workplace is resistant against medical cannabis use, and patients’ rights are on the line. Mr. Silverman ended the day with a call to action for all of us – some things need to change, and it’s up to each of us to make a difference.

Conclusion

We were thrilled by the attendance of so many Quebec healthcare providers, patient advocates and organizations, and industry representatives who came to learn about the current state and future of medical cannabis in Quebec. Our speakers brought their expertise, passion and new ideas and for that we are very grateful.

We look forward to hosting our next event in May – this one focusing on international research innovations to improve patient care; and to many more years of our Conferences on Cannabinoid Medicines. Will we see you there?

Authors: Charlotte Bastin, Andrée Charbonneau

Join us at our next event

Quebec Cannabis Forum: Moving Towards a Comprehensive Approach to Public Health

8:00-5:00 pm EDT May 18th, 2022
Scena, Montreal
(EVENT IN FRENCH)

Register here

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.