Tampa, Fla.—As more state legislatures consider joining the District of Columbia and the 22 states that have authorized medical marijuana, a new organization is seeking to position pharmacists as the professionals most qualified to help bring a more standardized and safer approach to cannabinoid therapy.
The goal of the new organization, called the National Association of Cannabis Pharmacy (NACP), is “to create a unified voice for all stakeholders in cannabis-based medicine who believe that the science needs to be developed and the stigma needs to be removed from this modality,” James E. Smeeding, RPh, MBA, a board member of NACP, told Pharmacy Practice News. “We think pharmacists are the appropriate dispensers to help protect patients and make sure they get the best benefit and value from cannabis-based medicine.”
NACP also aims to provide the means to track outcomes of patients taking medical marijuana and the metrics to convert those outcomes into real-world data that can be used to determine the safety and efficacy of products that are available or coming into the market, noted Mr. Smeeding, who announced the formation of NACP at the National Association of Specialty Pharmacy (NASP) 2014 Specialty Pharmacy Expo. Additionally, the association plans to offer educational products and an accreditation pathway, according to Mr. Smeeding, NASP’s executive director.
In some states, pharmacists already are on board. In Connecticut, for example, new regulations require pharmacists’ oversight and staffing at six new state-approved medical marijuana dispensaries. Nicholas Tamborrino, PharmD, is setting up a new ground-floor dispensing facility, called BluePoint Apothecary & Wellness, in a Branford, Conn., industrial park that is home to other medical offices. It is scheduled to open in August.
Mr. Tamborrino recently worked at Yale-New Haven Health System, where he oversaw information technology training for the system’s five hospitals. BluePoint Apothecary is an independent venture that he owns and manages. He said he has hired another full-time pharmacist, Colleen Higgins, RPh, who specializes in alternative medicines, to help dispense cannabis-based compounds and counsel patients. “We’ll implement our own medication therapy management service based on patients’ medication history, condition and medical marijuana requirements,” Mr. Tamborrino said.
BluePoint, he said, will be offering marijuana-containing products supplied by state growers approved by the Connecticut Department of Consumer Protection. “I’m trying to emphasize a medical office-type setting where patients get used to making appointments,” Mr. Tamborrino said. “This way I can set aside the appropriate time for each patient and make sure their medicine is in stock.”
In Chicago, Joseph Friedman, RPh, a compounding pharmacist at Mark Drugs, is scouting surrounding communities to find an appropriate location for a medical marijuana dispensary. It will be one of 60 facilities scattered throughout Illinois that have been authorized to distribute limited amounts of physician-approved medical marijuana to patients with cancer, HIV, multiple sclerosis and other serious illnesses, under a four-year pilot program that began in January.
The search has encountered resistance in some communities. “We want to work with a municipality that wants to work with us,” Mr. Friedman said. “This is going to be very important as we submit our applications.”
In Colorado, a “makeshift sort of cleanroom” contains homegrown marijuana plants. Caregiver Max Sherwood extracts active cannabinoids from the plants’ flowers and then compounds them into tinctures for patients with HIV and other chronic conditions.
The reluctance of financial institutions to deal with businesses that dispense a product that is illegal under federal law has been another challenge for medical marijuana dispensaries. Many have been forced to deal only in cash because banks won’t open business accounts for them. Mathew Sherwood, a licensed marijuana grower and patient caregiver in Colorado, said the cash-only status “has created a dangerous situation where you have a sought-after substance and large amounts of cash” on hand, inviting theft.
Marijuana’s status as a federal Schedule I controlled substance also has had a dampening effect on the participation of many pharmacists, who are concerned about jeopardizing their licenses, said Lawrence J. Cohen, PharmD, BCPP, a professor of pharmacotherapy at the University of North Texas System College of Pharmacy, in Fort Worth.
Still, Dr. Cohen said that he believes that with pharmacists’ unique knowledge, they could offer significant benefits to patients who require cannabinoid therapy. “I think we are in the best position and could contribute significantly in developing the materials to help people understand the risks and benefits” of medical marijuana, he said.
Mr. Sherwood, who is not a pharmacist, agreed. He has spent the past eight years helping patients cope with severe conditions, ranging from multiple myeloma to HIV to relapsing-remitting multiple sclerosis.
In a “makeshift sort of cleanroom” in his home, he said, he extracts active cannabinoid ingredients from the flowers of his homegrown marijuana plants (photos) and compounds them into tinctures using propylene glycol. The solution is then vaporized and inhaled through electronic cigarettes. “Dosages are not the same for all patients,” he noted, so he has them start low and then titrate up to an effective dose.
“I’ve seen it have unbelievable effects,” he said. “But I don’t feel like it should be my job. The skill set that I am using, the things I had to learn—these are things that are in a pharmacist’s wheelhouse.”
Movement Into Health Systems
Although American Society of Health-System Pharmacists (ASHP) policy opposes “the procurement, storage, preparation or distribution of medical marijuana by licensed pharmacies or health care facilities for purposes other than research,” it encourages “continuing education that prepares pharmacists to respond to patient and clinician questions about the therapeutic and legal issues surrounding medical marijuana use.”
Cynthia Reilly, RPh, the director of ASHP’s Medication Safety and Quality Division, noted that ASHP’s stance is based on “licensing implications that could result from the conflict between state and federal laws.” Ms. Reilly added that even if pharmacists are not involved in dispensing medical marijuana, they are “probably caring for patients who are using these products.” She said that ASHP has been providing education to its members because of the need for knowledge about how cannabis-based medicines can interact with other patient therapies.
Health-system pharmacies in New York may find themselves involved in the delivery of medical marijuana therapy under a new plan to allow 20 hospitals around the state to make medical marijuana available to patients. At least 10 hospitals have expressed interest.
“The day that was announced, we started getting requests from hospital pharmacists in New York about model rule policies and procedures,” Mr. Smeeding said. “Additionally, there is no surprise that by bringing [medical marijuana] into the hospital—which in many ways becomes a hub for the community—it would be the pharmacy that ended up figuring out how to manage that forward. I think that is a challenge but also an opportunity.”
Mr. Friedman said he has been working with a Chicago hospital that is interested in opening a medical marijuana dispensary but is concerned about jeopardizing its Medicare and Medicaid reimbursements. He noted that health systems in New York likely have similar concerns.
Where’s the Data?
There is universal agreement that more medical marijuana research is needed. “About 500 different strains have been identified that have different effects, containing more than 100 cannabinoids,” Dr. Cohen said. “And they all don’t cause profound sedation, for example, or have any kind of euphoria effect. Some are very targeted and have a positive effect on nausea, reducing pain or inflammation.”
Dr. Cohen said he hasn’t found any research that fully explains why specific strains of marijuana have such differing pharmacology. “And the reason why controlled research isn’t being done is because of the stigma—the view that this is an abusive substance and often a key ‘target’ of the ‘War on Drugs.’ I don’t believe that medical marijuana is always an abusive substance. Each patient’s medical conditions, health status and quality of life should be considered before discarding this as a truly viable treatment option for patients in need.”
Mr. Sherwood noted that legislatively, medical marijuana is a “giant gray area, but, in my opinion, if somebody walked out of the Amazon [rainforest] with this plant right now, they would absolutely win an award. It would be something that every pharma company would be studying—pulling molecules apart and doing research on them.”