In Utah, a pharmacist is required to be in the cannabis pharmacies during business hours. Each patient new to the medical cannabis program is required to have a one time pharmacist consultation. Pharmacists educate and answer questions as a free service to patients. All of the pharmacists interviewed can tell stories that would bring a tear to a person’s eye because many people with debilitating conditions are finding success through cannabis as a medicine.
The cannabis industry agrees that pharmacist consultations have been a great benefit to many. We spend years learning about dosing, drug delivery and dosage forms. Pharmacists, including myself, are now transitioning this knowledge to help patients discover how to best use cannabis, which is a natural and welcomed transition to many pharmacists. We are trained to manage complicated medication profiles by screening for drug interactions, duplication of therapy, and improper dosing. We empower patients to learn how to select products, safely medicate with cannabis, limit side effects, and manage tolerance. Pharmacists also have the legal responsibility of ensuring compliance with Utah cannabis law.
New cannabis laws and rules
According to new rules passed in Senate Bill 192, pharmacists will now review each medical cannabis transaction before dispensing in accordance with pharmacy practice standards. The Utah Health Department has also interpreted recommendations from providers to be binding, meaning the pharmacy and patient are both forced to follow these recommendations exactly. A binding recommendation is essentially an order or a prescription. So why do our laws use the word recommendation instead of prescription? Because it is not federally legal for providers to prescribe or order cannabis. The First Amendment right to free speech does allow providers to suggest or recommend cannabis and this is the foundation for all state medical cannabis programs.
Senator Evan Vickers, the sponsor of Senate Bill 192, agrees. “We do not want our program to follow a prescription model. I recognize that medical cannabis is a recommendation model as per the way the federal law has allowed medical cannabis to move forward,” he said.
Dispensing and prescribing cannabis also violate state laws such as the Utah Controlled Substance Act that places medical providers and pharmacists that work in cannabis at legal risk. Prescribing and dispensing cannabis also expose them to liability issues in an environment where it is nearly impossible to get cannabis malpractice insurance. Not only can our lawmakers not use the word prescribe, the Health Department should avoid implementing rules that create a program that mimics prescribing. Unfortunately, this is exactly what’s happening now in Utah. Why is the Health Department designing a medical cannabis program that places our providers at legal risk? That’s a good question.
The Health Department has told me that lawmakers intent is that cannabis pharmacies operate like a retail pharmacy where cannabis is dispensed like any other controlled substance. Their vision is a program where a medical provider recommends cannabis as a specific product or dosage form and the pharmacy dispenses exactly what’s recommended with specific directions of use on the label.
State leaders look to Connecticut and Minnesota as examples of states that use pharmacists in their medical cannabis programs. To better understand how other states are utilizing pharmacists, I reached out to a few people working in those states.
“Patients in Connecticut have the right to choose all products, dosing and delivery methods themselves,” said Connecticut Pharmacist Brian Essenter.
Melanie Kane, Minnesota Pharmacist and President/Co-Founder of the International Society of Cannabis Pharmacists, added that, “Minnesota doctors have no role in the selection of cannabis dose, ratio, or route of administration. Doing so would risk their DEA license.”
No other state operates a program that treats cannabis as a prescription like Utah is attempting.
The problem with low cannabis limits
Part of the design of our current cannabis program is the medical provider sets limits based on their recommendations. Rigid dosing is not recommended to calculate limits and currently there are no tests a doctor can perform to determine how much cannabis each patient will require. Some patients have a lower endocannabinoid tone or higher tolerance and require a much larger dosage. How exactly are medical providers selecting these limits? Cannabis dosing requires trial and error because effects vary for each individual with different dosage forms and chemovars. Patients need to try multiple products until they find their ideal medicine. Limits are of course necessary to prevent diversion, which is why there are state limits. Pharmacists honor any restrictions from medical providers but often these limits seem arbitrary and only in place because they believe the health department wants to see them. It’s more common that strict limits interfere with patient success than actually keeping patients safe. I encourage people to look up their limits on the EVS website and ask their medical provider to increase them if they feel they are so low they won’t allow people to medicate properly.
Patients should have the right to select their dose and dosage form
“Ideal cannabis dosing requires continuous patient adjustment in dose and dosage form. Under my guidance I empower my patients to make their own decisions that lead to the best outcomes,” said Utah physician and experienced cannabis educator, Corey Anden.
Cannabis experts agree there are no rigid dosing guidelines and patient involvement in product selection and dosing is the proper way to medicate. Healthcare providers across the country are finally starting to seek to involve and empower patients in their treatment plans yet Utah is moving in the opposite direction for their medical cannabis patients. Cannabis is not the best fit for everyone, but once you have a medical recommendation you should have the autonomy to select your cannabis product. I have asked the health department, medical providers, and many pharmacists to describe a situation where a patient was harmed because they purchased a product not recommended by their provider. I have yet to hear a single example.
The increased costs of more regulation and more pharmacists may translate to higher prices and lower quality of care.
Recent legislative changes could result in pharmacies needing 3-4 pharmacists at all times to follow requirements that a pharmacist review each transaction and provide patient consultations. Pharmacists are important in our program but let’s keep them doing what every single pharmacist I interviewed told me is their most important job…patient consultations. This increase in labor costs will likely continue to keep prices high for patients. Sadly just a few weeks into these changes and I have already seen a decline in pharmacists available for consultations, shorter pharmacist consultations, a delay in new pharmacies opening, and longer wait times. Every single pharmacist and pharmacy operator I interviewed agreed.
My vision for the ideal Utah medical cannabis program
I am proud of the program Utah has created.
That is why I am so passionate about advocating for it’s best version. I envision a program where the medical provider visits with the patient to educate and decide if medical cannabis is recommended. Then the patient visits the pharmacy where they receive an initial pharmacist consultation. The pharmacist should always be available to answer questions during operating hours. For most pharmacies, this may require a pharmacist consulting new patients in a private room to comply with HIPAA privacy laws plus another pharmacist answering follow-up questions at the register where the agent completing the purchase can ask each customer if they have questions for a pharmacist. Each pharmacy should have a pharmacist available via phone call, chat or email for follow-up questions.
I trust that patients can select their own products and agents can properly scan the barcode to sell them products. There is no need for a pharmacist to double-check each transaction. If the state wants to audit something, I’d encourage them to audit pharmacist availability to patients. If the state wants more pharmacist involvement, I’d encourage them to require pharmacies to offer follow-up consultations. In my opinion, it is not appropriate or legal for the pharmacists to force patients to follow specific orders from a medical provider for a schedule one substance like cannabis. The provider can review purchase history at any time and at follow-up visits they can decide if they wish to renew the recommendation. We need to start treating our patients as adults rather than criminals. Instead of focusing on the image of our program we should focus on how we can get the best patient outcomes. I would encourage everyone involved in this industry to consider the needs of the patients over politics, money, and personal or professional interests.
How can you help fight for safe and legal access?
I have seen frustrated pharmacists and pharmacy operators challenging these new changes for months and they are working hard fighting for your right to safe and legal access. Patients can help us pressure lawmakers and the health department to support patient autonomy in cannabis dosing and product selection like other states. The excessive enforcement that our lawmakers are striving for will bring unnecessary barriers to the medical patients of Utah. Whatever harm they are trying to prevent with these rule changes is nothing in comparison to the harm that comes from an overly restrictive program that denies patients the best treatments for their medical conditions.
Mindy Madeo is a medical cannabis patient and Utah pharmacist pursuing a Medical Cannabis Science and Therapeutics Masters degree from the University of Maryland College of Pharmacy. She currently carries the role as Lead Pharmacist for Beehive Farmacy in Brigham City, Utah.
