Can Medical Cannabis Dispensaries Be Saved in Canada?

Medical dispensaries in Canada have served a valuable role in securing patient access to high-quality cannabis over the past several decades, filling the gaps in access to Health Canada’s medical cannabis program. However, recent legislative changes
have excluded dispensaries from the federal regulatory framework for medical cannabis, despite the important role they have played in providing access and the high levels of utilization by patients.

Before recent policy changes, the key barriers to legal medical cannabis access included physician support for required documentation, affordability, and availability of strains and products.1 An article published in 2017, entitled Are Dispensaries Indispensable?, concluded that based on the strong endorsement of dispensaries by patients, future regulations should consider including dispensaries as a legal source of medical cannabis.2 In 2018, new legislation in Canada legalizing cannabis for nonmedical purposes included provisions for storefront sales of nonmedical cannabis.3 However, such provisions were not extended to the medical cannabis program, and dispensaries remain an unauthorized source.

Since the legalization of cannabis for nonmedical purposes in Canada, the number of medical dispensaries has dwindled considerably, and it is unclear how long these dispensaries will be tolerated. It is also yet to be determined how the barriers to accessing legal medical cannabis have been impacted by the recent legislative changes. The question is: Are dispensaries still indispensable, and if so, can they be saved?

The Federal Medical Cannabis Program

Under the current medical cannabis regulations in Canada, patients who have authorization from their health care practitioner can legally access cannabis online through a federally licensed cannabis producer or through personal/designated cultivation.4 Currently, there is no legal storefront option for patients seeking
medical cannabis in Canada.

A 2019 population survey found that only 23% of medical users were accessing cannabis from licensed producers in the federal medical cannabis program.5 Despite
physician associations issuing statements suggesting that with the legalization of
nonmedical cannabis there is no longer a need for a separate medical stream, the
number of health care practitioners providing documents for patients to register with
a licensed producer has increased steadily.6 As of September 2019, there were 369,614 actively registered clients in the medical
cannabis program.7

Although there has been a steady increase in the number of people registered in the program since its inception, after the legalization of nonmedical cannabis in October 2018, the sales of dried cannabis in the medical stream has dropped substantially.7
Potential reasons for the decrease in legal medical sales follow:

• An increase in the cost of medical cannabis resulting from a new excise tax that was applied to cannabis produced in both the medical and nonmedical streams may have led patients to seek cannabis outside the program, including from unregulated sources that have comparatively lower prices.8,9 These elevated costs also may have led to an increase in personal and designated production within the program.7 Some insurance companies have started to include cannabis in their drug plans, and patients are advocating for cost coverage from provincial health insurance plans. Additionally, some licensed producers are offering discounted priced on their medical lines.

• A new legal storefront retail source in the nonmedical stream, although not less costly, may be preferable to some patients than the option of mail order provided through the medical stream.

• Shortages of cannabis in the medical stream, possibly due to diversion to
the nonmedical stream, may have led patients to use other legal and illegal
sources.10

An additional legal source of medical cannabis has recently become available through the large pharmacy chain Shoppers Drug Mart, which was recently licensed by Health Canada to sell medical cannabis online to residents of Canada.11 The retail chain offers telemedicine consultations to receive authorization for medical cannabis use. One benefit of this source is the ability of patients to access products from various licensed producers from one source; this previously required the patient to order separately from each producer and to obtain separate documentation from their health care practitioner for each order.

This new source of medical cannabis also will offer pharmacist oversight regarding drug interactions, which is not available with online mail order directly from licensed producers. Some skepticism has been voiced about the ability of pharmacists to provide this oversight and support with their current knowledge base.12 It is yet to be seen how this source might impact the support of health care practitioners, cost, and the sales of cannabis within the medical stream.13

It is possible that clinicians’ comfort with medical cannabis may grow with the inclusion of pharmacies as a source of cannabis, as well as with the recent additional of new cannabis products in the program.14 Additionally, the legalization of nonmedical cannabis has resulted in more public and private funding for cannabis research, which also may increase the comfort of health care practitioners with use of this medicine. To address gaps in clinicians’ knowledge, which has been a barrier to their participation in the program, it is vital to provide education about cannabis and
the endocannabinoid system within school medical curricula.15

Medical Access From Legal Nonmedical Retailers
Under the Cannabis Act of 2018, cannabis for nonmedical purposes is legally available to adults in Canada (18 or 19 years of age depending on province/territory) from provincially licensed public and private retailers, including online and storefront sales (the specific retail options vary by province/territory).13

Although staff at nonmedical retail stores are not permitted to discuss medical efficacy or medical use of cannabis with customers, there is nothing preventing individuals from using the cannabis they purchase from these stores for medical purposes. Many medical cannabis users indeed do access cannabis from these legal
nonmedical retailers. Data from a large population survey indicate that in 2019, whether registered in the federal medical program or not, 29% of medical cannabis users were accessing cannabis from legal nonmedical retail storefronts.5

The number of individuals accessing cannabis for medical use from nonmedical retailers may increase as more retail stores are licensed across the country, particularly in the highly populated provinces of British Columbia and Ontario, which both have experienced a slow rollout of their retail licensing programs.13 The addition of new cannabis products, including edibles and concentrates, which became legal at the end of 2019, may result in even higher numbers of medical patients
accessing nonmedical retailers.14

Notably, health and wellness are among the top reasons why Canadian consumers use recreational cannabis post-legalization, according to a recent survey.16
In fact, according to that survey, the motivation to use cannabis as a health/medical product rose from 32% to 42% between the first quarter of 2018 and the first quarter of 2019. As the use of cannabis for medical purposes is increasing, it must be considered whether nonmedical stores are the ideal source for medical cannabis. Individuals accessing cannabis from the nonmedical stream will not have the benefit of physician oversight when taking cannabis for medical purposes and will not have a clinician monitoring for drug–drug interactions. They also will not have support
from retail staff for the selection of strains and products to address their symptoms and conditions.

Where Does This Leave Dispensaries and Patients?
Dispensaries have been one of most highly accessed and highly rated source of medical cannabis in Canada. A study of Canadian patients using cannabis for medical purposes in 2011–2012 found that only 7% of patients authorized to use medical cannabis under the federal program exclusively accessed cannabis from legal sources available at the time,1 with as many as 80% obtaining cannabis from medical dispensaries.17 Another study demonstrated the high ratings given to dispensaries, with dispensaries being rated equally to or more favorably than other sources
of cannabis, both legal and illegal, for quality, safety, availability, efficiency, and feeling respected; they were rated less favorably than self-production and accessing from other producers in terms of cost.2

Before the legalization of recreational cannabis in Canada, unregulated dispensaries flourished across the country, particularly in major cities. Although illegal, the activities of these dispensaries were tolerated in several major cities and smaller municipalities across the country in recognition of the shortcomings of the
federal government’s medical cannabis program.In 2016, approximately 175 dispensaries were serving an estimated 100,000 to 200,000 clients.18,19

However, since the 2018 legalization of nonmedical cannabis, very few dispensaries have remained open. Most of the dispensaries have either transitioned to licensed nonmedical retailers or have shut down by choice or by force.20 The provinces and territories, which regulate sales of nonmedical cannabis, no longer tolerate these dispensaries operating without a license and selling unregulated product regardless of whether the needs of patients are being met through the medical or nonmedical legal channels.21

Thus, in the context of legal nonmedical cannabis, it has become even more challenging for unregulated medical cannabis dispensaries to operate. The closure of these shops is reflected in the substantial drop in the use of dispensaries by
medical cannabis users in the general population from 28% in 2018 pre-legalization, to 12% in 2019 post-legalization.5,22 It is unknown to what degree patient needs are currently met through the legal medical and nonmedical sources, or through
illegal sources.

The loss of this source of cannabis may disproportionately impact some medical cannabis users. Previous research found differences in patient demographic and use patterns between people using storefront dispensaries and those using other sources.2 For example, individuals using storefront dispensaries were found to
be older than patients who used other sources. In terms of patterns of use, patients using dispensaries purchased larger quantities of cannabis and placed a higher value on access to specific strains than patients obtaining cannabis elsewhere. It is possible that the new legal sources may address the needs of some of these individuals.

Some of the few remaining strictly medical dispensaries are attempting to find avenues to continue providing the products and services that patients have valued for the past 2 decades. One of first dispensaries in Canada has garnered the support of its municipal government to petition the British Columbia provincial government to grant it a temporary exemption from the province’s Cannabis Control and Licensing Act,23 so it can continue providing “responsible access and a safe, welcoming community space for medical cannabis users.”24 It is unclear whether this dispensary, or the other remaining medical dispensaries, will continue to be tolerated until such a time when there are provisions for legal storefront retail for medical access.

Lessons From Canada: The Impact of Nonmedical Cannabis Regulation

An unintended consequence of nonmedical cannabis regulation may be that the needs of medical patients are overlooked. If the price of medical cannabis is too high, or products are not earmarked for the medical stream, patients will forego using the legal medical sources and will seek recreational or illegal sources. A review of the medical program is scheduled to take place within 5 years of the enactment of the 2018 Cannabis Act.25 It will be vital to assess the impact of the new medical and nonmedical sources of cannabis on patient access and whether patient needs
are being met through current legal channels. It is unclear what the outcome of that review will be, and how long it will take to implement any changes. It remains to be seen whether storefront access will finally be included in the legal medical stream, and, in the meantime, if dispensaries will continue to fill the gaps in this new regulatory climate.


References

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