Jul 08, 2019
Medical cannabis in Canada since legalization
- Legalization of cannabis has posed some challenges, including patients accessing medical cannabis through the recreational market and limited supply of some cannabis products.
- Harmonization of national, provincial/territorial and institutional policies related to medical cannabis is needed to ensure there is appropriate and equitable access to cannabis for therapeutic purposes for all patients.
- The role of nurses in providing care to patients using cannabis is increasingly recognized; nurses must stay current as new evidence emerges and advocate for appropriate education and policies to provide safe and informed care.
Last October, after months of public consultation and debate, Canada joined Uruguay and many US states in legalizing recreational cannabis with the proclamation of the Cannabis Act. This federal legislation grants Canadians legal access to recreational cannabis and controls how it is produced, distributed, and sold across the country. The regulations that accompany the Act provide details on how both recreational and medical cannabis can be accessed, purchased, and used. The overall aim was to streamline the control of recreational and medical cannabis in Canada and protect the public from the harms posed by the illegal market and interactions with the justice system. This significant shift in cannabis policy, from my perspective, has had some growing pains and caused some challenges for both patients and health professionals.
What has not changed is that Canadians who have a health condition for which cannabis is indicated can, with the support of a physician or nurse practitioner, register with one of more than 100 licensed producers to receive a 30-day supply of cannabis sent via courier to their home. They may also continue to choose from a broad variety of products, including fresh and dried cannabis, seeds, extracts and oils, and topical products. Edibles, despite their ready availability in the illegal market, will not become legal until the end of 2019.
Patients buying cannabis without authorization
Since legalization, patients can now purchase cannabis for therapeutic purposes directly from retail stores and websites without the need to register with a licensed producer and provide medical documentation. While this may seem, on the surface, to streamline access to medical cannabis, it has led some patients to purchase recreational cannabis for therapeutic reasons without first consulting a health professional. As the evidence grows on the health effects of cannabis, so too has research on the number of medical conditions for which cannabis is contraindicated, as well as medications for which there are known interactions with select cannabinoids (for example, coumadin and cannabidiol, or CBD). Many individuals, including health professionals, are also unaware that recreational cannabis may have levels of microbial or chemical contamination that can be problematic for some patients, such as those with a compromised immune system. Additionally, without the oversight of a health professional, a growing number of patients are trying to figure out on their own the type of cannabis, formulation, and dose that is most appropriate and safe for their health condition. This is not how medical cannabis should be provided.
Logistical issues have also surfaced following the legalization of cannabis. First are the supply issues, with many licensed producers across the country reporting shortages within the medical and recreational markets, especially for cannabis products high in CBD. This may have been a result of stockpiling by consumers, as well as lack of initial supply. I have also heard that the excise tax of $1 per gram on both medical and recreational cannabis has made legal cannabis products unaffordable for many patients, especially those living on a long-term disability allowance. Some of these individuals may return to the illegal market for affordable cannabis, potentially exposing them not only to criminal activity but to products that may be contaminated with dangerous pesticides, herbicides, and controlled substances. For those purchasing medical cannabis within the recreational market, the inability to claim such purchases on their health insurance or personal income tax has also been challenging.
One of the bright sides of the new regulations, however, is that patients can now easily move their registration between licensed producers or even split it among several producers, allowing more flexibility and easier access to medical cannabis products.
Confusion around regulations
For nurses, much confusion and hesitancy still exist regarding the authorization, distribution, and administration of medical cannabis under the new cannabis regulations. Although nurse practitioners (NPs) are allowed federally to provide a medical document to a patient who is under their care and requires cannabis, a big caveat is that NPs must not be restricted in their province or territory from authorizing medical cannabis. At the present time, British Columbia, Alberta, and Québec lack policies allowing NPs to authorize medical cannabis—despite the fact that all NPs in Canada now have the authority to prescribe controlled substances, such as opioids. With the continued hesitancy of many physicians in Canada to authorize cannabis, NPs may be some patients’ only hope in gaining legal access to medical cannabis, together with the necessary consultation and follow-up care. From my perspective, nursing regulatory bodies in Canada should thus ensure that NPs are not being unduly restricted, and advocate for the necessary education and training to expand their scope of practice related to cannabis.
The lack of harmonization across federal, provincial/territorial, and institutional policies regarding where medical cannabis can and cannot be used, and who is allowed to help patients in using cannabis, has further contributed to the confusion. Despite federal legislation allowing medical cannabis to be used in a hospital setting or public place, the definition of “hospital” or “public area” may differ across jurisdictions. Further, many hospitals, care facilities, and agencies have prohibited cannabis use by patients or limited nurses from engaging in certain activities, such as the direct administration of medical cannabis. This has meant that patients are unable to use a therapeutic agent that they have been authorized to use, and nurses have had their hands tied in providing patients access to medical cannabis. I encourage nurses to advocate for patients’ right to access cannabis, no matter where they are receiving care, and to work with local governments and institutions to ensure that medical cannabis does not get lumped in with policies aimed at controlling public use of recreational cannabis. Nurses should also encourage their regulatory body to create policies that align with federal regulations and support them in practising to their full scope so that no patient is denied the use of authorized medical cannabis.
Role of nursing being recognized
The good news is that with the passage of the Cannabis Act, there has been growing recognition of the role of nurses and other health professionals in providing care to patients using cannabis. This recognition has increased educational initiatives aimed at improving health professionals’ knowledge about recreational and medical cannabis, although some undergraduate and graduate nursing programs in Canada appear to be lagging behind in including cannabis in their curricula. The Canadian Institutes of Health Research (CIHR) has also prioritized funding to monitor the societal and public health impacts of cannabis legalization, as well as the therapeutic potential of cannabis across a range of diseases and populations. The recent announcement by CIHR to fund over 10 national team grants in cannabis research is a positive step in advancing our knowledge about the potential benefits and risks of both recreational and medical cannabis.
I urge nurses across Canada to stay current as research on cannabis advances, and to work with their employers and regulatory bodies as the evidence and policies associated with cannabis evolve. In this way, we can ensure that Canadians are able to access and use medical cannabis appropriately and equitably, and receive accurate information about the possible risks and benefits of this complex substance.
Canadian Nurses Association. (2017.) Harm Reduction for Non-Medical Cannabis Use [PDF, 669.3 KB].
Canadian Nurses Protective Society. (2018). Access to Cannabis for Medical Purposes: What Every Nurse Should Know.
Health Canada. (2018). Information for Health Professionals: Cannabis (Marihuana, Marijuana) and the Cannabinoids.
National Academies of Sciences, Engineering and Medicine. (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research.