Australian Pharmacist Magazine: Medicinal Cannabis In Pharmacy - Looking Beyond The High

Abstract

For over 4,000 year, cannabis has been used across various cultures medicinally, recreationally, and in religious ceremonies. 1 There are more than 60 active constituents believed to hold some pharmacological activity, including the main psychoactive Δ9-tetrahydrocannabinol (THC), the non-psychoactive, anxiolytic and antispasmodic cannabidiol (CBD), as well as the non-psychoactive anti-inflammatory cannabinol (CBN). 2

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Australian Pharmacist December 2015 I © Ph a rm ac eu ti ca l S o c ie ty o f Au st ra li a Lt d.
22
NEWS
Medicinal cannabis in
pharmacy – looking beyond
the high
BY SAMI ISAAC, DR BANDANA SAINI & DR BETTY CHAAR
For over 4,000 year, cannabis has been used across various cultures
medicinally, recreationally, and in religious ceremonies.1 There are more
than 60 active constituents believed to hold some pharmacological
activity, including the main psychoactive Δ9-tetrahydrocannabinol (THC),
the non-psychoactive, anxiolytic and antispasmodic cannabidiol (CBD),
aswell as the non-psychoactive anti-inflammatory cannabinol (CBN).2
THC acts on the CB1 cannabinoid
receptors in the central nervous system
and is known to cause sedation,
amnesia and appetite stimulation.
Itmimics and exaggerates the effects
of an endogenous ligand, anandamide
(Δ8-THC), which itself is a retrograde
messenger in the central nervous
system that affects memory, motivation
and pleasure.3 CBN is known to act
on the CB2 cannabinoid receptors
influencing immune cells and regulating
inflammatory and immunosuppressive
activity, while CBD’s mechanism of
action is still not fully understood.
Recently cannabis has amassed a
vocal calling across the world for
legalisation of its medicinal use
with a surge in consumer advocacy.
InAustralia, the most impact has
been propelled by consumers actively
championing its legalisation, possibly
one of the successful campaigners
may be Lucy Haslam. Her story
and active campaigning gained
the support of various politicians
including NSW Premier Mike Baird who
emphaticallyexpressed:
‘I honestly think that medicinal cannabis
would not be where it is today without
Lucy’s intervention together with [her son]
Dan’s.’ (NSW Premier Mike Baird)4
Ms Haslam’s efforts to push forth change
in legislation is to fulfil the wishes of
her late son Daniel to make medicinal
cannabis accessible and available to
those who, like himself – need it to help
with palliative and chronic refractory
conditions.
‘The long-term goal is for medicinal
cannabis to be legalised, but further to
that, we need to make sure that when it’s
legalised it’s affordable.’ (Lucy Haslam)4
There is an increasing amount of
research into the therapeutic benefits
associated with the medicinal use of
cannabis. A number of well-designed
trials have provided substantial
evidence to support its use for
spasticity, chronic neuropathic pain,
chemotherapy-induced nausea and
vomiting, cachexia, as well as appetite
stimulation in HIV/AIDS infection.5
Theexpanding body of research into the
medicinal application of cannabis has
initiated the development of marketable
forms of cannabis internationally, as well
as rapid policy making by governing
bodies worldwide.
In October 2015 the Federal
Government announced the finalisation
of a draft amendment to the Narcotics
Drug Act 1967 to allow for the controlled
cultivation of cannabis for medical
and scientific purposes.6 This followed
the Victorian State Government’s
introduction of legislation into
parliament to legalise public access
to medicinal cannabis by 2017,
basedon the advice of the Victorian
Law Reform Commission’s Report on
MedicinalCannabis.7
Various physicians have also voiced their
opinion on the matter with mixed views
of support, scepticism and cautionary
hesitation. ThePharmaceutical Society
of Australia has released a position
statement8 on the matter and internal
Sami Isaac, Faculty of Pharmacy, The University of
Sydney, NSW. Dr Bandana Saini, Faculty of Pharmacy,
The University of Sydney, NSW. Corresponding Author:
Dr Betty Chaar, Faculty of Pharmacy, The University of
Sydney, Sydney, New South Wales, Australia.

Australian Pharmacist December 2015 I © Ph a rm ac eu ti ca l S o c ie ty o f Au st ra li a Lt d. 23
NEWS
deliberations have taken shape.
However, little has been mentioned in
the public arena about pharmacists’
views regarding the issue, including
their needs and requirements for
the rollout of medicinal cannabis
inpharmacies.
As healthcare professionals whose
main role and responsibility is the
supply, safekeeping and monitoring of
medicines, pharmacists’ perspectives
need to be heard in this contemporary
debate. It is important that the
views of the thousands of Australian
pharmacists, their concerns, perceived
barriers and supporting needs are
explored and addressed prior to
implementation. Thisis not only to
sustain multidisciplinary collaboration
amongst healthcare professionals
but also to help influence policy and
instigate legislative change to ensure
that medicinal cannabis is introduced
and implemented into the healthcare
system successfully the first time round.
To shed some light on the perspectives
of pharmacists on this topic, researchers
at the University of Sydney recently
conducted a study exploring the
views of registered pharmacists from
Australia, predominantly NSW, about the
legalisation of medicinal cannabis.
Support
Findings of the study indicated that the
majority of pharmacists were in support
of and encouraged the introduction and
decriminalisation of a standardised form
of medicinal cannabis. However in terms
of legislation several questions were
raised, such as:
• What protocols will be set in place?
• Will it be a nationalised approach?
• Are the rights and responsibilities
of both the prescriber supplier and
consumer clearly defined?
The most significant suggestions put
forward were that legislation should be
nationalised and that clear protocols
should be in place, with a Schedule 8
classification regarded as most effective.
This was balanced by some participants
acknowledging that a Schedule 4
classification would be more suitable,
particularly for specific cannabinoid
products with minimal potential or risk
of abuse.
In regards to the place of supply to the
public, the majority felt that community
pharmacies would offer the best
accessibility for the patient, and could
be well monitored, but only with the
right support networks in place for
pharmacists.
The concern for safety of both patient
and pharmacist was an important
aspect highlighted in the study.
In relation to safety of the patient:
long-term risks need to be monitored
through post-clinical trials to safeguard
patientsafety.
Pharmacy safety
In relation to concerns for pharmacy
safety important issues were raised.
Due to the pre-existing recreational
use of cannabis, and its propensity for
abuse, and based on past experiences
with harm minimisation programs
such as needle exchange and Opioid
Substitution Therapy (OST), pharmacy
safety and security measures need
to be addressed in much detail.
Somesuggestions included training that
could be developed for both physicians
and pharmacists who may be under
duress, as a means of mitigating these
legitimate concerns.
Stigma is of course another facet
that appears to be strongly attached
to the term cannabis, primarily as a
result of the negative aspects and
side effect profile associated with its
recreational use. Stigma held by the
public about cannabis was seen to
be the reason for wanting to ensure
that utmost precautions be taken
during the introduction of medicinal
cannabis in pharmacies. There was
palpable apprehension from some
participants, not wanting to be seen
as a ‘cannabis-provider pharmacy’.
This is where public health campaigns
are needed to create and nurture
greater public awareness, and to help
differentiate between the medicinal and
recreational use ofcannabis.
All of these questions and suggestions
for the implementation of cannabis
if addressed successfully can help
generate a streamlined system of access
to medicinal cannabis that not only
alleviates pain and suffering of those in
need, but also maintains transparency to
all stakeholders involved.
Through the research findings, it is
evident that in pharmacy there are
strong views built on clinical awareness,
compassionate deliberation and
previous experiences. Pharmacists are
central within any team of healthcare
professionals that hold the important
role of monitoring the safe use and
supply of medicines, including the
future supply of medicinal cannabis
if or when it is legalised. By exploring,
discussing and addressing these diverse
views captured through this study
we may be empowered to help shape
future policies and enable the successful
implementation of medicinal cannabis
in healthcare.
References
1. Russo EB. H istory of cannabis and its preparations in saga,
science, and sobriquet. Chem Biodivers. 2007;4:1614–48.
2. Engels FK, De Jong FA, Mathijssen RH, Erkens JA, Herings
RM, Verweij J. Medicinal cannabis in oncology. Eur J Cancer.
2007;43(18):2638–44.
3. Borgelt LM, Franson KL, Nussbaum AM, Wang GS. The
pharmacologic and clinical effects of medical cannabis.
Pharmacotherapy. 2013;3 3(2):195–209.
4. Feller J. ABC Australian Stor y - Lucy Haslam’s plan to
supply medicinal cannabis unchanged by legalisation
proposal: ABC; 2015. At: www.abc.net.au/news/2015-
10-19/campaigners-plan-to-supply-medical-cannabis-
unchanged/6863816.
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Hernandez AV, et al. Cannabinoids for Medical Use: A
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2015;313(24):2456–73.
6. Murphy J. Government support to allow the controlled
cultivation of cannabis for medicinal or scientific
purposes Department of Health – The Hon Sussan Ley
MP Department of Health Australia; 2015. At: www.
health.gov.au/internet/ministers/publishing.nsf/
Content/546FB9EF48A2D57 0CA257EE1000B98F2/$File/
SL-123.pdf.
7. Cummins P, Freckelton I, Buchanan L, Fatouros H, Gardner B,
Hardingham I, et al. Medicincal Cannabis Report. Victorian
Law Reform Commission; 2015. At: http://lawreform.vic.
gov.au/sites/default/files/VLRC_Medicinal_Cannabis_
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8. The Pharmaceutical Society of Australia. Therapeutic use of
cannabis – Position statement: The Pharmaceutical Society
of Australia; 2015. At: www.psa.org.au/download/policies/
therapeutic-use-of-cannabis.pdf.