Medical Marijuana Dispensed by Pharmacists in Connecticut
Q: Please explain the medical marijuana law in Connecticut and the role of pharmacists in dispensing medical marijuana products.
Ms. Giuliano: The Connecticut medical marijuana law is one of the best crafted pieces of legislation on medical marijuana in the country because it is modeled after best manufacturing practices, and also requires testing and labeling of controlled substances before these agents reach dispensing facilities.1
The State of Connecticut has a limited number of growers that have been certified by the state. Growers have to send their products to independent testing facilities that have been certified by the Connecticut Department of Consumer Protection to analyze medical cannabis products. In addition, Connecticut was the first state to mandate that pharmacists dispense medical marijuana products and be the linchpin of dispensary operations.
Have we had any bumps along the way? Absolutely. However, because we have pharmacists as the gatekeepers advising patients on which medical marijuana product might be best for their condition and who are examining patient outcomes, I think we have addressed many of the questions that have been raised about standards and best practices.
Until recently, patients have had access to traditional marijuana products only, which could have adverse health ramifications because such products are smoked. Now, patients have access to edibles and different types of inhaled products and devices such as vaporizers, as well as oils, tinctures, capsules, and sprays.
Our pharmacists have raised concerns about what they see in clinical practice now that products have transitioned from inhaled to ingestibles. Specifically, pharmacists are looking at how producers are converting the maximum quantity allowed for inhaled products (ie, 2.5 ounces) to the quantity for edible products.
As a result, Connecticut pharmacists have asked the Department of Consumer Protection to mandate standards for dosing, labeling, conversion, and equivalency factors when converting from inhaled to ingestible products, as well as for consistency of the medical marijuana product and supply. Although these products are mandated to have labels stating cannabidiol (CBD)/tetrahydrocannabinol (THC) percentages and expiration dates, there are no standards regarding how the information has to appear.
That being said, I think our pharmacists are very confident in the labeling of drug products with regard to percent of THC and CBD. That has been very consistent.
In the next few months, the Connecticut Pharmacists Association will be involved in an observational study to help determine dosing standards and effectiveness of medical marijuana for various disease states. The study will involve all of our dispensaries, as well as experts from Yale and McGill Universities.
Our program has progressed tremendously, given the fact that dispensaries only began receiving medical marijuana products in October 2014. We have the right people in place to address some of our concerns and everyone is working together to make it the best program in the country.
Q: How do pharmacists in Connecticut help individualize medical marijuana dosages?
Ms. Giuliano: In Connecticut, there are 11 diseases that the state’s law authorizes medical marijuana to be used for, with additional disease states pending (Table 1).1 If a physician diagnoses a patient with one of those disease states, the physician may authorize the patient to participate in the medical marijuana program. If there is a particular product or dose that the physician wants to suggest, the doctor can enter that information into the comment field when they authorize the patient for medical marijuana. However, the product selection is typically left to the pharmacists and the patient.
The pharmacist meets with the patient to review the patient’s symptoms and medical history, and conducts a comprehensive medication review, and then works with the patient to select the best dosage and product formulation that fits with the patient’s lifestyle. Next, the pharmacist works with the patient to individualize the dose. Patients are allowed a 30-day supply, allowing the pharmacist many opportunities for follow-up to see how a patient is doing on a product and whether the dosage should be adjusted.
Q: What would you like to tell our readers about use of medical marijuana for the treatment of pain conditions?
Ms. Giuliano: Medical marijuana is a possible alternative for patients with chronic pain.2,3 Studies have shown that patients who use medical marijuana for chronic pain may be able to decrease their use of opioids; anecdotally, our pharmacists have found this as well.4-6 In addition, although it is too soon to have data from Connecticut, studies have shown that states with medicinal marijuana laws have significantly lower opioid overdose mortality rates.7 Certainly, a consideration is that medical marijuana does not have the same addictive qualities that some of our traditional medications do. Furthermore, our pharmacists have seen how valuable medical marijuana can be for end-of-life pain management.
—Reported by Kristin Della Volpe