This week's Allard court ruling has shaken up the cannabis world, with Federal Court Judge Michael Phelan affirming approved medical marijuana patients’ right to grow their own marijuana, and giving the current government 6 months to get the existing laws in line with this ruling.
While Phelan's ruling continues the current injunction in place allowing some registered under the MMAR to produce their own, what the proposed changes mean remains to be seen. One question is if doctors will be the gatekeepers of who gets to grow, and if so, if they will be comfortable with this role. While the court has ruled patients have the right to produce their own, it does not state how they should gain such authorization.
Currently, under Canada's MMPR, physicians are the main gatekeepers to accessing medical marijuana. Under the previous MMAR program, those seeking to use medical marijuana required permission from a doctor as well as Health Canada. If patients wanted to produce their own cannabis, they had to purchase seeds from Health Canada. The current government of Canada has been given 6 months to adjust the current access program to allow for home production, but the specifics of that program or how it will be managed are still unknown.
One of the current issues with medical cannabis access for Canadians remains the lack of mainstream acceptance by doctors. While the number of doctors willing to recommend medical cannabis is on the rise in Canada, the overall total remains a small subsection, although there is a previous precedent in Canada of doctors, in accordance with Health Canada, authorizing home production.
"When it comes to cannabinoids, you don't always know what is going to work for who, or what conditions, because people are a study of one. So how are you going to grow a plant, wait for it to mature, harvest and cure it, and then decide which of those is or isn’t going to work for you? It's just not going to happen. The average person is not going to do that." - Dr. Dave Hepburn
Prior to the 2014, under the MMAR only about 7% (about 5,000) of all doctors in Canada were willing to authorize medical marijuana, even with final, secondary approval from Health Canada. With the introduction of the MMPR, Health Canada’s role in approving individual patients was removed, placing the entire authority on the shoulders of doctors, a responsibility many have balked at.
When the MMPR replaced the MMAR in 2014, less than a few hundred doctors were willing to be the sole approving authority for the use of medical cannabis. This number nearly doubled to more than 1,200 by the end of 2015, but this is still a very small percentage of the over 75,000 physicians in Canada. Part of the reason for this relatively low level of acceptance from the medical community is not only the lack of familiarity with cannabinoid medicine, but also with how to prescribe a plant with many different levels of potency, potential effect, varieties, etc.
While most doctors are used to prescribing medication in very specific dosages, prescribing dried cannabis flowers on a grams-per-day basis is often seen as something more akin to a naturopath or holistic practitioner. The idea, say some medical professionals, that a doctor who is hesitant to prescribe someone a gram total per day due to product variability will be comfortable being the one giving permission to someone to grow a plant seems unlikely.
"It's hard enough for physicians to get their minds around how to use it now, even in a very organized format of capsules or vaporizers", says Dr. Dave Hepburn, a general practitioner based in Victoria who specializes in cannabis and cannabinoids. "If you say ‘now I just want you to grow it and try it and see how it works’, that is just not going to fly with any physician. We don't do this with any medications.”
Two examples Hepburn mentions are Digoxin, similar to digitoxin, an organic compound extracted from the plant foxglove, and various opioids. While both of these conventional medications are originally derived from sources found in plants (Foxglove and Opium Poppies), a doctor wouldn’t substitute the plants for these medications.
“We don't tell someone to grow foxglove plants because we prescribed them Digoxin, or tell them to grow opium because they've been prescribed a narcotic,” he says.
"When the face of the average medical cannabis user is, say, a 75 year old who is new to cannabis, you are not going to put them in a situation where you prescribe seeds or have them grow things that require a certain level of knowledge. People are not going to want to become botanists to get their medications. It's just not going to happen in the medical community. I don't know a single doctor who is going prescribe or authorize that.”
"When it comes to cannabinoids,” Hepburn continues, “you don't always know what is going to work for who, or what conditions, because people are a study of one. Someone may try 3 strains and only find one works for them and their condition. So how are you going to grow a plant, wait for it to mature, harvest and cure it, and then decide which of those is or isn’t going to work for you? It's just not going to happen. The average person is not going to do that."
"There's the benefit that if patients are unable to afford to purchase cannabis from a commercial producer, then they can grow it themselves. They can also get the therapeutic benefits of tending to a garden, which potentially are numerous from a physical and mental perspective." - Dr. Danial Schecter
Dr. Ian Mitchell, of Kamloops, BC echoes Dr. Hepburn's comments. He sees personal production being an important right, but doesn't see how physicians can fit into that process.
"Fundamentally, I think the allowance for personal cultivation is important, both for medical and recreational use. So I hope that comes in as part of the new regulation, some allowance for personal cultivation, if just to act as a bulwark against big marijuana and prevent profiteering. But I think the problem comes in now in that if you try to use home grows as a medical option, you don't really know what's in the product. So that becomes more challenging for a physician to support."
Older 'street' names of strains, says Mitchell, and how patients and doctors will select cannabis varieties that work for them, is changing and home production is hard to fit into that evolving, clinical approach.
"I think it's becoming clearer and clearer that strain names, indica vs sativa is all kind of nonsense and doesn't really matter compared to the amount of THC, cannabidiol, myrcene, those varied things", explains Mitchell. "So I think it's much more approachable as a physician to be prescribing product that has a known quantity of cannabinoids vs the mystery jar in the dispensary or the plant in someone's backyard.
"I see medical use going away entirely from dried herbs, I see it going much more towards concentrates, oils, and purified extractions because thats the stuff that doctors can deal with. Then you can have a purified product that, even if you're vaporizing it, at least we know what's in it, that there's no bacterial contamination and it's a more quantifiable product."
Dr. Danial Schecter, executive director of the Cannabinoid Medical Clinic in Toronto, agrees that physicians aren’t likely to feel comfortable authorizing someone to grow a plant, but feels the government could potentially put checks and balances in place to address these concerns.
"There's the benefit that if patients are unable to afford to purchase cannabis from a commercial producer, then they can grow it themselves. They can also get the therapeutic benefits of tending to a garden, which potentially are numerous from a physical and mental perspective. If the government is legislating that patients can grow themselves, then there will likely be some sort of supports in place and the ability for patients to test their own product.
“That would hopefully make some physicians more comfortable with allowing patients to see if that approach works for them. Physicians can then be happy knowing patients can use it safely and can know what they are growing doesn't have mould or bacteria.
“Already doctors feel uncomfortable prescribing marijuana,” continues Schecter. “Going forward, who knows if there's even going to be a requirement for doctors to be involved in a patient's desire to grow their own. I imagine it will be a prescription like anything else, and then they can either go through a licensed producer, or they can opt to grow it on their own.
“Cannabis has some parallels to conventional medications, but once you're giving someone a medical document to grow it themselves, that doesn't have any parallels, for anything else. I can't really see physicians being involved for the long term for patients who want to grow it on their own.”
What the current federal government does in response to the court ruling is still unknown, but without major changes that would address these concerns from the current gatekeepers of the medical cannabis system, patients may find themselves with a court ruled right to access something that very few doctors are willing to prescribe.