4 Way to Improve The Medicinal Cannabis Program in Illinois: A Case Study
As of September 2018, a total of 31 states, in addition to the District of Columbia, Guam and Puerto Rico, have a legal framework in place to allow the creation and rollout of comprehensive medicinal cannabis programs in their respective geographical areas. The status of these programs across the US varies hugely - from the long-established medicinal dispensaries that have been operational in Colorado since the early 2000s, to Oklahoma’s medicinal cannabis initiative that was approved only this summer.
Given this large variation and the lack of federal guidance, it is important that states continuously review the nature of their own medicinal cannabis programs in order to ensure that they are still serving the population of that state effectively.
A recent commentary in the Journal of Alternative and Complementary Medicine provides an effective review of the Illinois Medical Cannabis Pilot Program (IL-MCPP) from the perspective of a physician in the state who is responsible for certifying patients for medicinal cannabis cards. The commentary describes the experience of one clinician in a suburban Chicago medical practice, and based on this experience identifies a series of linked factors which, if changed, could lead to the improvement of the Program.
1. Insufficient Scientific Knowledge
In Illinois, there is no form of standardized training for cannabis dispensary workers. This means that different dispensary workers may end up giving conflicting advice to patients in regard to the most appropriate strain, delivery method, frequency, and dosage of medicinal cannabis products. Additionally, dispensaries in the Chicago area rarely have an on-site registered pharmacist, meaning that dispensary workers are also expected to understand the risk of potential drug interactions between cannabis and other medications, despite receiving no formal training on the topic.
In a recent national study which surveyed cannabis dispensary workers, 94% of respondents indicated that they were expected to provide specific advice to patients in the dispensary, despite only 20% of these respondents having received any form of medical or scientific training in their state. The consequences of this become clear in a later part of the study questionnaire, where 13% of the respondents answered that they would recommend tetrahydrocannabinol (THC) for anxiety treatment, despite scientific literature linking THC use with exacerbated anxiety symptoms.
These issues with cannabis science literacy are not limited to dispensary workers; pharmacists and physicians often have little knowledge of cannabis science beyond the basics learned in medical school, and so often rely on self-teaching in order to improve the treatment they provide.
To combat this issue, it is recommended that evidence-based cannabis education courses be developed for dispensary workers, pharmacists, and physicians in order to improve the cannabis science literacy of those involved in the industry. An online accreditation system, similar to that already run by the District of Columbia Center for Rational Prescribing, could be an easy and efficient way for healthcare professionals and dispensary workers in Illinois to improve their services. The addition of on-site pharmacists or physicians during dispensary business hours is also a good way to increase the medical expertise and better the advice given to cannabis users at the point of sale.
2. Inadequate Communication
While physicians are heavily involved in prescribing medicinal cannabis, creating a regimen for taking the drug is largely left to the patient. Physicians and dispensary staff often give conflicting advice as to appropriate dosages, use frequencies, and specific strain selections, and as cannabis effects vary widely from person to person, it is generally the patient's responsibility to monitor what works best for them.
The wide variety for choice available in dispensaries can often be overwhelming and confusing for new medicinal cannabis patients, and many patients don’t feel comfortable making a choice or administering the first few doses without supervision.
There are a number of medicinal cannabis coaches who offer services that help patients understand the choices available to them and instruct on how to take the first few doses, but this is not a practice currently licensed by the state of Illinois.
One improvement that can be made to communication within the IL-MCPP is to create more professional communication channels. Physicians should be opening electronic, written, or verbal channels of communication with dispensaries and patients that can help patients select the most effective cannabis regimen for controlling their symptoms. Records of this communication can also assist in creating more data-driven systems for regimen suggestion and for characterizing any observed cannabis-pharmaceutical interactions that arise.
3. Inconsistent Cannabis Supply
Dispensaries will usually offer a large variety of cannabis strains in order to satisfy the greatest range of personal tastes and preferences. While this may be a pleasant environment for the casual recreational user, it can be a very stressful experience for medicinal cannabis users if the strain they use is suddenly removed from the shelves in favor of something new. Alternatively, the patient could be recommended certain strains by their physician, and then be unable to find that strain at any of the local dispensaries, leading to distress and confusion when the patient isn’t able to fulfill their prescription.
To simplify this process for the medicinal cannabis patient it is essential that cannabis cultivators, dispensaries and physician communicate effectively in order to determine a shortlist of the most commonly used cannabis strains. This list should include strains used for medicinal purposes as well as those strains which are most effective at treating conditions with high referral rates for cannabis treatment, such as drug-resistant epilepsy. Dispensaries and cultivators could then ensure that there is always a reliable source of these strains available locally for medicinal cannabis users.
4. Environmental Factors and Bias
There are many social and societal factors that may cause difficulty in accessing medicinal cannabis treatment. These factors affect both the physicians (limited assessment time with the patient, paperwork burden, lack of easily available safety information) and the patients (cultural/religious beliefs, personal beliefs, societal stigma, workplace pressure) alike, and can prevent many eligible patients from pursuing medicinal cannabis treatment.
A study of primary care physicians and health specialists in Delaware found that respectively 34% and 39% of these professionals would categorize themselves as being “very unlikely” to prescribe a medical cannabis treatment to a patient. Along with the anticipation of a negative response being the main reason that patients feel uncomfortable discussing the possibility of medicinal cannabis treatment with their doctor, this attitude could be creating a significant barrier to access.
Some healthcare institutions in southern Illinois even imposed a blanket ban on their physicians from prescribing medicinal cannabis in the aftermath of its legalization, much to the frustration of eligible patients in the area. This was justified by the providers as a consequence of cannabis still being federally recognized as a Schedule 1 drug, which by US Drug Enforcement Administration’s definition states that there is “no currently accepted medical use” for the drug, despite a growing array of scientific literature suggesting otherwise.
The most effective way to begin dismantling this social stigma is through the reclassification of cannabis’ drug schedule to that of a lower class in acknowledgment of its medicinal properties. Reclassification also makes it far easier for scientific institutions to research the drug and to collaborate with their findings, potentially even leading to improvements in the drug’s medical efficiency or safe use. This official federal recognition of the medicinal benefits of cannabis could also lead to a shift in the cultural associations of cannabis use, leading it to become less stigmatized in the eyes of a patient’s peers or employers, further reducing the access barrier to treatment.