Pharmacy Focus: Pharmacists' Role in Medical Cannabis Counseling and Patient Education

In this episode of Pharmacy Focus, a podcast from Pharmacy Times®, Jill Simonian, PharmD, and Codi Peterson, PharmD, MS, co-founders of the Pharmacists' Cannabis Coalition of California (PCCC), discuss the challenges pharmacists face in navigating the fragmented legality of medical cannabis across the United States. Simonian and Peterson advocate for greater pharmacist involvement in cannabis education and policy, stressing the need for accurate, evidence-based resources to guide patient care.

Luke Halpern: Hello everyone, and welcome to another episode of Pharmacy Focus, a podcast by Pharmacy Times. I'm Luke Halpern, an assistant editor with Pharmacy Times, and today I have on Dr. Jill Simonian and Dr. Codi Peterson to discuss pharmacist counseling of cannabis use. Dr. Simonian and Dr. Peterson, would you each like to briefly introduce yourselves?

Jill Simonian, PharmD: My name is Jill Simonian, and I am a pharmacist, of course. I have a background in clinical pharmacy, mostly working at the VA Medical Center in San Diego for most of my career. But about 8 or 9 years ago, I shifted my focus to focus more on cannabis education, mostly because I saw at that time a glaring gap between the increased use of cannabis for just the general population but my patients as well, and the complete lack of education in our pharmacy schools and in pharmacy education in general. I endeavor to teach a course at the University of California San Diego, an elective on cannabis pharmacology. This will be my fifth year doing that. And then together—I’m about to steal your thunder—Codi and I took that class to UC Irvine, where we're running our third year this year on doing the same class. And together, I'll let Codi talk a little bit more about this, but we, along with 3 others of our esteemed colleagues, formed the Pharmacists’ Cannabis Coalition of California (PCCC), with the aim to really bring awareness and education further educate pharmacists about cannabis. Codi, you can take it from there.

Codi Peterson, PharmD, MS: You did such a good job, all the pressure is on me to one-up you. My name is Dr. Codi Peterson. I'm a pediatric pharmacist, still practicing to this day, primarily emergency medicine here in Southern California, and that's by night. By day, I've turned myself into a cannabis educator. Along with Jill, I'm an associate professor at UCI, where we teach a 2-credit elective to pharmacy students, where they get to learn about cannabis, cannabis use, cannabis history, cannabis harms. I also teach paramedics about pharmacology, and just in general, love talking about the way drugs work. It's been really great to have bumped into Jill on this journey and then been able to upstart these programs. But we continue to drive forward with what we're trying to do here in California, sort of hoping that we can reestablish ourselves as the leaders in medical cannabis. We believe that pharmacists are a key part of that solution. Health care professionals in general are important, and we're biased, but we think pharmacists are key.

Halpern: That was great, both of you. And I agree, I think pharmacists are key in this emerging industry, especially, we talked about it a little bit before the call, but you said it's a lot of changing happening, not a ton of advancement, but a lot of changes. I think you 2 are the perfect candidates to talk about all these changes. Just to begin, I think it makes the most sense to ask you—we'll start with Codi—if you could give a brief overview of how medical cannabis has emerged and become increasingly more accepted as a therapy in recent years.

Peterson: Yeah, it's kind of a story that goes back way longer than recent years. We all think of the beginning of medical cannabis as 1996 when California led the state by nearly 10 years, sort of creating a medical cannabis structure that disobeyed federal law, which where marijuana—high THC cannabis—had been illegal since about the about 1970 when the War on Drugs began. Now, if you go back between 1970 and 1940, there's not a lot going on with medical cannabis, sort of dwindling or withering away in our mind, in our memory. But before 1943 or something to that effect, cannabis was in the US Pharmacopeia. It was in the list of medications that is available for prescribers to use. And if you go back, I don't know, maybe 40 years before that, to 1900, cannabis was available, or tincture of cannabis, or some sort of cannabis extract, was available in many pharmacies in the country. It was not that different than the cough syrups and the other the other plant-based medicines that existed, whether it was from opium or whether it was from scopolamine, Atropa plants. There's so many medicinal plants that, if you just go back 120 years, these were all in the pharmacy, and now they're in this sort of very restricted class back in the 1970s. But we can go back even further than that. We can continue through 1850 to 1940, there was a lot of medical cannabis use in western medicine. But before that, if you go back, we have 1000s of years, at least 2000 years, of known medical use. In the Chinese Pharmacopeia written by the Emperor Demigod Shen Nung, going back to a story 5000 years old, but written down at 200 AD was the first pharmacopeia in the natural medicines of China and cannabis—“ma”—was absolutely included in that list. This is a newly revitalized topic, but not new in most stretches.

Simonian: Yeah, I agree with everything Codi said. It's an ancient plant medicine, but currently, it's because of the decreased stigma, it's legalized across the nation in a really advancing degree. It's schedule I, but it's legal for medical use in 40 states. [Through] word of mouth, anecdotal use, I think people are just starting to realize that they can use this as a safe medicine.

Peterson: Yeah, I think people realized for a while. I think we're really at a phase right now where medical establishments are realizing it, and we're identifying some more harms as this medicine has mobilized to the masses, like any medicine. We’ve identified a couple more of the risks, a couple more of the benefits, some of the nuance involved, and it's growing. The field is much bigger than THC and CBD, which is where it has been for the last decade.

Halpern: Absolutely. And yeah, it's schedule I, but it's legal in countless states. I think it's something like 34 or maybe even a little bit higher, last I checked.

Peterson: Thirty-eight, I believe, have medical laws.

About the Guest: Jill Simonian

Jill Simonian, PharmD, received her PharmD from UCSF, followed by an acute care residency at UCSD Medical Center. Her professional career includes 25 years as a clinical pharmacist at the VA San Diego Healthcare System and a brief time as a part-time pharmacist at an independent pharmacy in Carlsbad.

She is currently conducting a course on Cannabis Pharmacology and Therapeutics at UC San Diego Skaggs School of Pharmacy and, with Dr. Peterson as co-chair, at UC Irvine School of Pharmacy. Dr. Simonian is a founding member of the Pharmacists' Cannabis Coalition of California, a nonprofit organization aimed at bridging the gap between healthcare and cannabis for the purposes of patient safety.

Halpern: Yeah, so people are using it for a lot of conditions, but I feel like a lot of times, people don't, off the top of their head, know what conditions someone might use medical cannabis to treat. They might think it can treat pain, [but] there's not anything specific they could put on their mind. Do we know what conditions patients have been using medical cannabis to treat and have there been clinical trials that have evaluated the efficacy of cannabis for these conditions?

Simonian: Cannabis is used widely as a medicine for across the spectrum, for a variety of conditions—substantiated by the literature or not. I would say, overwhelmingly, the most common use that does have some literature to back it up is chronic pain, like you mentioned. There's the most evidence for use in chronic pain. Chronic pain, meaning mostly neuropathic pain, as to what I see, neuropathic pain, fibromyalgia, cancer pain, palliative care, and so on. This is not acute pain. It does not appear to be efficacious for acute pain. And there is a large body of evidence for chronic pain. I mean, you could look at the authoritative bodies like NASM and FDA, who have done some comprehensive reviews of the literature and came to the conclusion that yes, there is substantial evidence for use in chronic pain. There was a study out this week, actually, by Wasan, who did a study, it’s an interim report right now, but they looked at in a pretty tightly controlled environment at a university, in a pain clinic, medical marijuana patients versus traditional therapy. The conclusion at the end was that the medical marijuana patients did as well and slightly better than the traditional therapy. This was nice real-world data. I mean, the dosing and formulation wasn't controlled, but I thought it was a nice paper on that. There's plenty of evidence for chronic pain, and there's so many more, Codi if you want to take one of the other conditions?

Peterson: Yeah, I totally do. But Luke, I almost want to back us up and, not to take the wheel, but I want to explain to people what we're talking about. Because what has been approved for chronic pain, or what is the FDA looking at now that's different than what's out there? I talked about the history of medical cannabis going back thousands of years. What is that? Well, cannabis is a plant, a species or genus of plant that comes in all sorts of different shapes, forms, sizes, and growth patterns. But what people talk about, or what we really talked about in 1996 in California, was medical marijuana. Marijuana is the dehydrated or dried flowers of a cannabis plant that are rich in psychoactive molecules known as cannabinoids. Now the cannabinoid that everyone knows is THC, more specifically, delta-9 THC. The reason every pharmacist listening to this should know about that molecule is because since 1985, delta-9 THC has been FDA approved to treat chemo-induced nausea and vomiting as well as, what am I missing Jill, not cachexia? Maybe. Yeah, cachexia and wasting disease, secondary to HIV-AIDS. It's been used off label. We have approved use in pediatrics; this is called Marinol, at least, historically, the brand name was known as Marinol or dronabinol, which is delta-9 THC, a very similar, or the degraded product of what is produced in the marijuana flower, which is known as THCa, an acidic form that, when ignited in, let's say, a bowl, a blunt, a joint, etc., these delivery systems for marijuana, that it's activated into delta-9. Every pharmacist already knows about that. However, there are other bioactive molecules known as cannabinoids, once again, in the cannabis flower. These cannabinoids include CBD—in its acid form, CBDa—CBG—in its acid form, CBGa. There's a whole plethora of other essential oils and smelly molecules that are that are in cannabis as well. FDA has approved a synthetically created delta-9 THC, because it met the regulatory and research burden necessary to prove its utility. But cannabis flower, which is what we're sort of talking about more and more, the Health and Human Services have now proposed that cannabis flower and cannabis products do have medical use. That is really where everything is focused right now, because it remains federally illegal, no one has been able to get the FDA to sort of budge on its position that it doesn't have medical use. That's what keeps it in the status of schedule I, and that is what's currently being challenged to change marijuana's designation from a schedule I substance to a schedule III substance, so one without medical use versus one with. Yeah, I think I covered a lot there.

Halpern: Yeah, that was all great and very interesting. I'm glad you jumped in and explained the history with the cannabis flower and the differences between them. And as it's becoming more legal, pharmacists [and] their role in counseling patients who may come to them and say that they're using cannabis, medical cannabis, for therapy, their role is growing, for sure. Whoever, I think we're on to Jill now—it's a multi-part question, so it's a little dense—what is the role, generally, of pharmacists in the patient use of medical cannabis, and are they limited to providing education and counseling, or can they have a more hands-on role? And what kind of counseling can they ultimately provide for this very unique therapy?

Simonian: Ideally, I think pharmacists are perfect for counseling patients. There's so much they can do. They can counsel them on how to use it, what the dosing is, how not to overlap doses to prevent any major side effects, what the side effects are, how to look for them, how to prevent them, what any potential drug interactions are, how to choose a delivery method or a formulation. It's very complex to counsel a patient [and say] “Yeah, go ahead and get your cannabis. Go to that dispensary over there. You're on your own.” It is very tricky. In the ideal world that Codi and I have proposed, there would be a manufactured product that pharmacists could counsel on and dispense that would be a reliable, tested, consistent product. That does not occur right now, however, pharmacists are very accessible, and we should at least open the conversation, decrease the stigma, to just say, “Are you using it? Do you want to use it? And here's how we can help you.”

About the Guest: Codi Peterson

Codi Peterson, PharmD, MS is a pediatric pharmacist and cannabis science expert. He is a PharmD graduate from Duquesne University and later graduated with an MS in Medical Cannabis Science & Therapeutics from UMaryland, Baltimore. Codi is the Chief Science Officer of The Cannigma, a science-forward media company dedicated to helping the world understand cannabis. 

Dr. Peterson is also an associate clinical professor at UC Irvine, where he contributes to advancing medical education. Additionally, he teaches pharmacology to paramedics in Southern California through OCEMT, and continues to practice pharmacy in an emergency department to this day. Codi is a co-founder of the Pharmacists Cannabis Coalition of California (PCCC), a public-benefit nonprofit dedicated to educating and elevating California pharmacists in the cannabis space.

Peterson: It's critical again, to sort of look at the different lanes that exist in the current regulatory framework. With cannabis as a schedule I, it's never been able to be properly integrated into the medical model in this country. Now, if you look around the world, there are different models where the pharmacist is absolutely the place where you go to get your cannabis, sort of a revitalization of the way it was 100 years ago. We've got countries like Portugal where the medical cannabis is dispensed through the pharmacist only. We've got the medical model in Germany, which integrates pharmacists and integrates medical care providers. Regarding the United States, I think it's important to point out that there are multiple states that are pharmacist-led. Minnesota has a very pharmacist-centric medical cannabis program, and they're doing a really great job of gathering a lot of data and results from their patients. I just think that there's so many examples of where pharmacists are leading, is I guess my point. There's a lot of models where pharmacists are sort of the driver of this. There are a couple states, or the current models in a lot of states, is where the medical doctors [are]—I don't want to say driving, but approving. Because cannabis is a schedule I substance, as we listed already, it cannot be prescribed at this time. It can only be recommended, which has sort of set us up to be leaning on physicians to provide care, but the physicians aren't talking to the dispensaries, which don't have a pharmacist or a medical professional, and there's a disjointedness in the recommendation and in the communication. Really that's one of the things that we aim to resolve; not to fully cut out medical doctors, but to create a system where physicians and pharmacists and nurses can all work together to take care of patients. It's not that novel of an idea.

Halpern: Yeah, absolutely. And you mentioned how there's a bunch of pharmacist-led initiatives in separate states, but it's still, I would say, difficult, because there's not really a national standard because of the illegality of it in a lot of states. And as you mentioned, some states have medical use legalized, but not adult use. Some states, it's adult use and not medical use. How can pharmacists and other treatment providers, like physicians like you said, if they want to provide a recommendation, how can they navigate the patchwork legality of cannabis across the United States, and if a patient resides in a state where medical use is illegal, are there alternatives?

Simonian: It's tricky, for sure. Each state has its own set of laws. It is illegal federally to travel interstate with any product you can't ship interstate. I mean, we can advise about traveling, which is something that could be important. Don't take your cannabis somewhere that's not legal, certainly not overseas. I would strongly recommend [against] bringing anything, including CBD, anywhere on a plane. We can advise about that. But in an illegal state, practically speaking, illegal states are adjacent to legal states. So that's what happens; patients go to the adjacent state. We're in California, it's a really large state, but most states are pretty close together, so they can access that. Some can use CBD; it's different than THC, obviously. I suppose you could ask your provider to prescribe you Marinol (dronabinol), like Codi was suggesting but that doesn't appear to be a very popular option. I don't know; Codi, do you have any other thoughts about that?

Peterson: So Marinol is an example of an FDA-approved, cannabis-inspired, although not cannabis derived, medicine. But we also have the example of cannabidiol (Epidiolex; Jazz Pharmaceuticals), which is prescription CBD. It's mostly a CBD isolated but it is extracted from plants, and it's sort of a novel exception, and it's almost a blockbuster drug—$900 million in sales, I think, last year. There are a lot of prescriptions, but it's very limited and formulary restricted. To get back to Jill's point, every state is different. That's part of the problem with the patchwork, compassionate use model that we've created. We said, okay, medical marijuana is medicine. We recognize that as a state, we've legalized it despite what the federal government has done, and the federal government since about 2014 has taken a pretty hands-off approach. But, it's still illegal. It's still very much that these companies are being taxed to death. It's still very much true that patients can be arrested. If for whatever reason, you were pulled over, and the DEA agent said, “Empty your pockets”, and you pulled out marijuana? Federally which they are an employee of, there would be a crime there, which is crazy, because, again, I would just remind everyone, we're talking about a flower. We've got all these synthetic drugs killing all these people around the country and cannabis is not. Is it perfect? Certainly not. But we just need to realign our understanding, expectations, and our criminality around this with what we're really dealing with, because the history of it is not as cut and dry as a lot of us have been led to believe.

Halpern: Definitely. How can pharmacists, like play a role in educating patients who might be hesitant to use medical cannabis because of maybe its reputation or the stereotype surrounding it or the stigma surrounding it, as you mentioned, the War on Drugs in the 80s, that definitely did not have a great impact on the overall view of marijuana and cannabis, I think nationally. How can pharmacists ease patients concerns? If medical cannabis is really a good option for them, for their condition, how can they provide some clarity on its use?

Simonian: I think pharmacists can be good to provide information on this, because we can advise them about the risks and benefits and really be clear about that. Most important, because there are a lot of senior patients right now who want to start using this and get off their opiates. And they're more at risk for some of the side effects of cannabis. Pharmacists can advise them on starting at a very, very low dose. Instead of just going to a dispensary and picking out what is almost always a very high percent THC, and that's the advice they get from the staff there that's untrained medically, a pharmacist can advise on, at least, finding a product to start very low, and how to do it properly. Starting at night when you're in bed, so if you're dizzy or sedated, you're not going out and working or driving. Just the right way to titrate and monitor any kind of side effects and try to avoid those.

Peterson: Yeah, I mean, this is always the role the pharmacist has played. It's just that we're now in a different arena, and we've been sort of disconnected from the product side, which is one of the challenges. Historically, the pharmacist has been able to look at an inventory and say, “This is what we have, and this is how we would navigate it.” And now the pharmacist, for example, the few patients that I do this sort of consulting with, you've got to pull up the dispensary menu and try to discern what you can from the information available, which is not great. It's legal that all these products have a certificate of analysis, but because we've done such a mediocre job at truly creating a comprehensive and well-run market in California and many states, but California is a glaring example of challenges, that information isn't even available, which is the laboratory analysis. Getting back to how pharmacists can help, having a baseline understanding of what we're talking about here is important. Because we're not talking about some niche medicine that very few of your patients, if ever, you will see taking, which is plenty of the medicines we learn about. What we're talking about is an herbal botanical that is used by more people than basically any other substance on the planet. Other than alcohol and tobacco, this is right there as something that many, many, many of your patients are consuming. Being informed about it, understanding that it's a cannabis flower, and what these cannabinoids are and/or do, the risks, the potential benefits, all of this is on you, as a pharmacist. We've been able to put our head into the sand because, “Oh, it's illegal. Oh, it's a schedule I. We don't need to know about that medicine or about that.” But we're educated on tobacco and tobacco cessation. Why wouldn't we be educated on the herbal botanical that is marijuana and cannabis and understand it? Again, the bio-actives, the active ingredients [of] CBD and THC, are both FDA approved. We [have] got to take our hand out of the sand and address that this is a plant that people are using, and the onus is on us.

Halpern: Great answer, Codi and Jill. And Jill, you kind of got into some of the possible adverse effects that could be associated with medical cannabis use. Just for the sake of time, you went over some of them briefly, like the dizziness that could be associated with it. Are there any other major ones that patients should be aware of, and what strategies can pharmacists employ to properly monitor for adverse effects in patients using medical cannabis.

Simonian: Alright, I'll share this with Codi, but I'll take one and its tachycardia, which is a very common side effect with THC. Of course, dose matters for all of this, and the higher the dose, the more side effects, including tachycardia. But even at low doses, some patients do experience tachycardia, so that it could be maybe just scary, or it may be concerning, depending on the cardiac history of the patient. That's one Codi.

Peterson: It’s such a good one, because if it's not one that everyone talks about, it's the reason the reason the pharmacist needs to be more involved, and people need to be aware, because some patients are going to be at extremely high risk of this side effect. It could be concerning to them, because maybe they have an underlying anxiety disorder, or maybe they have a heart condition where their heart sometimes goes into an arrhythmia, and so this is a bigger concern for them, as opposed to the other patients. Teaching people that it's dose-dependent, to expect it; yes, you're going to feel anxiety or rapid heart rate. I think one thing is the patients really need to know about edibles, that they can take 2 or even 3 hours to start to take effect. What they've eaten that day influences how they're absorbed. It's really critical that, until you know how a dose affects you, that you kind of slowly work up to that. Unfortunately, especially in in the sort of black market, which is also thriving in California, there's no requirements or sort of limit on how much people can put in a single candy bar, so to speak. We've got products with 300 or 500 milligrams out there that people don't realize, don't understand, or have the aren't informed enough to know that that's a huge dose for them. The quality of those products is low, so they're mislabeled. There may not be that much. There might be a little bit more than that. There's a lot of places that people can find hiccups. I think some side effects to be aware of is the delayed onset of edibles, and that we need to be giving that the medicine 3 or more hours before taking more, so that we don't stack doses and find ourselves in a very uncomfortable situation. One example of those side effects that can happen there is paranoia, and so you're really nervous, and you feel unsettled, and that the world is sort of coming in on you, or you're going to get in trouble because of the schedule I substance you just consumed. Fortunately, that's come down a little bit, but it's still very much, “I just did something that's bad,” and that can really on a new patient, or one who was around during the heaviest time of DARE and the drug war and all that, that could be really disconcerting.

Simonian: I agree. I think that's one of the most important pieces to educate, counsel your patients on is that stacking the doses, and that it tends to be what brings these naive users to the emergency rooms. I would say another issue to communicate with our patients is the combination of different drugs that they might be using that that, in combination, can increase the side effects. For instance, any kind of CNS-depressants—opioids, benzos, any other antidepressants, perhaps gabapentin—in combination with THC, can increase those side effects. You definitely need to warn about that, and also about driving, because there's that can interfere with your driving ability.

Peterson: Totally agree, that's THC-oriented. And then I'm just going to piggyback off Jill and say that specifically, when we're talking about CBD, and larger doses of CBD, like the prescription strengths, that's when we start to think as pharmacists about drug-drug interactions from a metabolism perspective and inhibition of enzymes. CBD inhibits some P-glycoproteins, and the CYP 450s, especially 3a4, 2c9, 2c19. Any drugs that are really heavily metabolized and important, right, narrow therapeutic window, those are the ones we think about. An example is tacrolimus (Envarsus ZR, Prograf). Another would be warfarin (Jantoven, Coumadin; Bristol-Myers Squibb). There's a number of them, but I encourage the pharmacists in the room to go use those that information and learn about that. But large doses of CBD do have these enzymatic effects in the liver. And then one more to note would be the valproic acid-CBD combination that doesn't appear to be altering the levels of valproic acid, but increasing risk of liver toxicity. So those are some ones that come to mind. You

Simonian: Real quick, I have to say that please, I would not advise your pharmacist to go to drugs.com and look at the drug interactions, because it's very misinformed. Any drug that is metabolized in the liver is listed there, and it's not true, and there's no evidence to support that. And it is, again, like Codi said, high doses of CBD seem to be the culprit, not necessarily THC, and certainly not the doses of CBD that people are getting from their supermarket.

Peterson: Yep, those are much lower usually, I totally agree. There's a tool from Penn State that is pretty strong. I like to recommend that one. There are companies’ kind of looking at, can they develop a drug interaction checker? But it turns out this information, there's just not that much data out there on it, and there's so much variability in dose and things like that that it's been a challenge. These tools are eventually going to have to come because cannabis is coming into the hospital. One of our big initiatives at the PCCC has been to help hospitals in California address Ryan's Law, which is a [law] that mandates that your terminally ill patients have the right to consume enteral cannabis while in their institution. There's a lot to unpack there, but if you're more interested in that, definitely come check out our website and learn about Ryan's Law and learn what sort of tools and assets we've already developed for you and your hospital to help meet this regulatory necessity.

Halpern: Yeah, that was all great, and that was a good segue, because I think we covered a lot, and I think this is a perfect area to conclude our conversation. I wanted to ask you guys if you had anything else that either of you wanted to add in our short time remaining, if you wanted to plug anything, and where you can be reached at, what initiative initiatives you guys are doing. You guys, you have the floor for a minute and 40 seconds.

Simonian: Well, our group is PCCC, and I'll throw out our other colleagues, Kari Franson, Paul Lofholm, and Leah Johnson, and the 5 of us form this group, and that's us. You can reach us at info@PCCCrx.org and we also have a website at PCCCrx.org same thing. If you want more information, please reach out to us.

Peterson: Yeah, I would say definitely that, if you're interested in what we're working on, for pharmacists, and especially pharmacists in California, reach out there. If you just want to give a follow and learn more about this topic, Jill and I are both on LinkedIn, and I'm on Instagram. It's @CannabisPharmD, kind of my flower and my degree and no underscore, no dot. I want you to come check it out. I encourage pharmacists to have this mindset and to teach and tell all of our students that we're already pre tuned for this work. We have been introduced to this work, so I have full faith that pharmacists can lead this forward. And I encourage you all to get involved.

Halpern: That was awesome. This was a fantastic conversation, guys. Jill and Codi, thank you both so much for taking this time out of your I'm sure busy schedules to talk about this important topic. I guarantee pharmacists listening have learned a lot today. Thanks guys. Have a good rest of your day.