Are Pharmacists Ready for Recreational Cannabis?

On October 17, 2018, Canada became the second country to legalize the recreational use of cannabis.¹ While the new legislation only authorizes recreational use for those 18 years or older with specific restrictions controlling the production, distribution, sale, and possession of cannabis, Canadians were still divided in their support of the legalization in the months leading up to the date.^1,2

How do pharmacists feel?

Pharmacists proudly wear the title of medication experts, however 75% of Canadian pharmacists admitted to never asking about cannabis when reviewing a patient's medication to assess for drug interactions and 82% said that they don't know about the Canadian cannabis guidelines.³ Although cannabis for medical purposes has been legal since 2001, Canadian pharmacists generally feel unprepared the handle the influx of questions that will follow the legalization of recreational cannabis.³

Finding our place

Personally, I think pharmacists should embrace this new legislation as an opportunity to show the value of our profession to patients, rather than being too afraid to admit that we don't know all the answers right now. Here are some of the ways that I envision pharmacists applying their expertise to help patients using cannabis both recreationally and medically.

1. Harm Reduction

Legalization will likely increase people's comfort and openness to sharing their cannabis use with  healthcare providers. Coupled with the idea of pharmacists being the most accessible healthcare provider, pharmacists are in a good position to screen for a cannabis-use disorder. Similar to principles we use in harm reduction for alcohol or opioid dependence, we can provide patients with practical tips for reducing the harms of cannabis^5,6:

• Avoid driving for 4-5 hours after use
• Shift away from smoking to other routes (i.e. vapourizers, edibles)
• Delay use until after 25 years old since the brain is still developing
• Avoid frequent (daily or near-daily) use
• Store cannabis safely and away from children

2. Drug Interactions and Managing Side Effects
Using the current understanding of cannabis drug interactions, pharmacists are able to provide evidence-based answers to patients wanting to know how cannabis fits in with their prescription and non-prescription medications. In addition to using our unique knowledge of drug metabolizing enzymes, we can use our clinical judgment to examine the significance of cannabis side effects overlapping with prescription drug side effects.

Common unwanted side effects of cannabis include uneasiness, sedation, muscle twitches, and impaired memory or confusion.⁶ We can help patients manage these short-term side effects by encouraging them to reduce the tetrahydrocannabinol (THC) content of the strains being used or reduce the frequency or amount of cannabis being used.⁶ It is important to communicate with patients that the long-term side effects of cannabis remain unknown.⁶

3. Filling in Knowledge Gaps
One main barrier to conducting extensive research on cannabis is that it is not widely legalized. At present, what we know about cannabis for medicinal and recreational use is based on evidence gathered from small short-term studies. Despite this, pharmacists should be knowledgeable about the current information and be willing to share it with patients. Looking to the future, legalization in Canada can create an opportunity for further research in areas that are lacking - long-term side effects, optimal strains and dosages for medical uses, and impacts of legalization on society.

If you'd like to brush up on the current evidence on cannabis and its medical use in time for the recreational legalization, consider the course Medical Cannabis IQ: The Fundamentals on Advancing Practice or other continuing education courses offered by the Canadian Pharmacists Association.

Chantel

References

1. Government of Canada. Cannabis Legalization and Regulation. Accessed October 15, 2018: http://www.justice.gc.ca/eng/cj-jp/cannabis/
2. Navigator. Cannabis in Canada. Accessed October 15, 2018: http://www.navltd.com/wp-content/uploads/2018/03/Cannabis-In-Canada_03_2018.pdf
3. Pharmacy5in5. "Recreational cannabis will be legal on Wednesday". Message to Pharmacy5in5 Mailing List. October 15, 2018. Email.
4. Government of Canada. Understanding the New Access to Cannabis for Medical Purposes Regulations. Accessed October 15: https://www.canada.ca/en/health-canada/services/publications/drugs-health-products/understanding-new-access-to-cannabis-for-medical-purposes-regulations.html
5. Government of Canada. Cannabis in Canada: Get the facts. Accessed October 15, 2018: https://www.canada.ca/en/services/health/campaigns/cannabis/canadians.html
6. Grindrod, K & Beazely, M. Cannabis 101. Accessed October 15, 2018: https://uwaterloo.ca/pharmacy/sites/ca.pharmacy/files/uploads/files/cannabis_infographic_2_sided.pdf

Flu Season is Coming ... with Some Updates

"When are flu shots coming in?" is the most frequently asked question at every community pharmacy counter once Thanksgiving weekend rolls around. Although pharmacies will have to brace themselves for the increased workload and disruption to normal prescription workflow, it's great to see that so many patients understand the importance of protecting themselves and the people around them against the flu and its complications.

While flu shots are slowly making their way into community pharmacies, pharmacy students are also preparing for the extra volume of patients flu season brings. For some of us, including myself, this year's influenza vaccine will be the first vaccination we've ever administered.

On top of remembering documentation requirements, the correct process for land-marking an injection site, and procedures for anaphylactic reactions, we should also keep in mind the important update for those 65 years and older as we're handing out influenza vaccination questionnaires to patients.

What's the update? 

The Canadian Immunization Guide created by the National Advisory Committee on Immunization (NACI) details current evidence-based recommendations on the use of vaccines for disease prevention in different populations. In an update for the 2018 flu season, NACI acknowledges evidence that the high-dose trivalent inactivated vaccine (TIV) provides better protection than the standard-dose TIV against flu-related complications and hospitalizations in those aged 65 and older.¹

When considering the evidence for provincial and territorial funding, NACI recommends that any of the four influenza vaccines indicated of those 65 years and older - standard-dose TIV, high-dose TIV, adjuvanted TIV, and quadrivalent inactivated vaccine (QIV) - can be used.¹ On the other hand for individuals 65 years and older seeking to get vaccinated and clinicians who are advising individual patients, NACI recommends the high-dose TIV be offered over the standard-dose TIV.³

How will this impact community pharmacy?

Currently in Canada, Ontario is the only province to publicly fund the high-dose TIV for all adults 65 years of age or older, while Nova Scotia, Manitoba, Saskatchewan, and Prince Edward Island are only funding the vaccine for elderly people living in long-term care facilities.² Ontario pharmacies will not be receiving high-dose TIV as a part of the Universal Influenza Immunization Program (UIIP) and so the vaccination will only be publicly funded if received at a physician or nurse practitioner's office, retirement home, long-term care facility, or hospital.³ 

While sharing the demands of flu season with other healthcare providers may relieve some of the burden on Ontario pharmacies, it leaves us with a question - what should we be doing with patients 65 years and older? There isn't enough evidence to make a comparative recommendation between the high-dose TIV, adjuvanted TIV, and QIV.¹ So should we be vaccinating patients over 65 in community pharmacies or send them straight to their doctor's office? We can't possibly expect physicians and nurses to vaccinate all Ontarians aged 65 and older, so how do we decide which patients to refer? Would turning patients away significantly delay vaccination or even discourage them from getting vaccinated?

How will you apply NACI's recommendations to patients over 65 wishing to get vaccinated in your pharmacy? Please send me your comments and experiences using the form to the right.

For more information on influenza vaccinations in older adults and how to approach vaccine hesitancy, see the Influenza in Older Adults - Ensuring Optimal Protection course offered on rxBriefCase.

I look forward to reading your comments!

Chantel

References

1. Government of Canada. (2018, May 1). Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2018-2019. Accessed October 9, 2018: https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-statement-seasonal-influenza-vaccine-2018-2019.html#1.1
2. Sanofi. (2018, October 1). Sanofi aims to topple the flu as it marks National Seniors Day with a Guinness World Record attempt. Accessed October 9, 2018: https://www.newswire.ca/news-releases/sanofi-aims-to-topple-the-flu-as-it-marks-national-seniors-day-with-a-guinness-world-record-attempt-694786581.html
3. Ontario Ministry of Health and Long-Term Care. (Updated 2018, September 19). Universal Influenza Immunization Program (UIIP). Accessed October 9, 2018: http://www.health.gov.on.ca/en/pro/programs/publichealth/flu/uiip/

WPD - The Significance behind the Abbreviation

In 2009, the International Pharmaceutical Federation (FIP) designated September 25th as World Pharmacist Day, commonly abbreviated as WPD.¹ The theme for this year is "Pharmacists: Your medication experts".¹ Although World Pharmacist Day shares the same date as other international holidays - World Dream Day, German Butterbrot Day, and One-Hit Wonder Day - the day has a great meaning to pharmacists and pharmacy students across the world.²

The Theme

The goal of World Pharmacist Day is to encourage pharmacists to advocate for their role in healthcare and to bring awareness to their unique knowledge base. Regardless of the differing scopes of pharmacists across the world, the most fundamental responsibility is to ensure that the right patient receives the right medication. This breaks down the perception of pharmacists as "pill counters" and emphasizes that pharmacists have a role in protecting health by using their expert medication knowledge to assess the appropriateness of medications for each patient. In keeping with the idea of pharmacists as one of the most trusted professionals, this year's theme also highlights that not only do we provide current and evidence-based information about medication to patients, but also to other healthcare professionals.^1,3

Past World Pharmacist Day themes, such as last year's theme "From research to healthcare: Your pharmacist is at your service", have similarly countered other publicly-held opinions of pharmacists.⁴ The 2017 theme reflects that pharmacists contribute to patient health not only in patient-care settings like hospital or community pharmacy, but also in diverse settings like research, industry, and education.⁴

The 2018 Celebrations

The president of the International Pharmaceutical Federation, Dominique Jordan, invited pharmacists across the world to spread this year's message within their communities, at work, and on social media by decorating their profile pictures with a World Pharmacist Day Twibbon.¹ 

Pharmacy students at the University of Toronto embraced the theme by participating in a social media competition that involved completing the sentence "I am a future pharmacist and I am an expert in ____" and posting a photo on social media holding up the message. Outside of the University of Toronto pharmacy world, a simple search of "World Pharmacist Day 2018" or "WPD 2018" on Facebook, Twitter, or Instagram pulls up a long list of pharmacists, patients, and organizations from across the world celebrating the impact of pharmacists.

The Impact

Appreciation days, whether they are for bringing awareness to pharmacists or the best one-hit wonders, are meant to get the conversation started and serve as a platform for more questions and opportunities to advocate in the future. From my experience participating in Pharmacy Awareness Month last March where I spoke to patients about the expanded scope of Ontario pharmacists, many people were unaware of some of the things their pharmacists could do for them. Although I didn't have an extensive conversation about it with every patient, I'm sure I left the door open for them to ask their pharmacist about it at their next visit or ask their friends or family if they've had experience with it. 

Judging by the number of likes, comments, and shares of WPD 2018 social media posts and pictures, the campaign must be working to get people engaged and talking about the role of pharmacists.

Hope you had a happy World Pharmacist Day!

Chantel

References:

1. International Pharmaceutical Federation. World Pharmacist Day. Accessed on October 2, 2018: https://www.fip.org/worldpharmacistsday
2. Days of the Year. Browse all the weird holidays on ... 25th, September 2018. Accessed on October 2, 2018: https://www.daysoftheyear.com/days/2018/09/25/
3. Marotta, Ryan. (2018, February 9). Pharmacists Remain Among Most Trust and Ethical Professionals. Accessed on October 2, 2018: https://www.pharmacytimes.com/news/pharmacists-remain-among-most-trusted-and-ethical-professionals
4. International Pharmaceutical Federation. Diversity of profession to be focus of World Pharmacist Day 2017. Accessed on October 2, 2018: https://www.fip.org/www/index.php?page=news_publications&news=newsitem&newsitem=242