Expanding medical marijuana access in Canada: considerations for the rheumatologist.

Similar to the enthusiasm for treatment of various ailments that greeted Nicotiana tabacum when brought to Europe from the New World 500 years ago, Cannabis sativa is now hailed as a possible treatment for a multiplicity of symptoms1. Embraced by physicians and the people, from commoners to the aristocracy, the enthusiasm for Nicotiana tabacum was questioned by a discerning few with concerns about the “indiscriminate use of the herb for all diseases in all age groups without specific measured prescriptions”1. Much like for tobacco many years ago, marijuana as the byproduct of Cannabis sativa, with significant financial incentives, requires careful appraisal regarding true therapeutic potential. Cannabinoids are a diverse group of compounds, including in the animal/human system, phytocannabinoids derived from plants, and pharmaceutically prepared synthetocannabinoids. The herbal product is a complexity of over 400 molecules, thereby not allowing for direct comparison or interchangeability with synthetocannabinoids. While the latter are currently available as treatments for some conditions, we will focus on issues pertaining to the use of the phytocannabinoid marijuana (hereafter “herbal cannabis”) in rheumatic diseases. Therapeutic effects have been claimed for various conditions for centuries, but herbal cannabis largely fell into medical disfavor because of variable potency and short shelf life, and was superseded by synthetic analgesic agents that could be reliably dosed and studied2. As pain relief for rheumatic conditions is commonly cited as a reason for medicinal cannabis use, rheumatologists are increasingly caring for patients who are either selfmedicating or requesting advice regarding use. Legislators worldwide are currently debating the merits of expanding access to herbal cannabis for medicinal purposes. In some countries such as Canada, physicians will now be required to write a prescription for herbal cannabis. With increasing pressure from legislators, driven by public advocacy, there exists a discord between patient perception of a need and responsible clinical care. Health Canada Regulations, Current and New As Canada has been at the forefront of legalizing herbal cannabis for medicinal reasons, the timeline for access and current legal status for medicinal herbal cannabis use will be examined. In 2001, Health Canada adopted Marijuana Medical Access Regulations (MMAR), which recognized herbal cannabis as a treatment option for patients with various medical conditions, including severe pain from severe forms of arthritis, when the medical practitioner attested that “conventional treatment(s) have been tried or considered, and have been found to be ineffective or medically inappropriate.”3 Under these regulations, the medical practitioner provided the medical justification for an application, but not a prescription. Approval for possession of a specified amount of herbal cannabis was given by Health Canada officials. The Government of Canada repealed the MMAR on March 31st 2014, and replaced these regulations with the Marijuana for Medical Purposes Regulations4. Under these new regulations, the medical practitioner will be entirely responsible for herbal cannabis prescriptions, similar to current prescribing practices for other drugs. A “medical document” stating daily dose and duration of use will be completed. These new regulations do not restrict use of herbal cannabis to any specific medical condition, nor do they require demonstration of failure of conventional treatments.