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T here’s a lot more to medicinal cannabis than meets the eye. Speak with the experts and you soon discover that the cannabis compounds of tetrahydrocannabinol (THC) and cannabidiol (CBD) might just have their place within mainstream healthcare. Currently, in Australia, “almost all medicinal cannabis is scheduled under the Special Access Scheme and thus can only be prescribed by a registered medical practitioner”, states the Therapeutic Goods Administration (TGA). The TGA continued: “With the exception of one product (Nabiximols), medicinal cannabis products are not registered medicines in Australia, so they must be accessed through special pathways available for unapproved medicines ... Such access can only be arranged through an Australian- registered medical practitioner with appropriate qualifications and/or expertise for the medical condition requiring treatment. “This doctor can notify/apply on the patient’s behalf for approval to import and supply these products through the Special Access Scheme (SAS, category A or B). Alternatively, the doctor can apply \\\\\\\\\\\\\\\[to the TGA\\\\\\\\\\\\\\\] to become an authorised prescriber (AP).”1 In addition, some states and territories may have their own qualification criteria. While currently THC (Schedule 8) and CBD (Schedule 4) both remain drugs that can be prescribed only through the SAS or an AP, access to low dose CBD is being reviewed. Last November, as reported on the TGA website, an inquiry into the current barriers to patient access to medicinal cannabis in Australia was referred to the Senate Community Affairs References Committee for inquiry and report by March 26, 2020.2 According to the TGA, in January this year the Department of Health made a submission to this inquiry, including that the TGA was undertaking a safety review of CBD at lower doses, noting that there were “only limited published studies”.3 The Department also noted, within the submission, that “depending on the outcome of the review, the scheduling status of low dose CBD products would be considered”,4 meaning that CBD would go from a Schedule 4 (prescription only) to a Schedule 3 (pharmacist only) medicine. This makes community pharmacy, pharmacists and pharmacy assistants significant players within the medicinal cannabis space, with an important role. “It’s critical that pharmacists \\\\\\\\\\\\\\\[and assistants\\\\\\\\\\\\\\\] have the facts ... a lot of the time people go to a pharmacist first \\\\\\\\\\\\\\\[so\\\\\\\\\\\\\\\] pharmacists \\\\\\\\\\\\\\\[and assistants\\\\\\\\\\\\\\\] need to play a key role \\\\\\\\\\\\\\\[in this space\\\\\\\\\\\\\\\],” said Pharmacy Guild Queensland Branch Vice-President Kos Sclavos AM, a passionate supporter of medicinal cannabis use in healthcare. “\\\\\\\\\\\\\\\[Pharmacy assistants\\\\\\\\\\\\\\\] need to be able to triage patients to the pharmacists. I expect many patients are carers \\\\\\\\\\\\\\\[and\\\\\\\\\\\\\\\] will engage with pharmacy assistants. In addition, pharmacy assistants will be required to assist with administrative roles to do with the ordering and supply of the products.” According to Mr Sclavos, “the knowledge base of CBD and THC – how they work and what they’re for – is not covered” within the medical education/training streams, and this is something that all pharmacists, and other health professionals, need to be upskilled in. “At the moment a lot of people rely on illicit \\\\\\\\\\\\\\\[cannabis\\\\\\\\\\\\\\\],” he said. “They can’t get a prescriber. \\\\\\\\\\\\\\\[My\\\\\\\\\\\\\\\] driver is to make sure that medicinal cannabis is normalised in the pharmaceutical supply chain.” psychoactive effects. According to the TGA, “unlike THC, CBD does not cause psychomotor or cognitive impairment, 5 or strong psychoactive effects”. THC is the cannabinoid “responsible for the psychoactive effects of cannabis and is the reason cannabis is used recreationally”, the TGA says.6 According to Justin Sinclair, research fellow at NICM Health Research Institute, Western Sydney University, “essentially the difference between medicinal cannabis and illicit cannabis is one of quality assurance and the standardisation of cannabinoids, the former being an important aspect of safety, and the latter \\\\\\\\\\\\\\\[allowing\\\\\\\\\\\\\\\] for consistency in therapeutic results”. He adds that surveys have shown that many Australians are using illicit cannabis for therapeutic purposes (i.e., without medical supervision) for a wide array of different conditions and symptoms. “THC is the main cannabinoid associated with the intoxicating effects of the plant, and while generally found in higher concentrations in illicit supply chains, THC is still present in many of the products being used by medical practitioners in Australia – particularly for chronic pain,” Mr Sinclair said. Dr Ben Jansen, Clinical Director of Cannabis Doctors Australia and CDA Health, added: “When you say medicinal cannabis, it’s a broader term because it’s not just CBD by any means. We’re prescribing THC as well. “About 40 per cent of our prescriptions are CBD alone, the other 40 per cent are THC alone and then 20 per cent are blended products. Commonly we will prescribe a CBD and a THC so that a patient can adjust the dose of the CBD for their conditions that respond to the CBD, which will be different, in general, from what will respond to the THC.” What conditions does medicinal cannabis manage? Dr Jansen says the medical team at Cannabis Doctors Australia prescribe CBD and/or THC for a variety of medical issues, including “neuropathic pain, inflammatory pain, degenerative pain, and beyond that the next most common \\\\\\\\\\\\\\\[condition\\\\\\\\\\\\\\\] is anxiety”, which makes up “anywhere from five to 10 per cent of prescriptions”. TO PAGE 32 MEDICINAL CANNABIS 31 “At the moment a lot of people rely on illicit \\\\\\\\\\\\\\\[cannabis\\\\\\\\\\\\\\\]. They can’t get a prescriber. \\\\\\\\\\\\\\\[My\\\\\\\\\\\\\\\] driver is to make sure that medicinal cannabis is normalised in the pharmaceutical supply chain.” What is medicinal cannabis? When talking about medicinal cannabis it’s important to differentiate what, exactly, the discussion is about, as up to 100 cannabinoids are present in the cannabis plant. The major cannabinoids found in the plant are CBD and THC, which are typically what is being referred to when we speak of medicinal cannabis. CBD and THC both have therapeutic uses and differ based on their RETAIL PHARMACY ASSISTANTS • AUG 2020