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“In a perfect world, we’d see cannabis available in pharmacies, just like any other drug or supplement. And if you don’t need the pharmacist’s help, great — somebody else will,” says cannabis pharmacist Dr. Melani Kane.
In some US states, pharmacists are required to be on site at cannabis dispensaries to help with dosing, build treatment plans, and to watch out for potential drug interactions. And cannabis, CBD in particular, can affect the ways other medications work in your body.
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For patients, just having a medically knowledgeable resource available can ease some of their anxiety, Dr. Kane says. Explaining what to expect is a huge part of that.
“The side effects of THC can be very uncomfortable. They’re not life threatening in any way, shape or form — it’s definitely the safest drug I’ve ever dispensed,” Dr. Kane continues. “But if you have that feeling of anxiety or dysphoria, if you’re expecting it to make you sleep and it doesn’t and you’re up all night, I think that can be very discouraging to patients.”
Dr. Kane also spoke about the pitfalls of adult use legalization displacing or replacing medical cannabis programs.
“The populations that [most] benefit from these medical programs are the very young and the elderly, because you’re not going to have a 85 year old going into a dispensary trying to figure out what works for them,” she explains. “And kids can’t use adult use programs without that medical permission.”
Dr. Kane is the co-founder and executive director of the International Society of Cannabis Pharmacists, which is holding its Clinical Cannabinoid Pharmacy Conference in mid-August 2020, helping to educate medical professionals, particularly pharmacists about cannabis medicine.
For 15% off tickets to the conference, use coupon code “Cannigma15.”
This episode was edited, produced, and mixed by Michael Schaeffer Omer-Man with production assistance from Matan Weil. Music by Desca.
Full transcript:
Michael Schaeffer Omer-Man: Dr. Melanie Kane. Thank you so much for speaking with us.
Dr. Melani Kane: Thanks for having me
Michael: I want to start with the most obvious question to me, which is what is a cannabis pharmacist?
Dr. Kane: So we are regular pharmacists that understand the science and the potential value of using cannabis as a medicine. So in the United States and around most of the world, cannabis is not viewed as a medicine with any potential medical benefit.
And so with our understanding of pharmacology and the body, it really helps. From our perspective to explain to other physicians and other patients. And of course, other healthcare professionals, what the role of cannabis may be in the body, in disease and in compassionate care.
Michael: And what does that work look like for you for others?
Dr. Kane: So my first job out of college, after I graduated and got my doctor of pharmacy license, I returned home to my home state of Minnesota and we require pharmacists in the dispensaries to make clinical recommendations. So the doctor is diagnosing. They see patients, they look at their medical conditions and determine whether they are a valid candidate to use cannabis, and then they come to me, the dispensaries where pharmacists like myself are charged with creating initial recommendations, as well as monitoring and evaluating for side effects and other reasons that we might need to change therapy.
So, not only are we providing direct clinical recommendations, but we can also counsel and educate on drug interactions, side effects, formulations, you know, just like with any medicine, if there’s a device involved, whether it’s a syringe or if it’s an inhaler, there’s a technique that is to be used.
And a lot of times there’s that communication piece, that education piece is missed from the initial consultation or, you know, when the patient is visiting the doctor. So we kind of focus on the drugs.
Michael: I feel like that’s a piece that’s missing for, at least most of the places in the United States where medical cannabis has become available over the past decade or so, where, let’s say in California, you get a recommendation from a doctor, you go into a dispensary and you have somebody who doesn’t have any medical training giving you recommendations that are probably based on no science at all.
Dr. Kane: And unfortunately, you know, we’re in such a legal regulatory landscape where a lot of states thought that was the best course of action. You have a lot of different organizations lobbying both for and against healthcare professional involvement. I’ll give you a personal story. I was walking through the waiting room in between consultations and I heard one of the technicians. So we have pharmacy technicians, of course, and I heard them on the phone with a patient and I couldn’t hear the patient, of course they are on the phone, but I could hear the technician. And she said, “look, man, I don’t know what a PE is, but yeah, I’m sure you can vaporize just fine. Don’t worry about it.” And I like my eyes bulge. I thought, a PE is a pulmonary embolism. Like if you don’t know what that is, why are you, why are you providing a recommendation on its behalf?
So I, you know, I stopped dead in my tracks and I said, just let them know, the pharmacist will call them back. This is the exact ideal situation in which, you know, you have people that might not understand what is that disease state, or what is it is that contraindication, which is really a reason that someone would not want to use cannabis.
And using it in a way that is both safe and possibly effective. I think that’s kind of the biggest challenge that our healthcare professionals have. It’s not just one pill fits all. When I look at modern medicine, we have these pre-formulated tablets and capsules and liquids that are in very precise concentrations. And we study them in thousands of different bodies and they all have the same response. And you know, of course every drug has a side effect or a potential adverse effect. But when it comes to cannabis, the body responds so uniquely that you can’t predict what will happen.
And I know people will ask me, like, what, what does it feel like? I don’t know, well, it feels like you need it. If you need to sleep, it’ll help you sleep. If you need to increase your appetite, we can do that. Nausea. There’s no other medicine that can target so many different symptoms. So it truly is, you know, seen as this magic snake oil cure all.
And unfortunately that’s because of the education that’s put forth. I’ll tell you in pharmacy school, we spent a whole two minutes learning about the endocannabinoid system and phytocannabinoids because we have dronabinol or Marinol in the market. And even still, you know, they said “we never use this in practice, you’d be a fool to recommend it.”
And they’re right. You know, it is very potent. Medicine that is more likely to elicit side effects and patients don’t like that, they don’t like to feel out of control, out of body, out of mind. And so when I had the opportunity to work one-on-one with medical cannabis extracts and see how, not only can you fine tune the dose and the ratio, but, you have all these different formulations that can be tailored to help patients find what they need. And so whether that’s a long-acting product or a short-acting product, you know, that’s really the, I consider the beauty of medical cannabis because we have that versatility. We can personalize this medicine to the patient’s needs and that’s something that medicine has gone away from.
Michael: I wanted to circle back to something you said a little bit in the beginning of that answer, which was about interactions and contra-indications. We generally do think of cannabis, at least compared to a lot of the drugs that are used to treat, you know, similar conditions, particularly pain, as having a very good safety profile, but there are drug interactions.
Can you talk us through, tell us what some of those are and why it’s important for somebody to be able to look at what you’re taking and say, hey, wait a minute, maybe we should address this differently?
Dr. Kane: So there’s a few different types of drug interactions. There’s the type that, you know, two drugs, both cause low blood pressure and so we can have this additive effect with cannabis. It’s more so with THC, we can see additive sleepiness, dizziness, and that can be very interrupting or distracting for the patient. And so I think with a perfect medicine, with a perfect cannabinoid medicine, we’re not causing impairment or intoxication.
And I think that’s, you know, a clear distinction from what I consider recreational or adult use, is the goal of therapy, right? Feeling impaired or intoxicated. Yeah. So, THC has its own potential for drug interactions from a pharmacodynamic perspective, meaning its effect on the body.
And then when you have CBD — so everyone thinks CBD is like the safest thing and it should be in the water supply but I actually, in my personal and professional experience encountered more drug interactions with CBD. So it is an enzyme inhibitor, meaning it prevents the function or the action of certain enzymes, which typically function to detoxify and get rid of things in the body.
And so some of the drug interactions that I’ve personally seen with it are typically with antiepileptic drugs. So anti-seizure medicines. I’ve also seen it with other types of pain medicines or mood medicine. So like antidepressants, antianxiety drugs. And when you think of the patient population that’s gravitating towards CBD or cannabidiol, they are the ones that are seeking its anti-anxiety benefit or seeking its use as an antiepileptic.
And so that’s really where we can get into trouble. I remember having a, I think he was like four or five years old, very young kid coming in, and I’m talking to the parents and I said, you know, he’s already taking three different antiepileptic drugs.
And I asked like, when was the last time we took a level of these medicines? And they’re like what? We’ve never taken the level. I’m like, I’m sure your neurologist is checking the levels. Like, you know, this is something we do. It’s quite common in practice. You do a blood test. She’s like, no, no, no. He’s never mentioned anything that their neurologist never recommended.
And I thought, I don’t feel comfortable with you starting this without getting a baseline level. How are we going to know if it’s working or not? Because with a lot of conditions, seizures being a prominent one, I’d say Tourette’s is another one, it’s a very fine line of symptom control and being very, very sleepy.
And again, that’s the impairment, that’s the intoxication that we want to avoid. And there’s other drug interactions that can occur as well, where it may be the cannabinoid prevents that other medicine from working, or another medicine prevents cannabis from working. I read some case reports that anti-inflammatories, so you might know them as NSAIDs, that’s like your ibuprofen or Naproxen, your Meloxicams, these types of medicines, just the way that they work in the body could potentially decrease the effectiveness of THC as an anti-inflammatory. Which in turn is a pain, anti-pain modality or an analgesic. And my favorite story I like to share about my drug interactions is I had a patient using seizures.
She was using CBD for seizures and she was, she was like 19 or 20, you know, not a child, but she was very developmentally delayed. So we didn’t have that advantage of being able to talk to her and find out how she was feeling. We could only see the seizures and use that as our course of therapy determinant.
So her, her dad comes in and he says, you know, her seizures are getting worse over these last few weeks. And you know, I do my typical, what have we changed about her other medicines? And he says, there’s been no other changes, but we have increased the dose of CBD. And you’d think if you increase the dose of CBD you’re going to have better seizure control. And at this point, the dad had met with like three other pharmacists and like, nobody could understand why seizures were getting worse. And so I finally said something like, you know, are we holding it? Because it was a liquid. I said, are we holding it under the tongue? Or are we just swallowing it? Um, cause you know, a lot of these developmentally delayed patients, they have swallowing difficulties. I said, are we putting it with yogurt or something?
And the dad’s like, no, she has a, a tube, a G tube. So we’re bypassing the mouth entirely and we’re shoving this medicine into a tube and it’s going straight into her, to her stomach and her intestines.
And I thought, okay. What is the timing between, you know, this med, this CBD and her other seizure meds. And he’s like, Oh, I put them in the same syringe and I just shove them in. And I was like, okay. So I was like, let’s do a level and see, you know, what’s going on in the body. And sure enough, the concentration of the other seizure medicine, which in this case was levetiracetam, or Keppra as we call it the United States.
And I’ll tell you, this is like the neurologist go to, cause it has very little potential for drug interactions. So when it comes back that the level is decreased. And typically when CBD interacts with the medicine, it increases that drug’s concentration. You know, my only thought was it must be binding to itself in the tube binding to each other.
So the CBD binding to the levetiracetam, and that’s preventing it from being absorbed and utilized and exerting its antiepileptic action. And, you know, you just, you never know, you really gotta rely on your basic understanding. Cause a lot of times it really is that simple. And other times you go down this rabbit hole of all the research that’s out there and you know, if you’re looking at stuff from 20, 30 years ago, it can be conflicting with the reports from five, 10 years ago. And it makes it definitely more challenging, but just understanding how it works in the body, um, and the potential pluses and minuses thereof. I think that’s really the education that’s required to evaluate drug interactions.
Michael: You said that you got all of two minutes on cannabinoid medicine in pharmacy school. How did you get this education? And is that changing, that pharmacy schools aren’t teaching this at all?
Dr. Kane: Yeah, so I started from the beginning. I said that in Minnesota, we have vertically integrated dispensaries. So the same company grows, extracts processes, and then dispenses these products. And so I said , I need to go see the greenhouse. I need to see how the medicine is made, because these are questions I will get asked. And so I kind of started from the seed and worked my way up. And then when it came to understanding how these medicines are being used in the body and for different conditions, um, I would say it was really trial and error.
I read a bunch of different studies and scientific summaries and meta analyses and there they were somewhat helpful. I think the most helpful thing for me was learning about the endocannabinoid system and understanding it’s integral role with every other system and it kind of made it easier to understand, okay, well, you know, if we are using it for this action, we’re probably gonna need a lower dose or, you know, a better ratio.
And honestly, it’s, it’s experimentation. You know, I mentioned that this is such a personalized medicine. Not only does time of day affect your dosing strategy, whether it’s AM or PM, but symptom severity. That’s another one. But I think them knowing that there’s a resource available, that has an idea of how medicine in the body and they interact with each other, and, you know, obviously the goals of therapy. I think that is really what kind of eases some anxiety for a lot of our patients. In Minnesota, our average age is around 50 years old. So my youngest patient I’ve ever had was two months old and my oldest was 101. So there’s a quite a variable spread.
And you never really know how they’re going to respond, what’s going to happen. But I think you get to a certain point where you’re willing to try anything. If the doctor is willing to try cannabis, it tells me that they’ve already tried and failed every other pharmaceutical option on the market.
And I don’t want to use the term that they’re desperate, but they’re willing to try something that’s been demonized for the last 80 years. And, you know, I think about how low potency products were 50 years ago, 10 years ago, even. And so these are different products, it’s on the market. And now in Minnesota, for example, everything we have is an oil extract.
So I don’t have the flower in front of me to give to patients. Everything is precisely dosed in a very standardized ratio. And that also makes it easier. And then, um, another kind of tactic I employ to help myself understand as well as other healthcare professionals, um, utilizing support groups.
And when I first started our support groups, I thought, you know, let’s do this by condition. Let’s do intractable pain and then we’ll do cancer. And then we’ll do seizures. And I had one for adults and I had one for kids. And then, you know, I took a step back and I thought. These are all the same products, right?
We’re using THC and a vaporizer for this and that and this, and I thought, why am I making it harder for people and siloing people based on their qualifying condition when I’d rather they talk to each other and say, you know what, even though I’m using this for PTSD, I have found is also helping my sleep.
And, you know, that helps my mood the next day. Like there’s all these different cascading effects from the use or the benefit of cannabis. And so that was, I think, very helpful for me to understand. And for patients, you know, being able to talk to each other, we would also invite healthcare professionals, like other doctors and physical therapists and occupational therapists to join these, the support groups, because their patients are using it. And I know they did not feel comfortable asking them, how does it feel? Are you impaired, you know, these types of questions? And so being able to hear it just like a fly on the wall, I think was very beneficial for these doctors.
And then the other thing that I found was very important was doing regular follow ups. So typically if, you know, I think of cannabis as more of like a supplement in the sense that it’s not as heavily regulated as all of our other prescription drugs. Yes. You know, there’s really no one enforcing you to get it refilled at a certain time because you use it as you need it.
And so I would do these like weekly phone consults just to check in with like new patients. And especially if they were having side effects, I wanted them to know that like, we’d be calling them that. They can call me sooner, but you know, that communication and that connection was being established.
And there’s so many people that, you know — my favorite story is, you know, 70, 80 year olds using their vaporizer and they don’t turn on the battery. So they’re like, you know, sucking on this device, it’s heating anything up and they don’t know why it’s not working. So it’s like little things like that.
But from that, I call them virtual consults. So from these virtual consults, which I think is all the craze right now with the coronavirus, um, but it really helped me understand those at-home moments when people are like, okay, I’ve tried this, it isn’t working. What next?
Michael: So we talked about how in most other States that that interaction with the pharmacist at the dispensary doesn’t exist and patients are left on their own, but in more and more States, it’s also available without any medical recommendation and especially with the, the availability of CBD across the whole country and much of the world these days, you know, at vitamin stores and gas stations even.
Do you think that’s a good thing or a bad thing? As far as, you know, there are some supplements and over the counter medications, treatments that you can get, that you don’t need to consult with a medical professional about, and, but everything I’ve heard you say right now makes me think that maybe we probably should.
Dr. Kane: Yeah, I feel that way as well. It’s our mission and vision to see cannabis based products in the pharmacies. So not only would patients have access to licensed healthcare professionals, but there’d also be a different feeling towards the med, seeing it as a medicine versus as an intoxicant. And so, I don’t think CBD belongs in gas stations.
I also think, you know, and I mentioned this earlier, a lot of people turn to cannabis as a last resort. And if you’re self-medicating incorrectly, you’re going to get more frustrated, spend more money. And you know, that in turn can make your disease state worse, just the stress of not, not knowing and not feeling good.
What I like about our organization, so we have a little over 300 pharmacists across the United States. And we do have some in other countries as well, but predominantly the United States and in the States where cannabis is legally available to adults, um, we’re seeing more and more pharmacists developing their own consultation practice.
So a lot of pharmacists do something called MTM, medication therapy management, and you’re basically going through the patient’s medicines. And it’s very easy to see, okay, these are the medicines you’re taking. These are your medical conditions, but still having that conversation because our doctors love using things off label.
So sometimes just seeing the drug doesn’t necessarily mean that their diagnosis. So having that one on one conversation, identifying their goals of therapy, which is basically the symptoms they’re looking to treat and then, from that, making a recommendation for cannabis. And like I said, it’s dynamic, you know, I, I wish everyone would get it right on the first try, but you don’t know how you’re going to respond.
We don’t know how it’s going to interact with the other medicine. So from a safety perspective, we’d rather start low and see no change versus start and side effect because the side effects of THC can be very uncomfortable. They’re not life threatening in any way, shape or form. It’s definitely the safest drug I’ve ever dispensed.
But if you have that, that feeling of anxiety or dysphoria. You know, if you’re expecting it to make you sleep and it doesn’t, and you’re up all night. I think that can be very discouraging to patients. And it’s kind of depressing, you know, you’re like, Oh my God, this is supposed to put me to sleep. What’s going on.
So anyway, um, these consultant pharmacists there. They’re doing well by creating this business model in these legal states. And again, there’s very little oversight. But I always tell my members, make sure that you have proper signed, informed consent. Make sure your patients know that this is an experimental therapy and it’s not FDA approved, you know, little things to just cover ourselves and really help align the patient’s expectations with reality.
I think in a perfect world, we’d see a couple things. We’d see cannabis available in pharmacies, just like any other drug or supplement. And if you don’t need the pharmacist’s help, great. Somebody else will. I liked to also think that it would then normalize its use as a medicine.
So if you have a seizure patient coming in for who knows what reason they’re going to the hospital and they’re admitted, you know, I would not feel comfortable stopping someone seizure medicine, if it’s controlling their seizures. Cause then you run into the risk of, okay, now you’re going to throw off their levels.
They’re going to see is they’re going to be in the hospital longer. It’s more expensive. And you know, just looking at it from that perspective, it makes it very difficult. Now, the current advantage that we have right now is that we do have one commercially available, FDA approved CBD, and that’s Epidiolex.
And so I know a lot of hospitals are physically switching people when they’re admitted from their CBD to Epidiolex, which is standardized, controlled, it makes it a little bit easier for doctors to dose. But you know, until we have that normalization patients are the ones that suffer.
Another thing I like to point out while I have your attention, not getting into the politics here, but when we legalize adult use of cannabis, we are effectively ignoring the medical programs and the people or the populations that will most benefit from these medical programs are the very young and the elderly, because you’re not going to have a 85 year old, going into a dispensary, trying to figure out what works for them, right. That’s not really the most likely person coming in.
And kids can’t use adult use programs without that medical permission if you will. So I think, as much as we need to free the plant and not criminalize its use for people trying to seek relief, we also need to consider the regulatory challenges in doing so. Because these are the most vulnerable populations. These are the ones that needed the most and could benefit the most, really. And so that’s just kinda my 2 cents about that.
Michael: How much of all that change you’re talking about comes down to educating the medical community?
Dr. Kane: It’s very important to educate the medical community. However, I think it’s society itself that needs to be educated because even when doctors say, you know what, this might be a good choice for you. No, they are adamant. They’re like, what will my church think of me? What will this think of me? My community, my neighborhood. And it’s like, They’re not feeling the symptoms you are, why would that alter your decision?
And so just that public stigma that’s in society that accompanies using cannabis. I think that’s really what needs to change. And I think when you have more healthcare professionals that are.
Actively involved in advocating for safe use. I think that is ultimately what changes society. So yeah, if we have educated healthcare professionals, patients and other healthcare professionals will feel more comfortable turning to these, I don’t want to say experts, but you know, experts in their field.
That’s one reason that we’ve created the clinical cannabinoid pharmacy conference and subsequent certificate program, because there’s so much to know about cannabinoids. And a lot of people have difficulty learning where to start. So our first series for 2020, and this is going to be August 14th and 15th, and it’s virtual of course, with our current state of pandemics.
Our first series is really looking at the basics, understanding phytocannabinoids and the endocannabinoid system and how to medically use compassionate care to dose cannabinoids. And then, you know, day two, that’s really going to focus on a more advanced patient population. So your geriatric, pediatric, your pregnancy and lactating.
And I think another kind of black hole in all of medicine, especially cannabis are the psychiatric conditions and contra-indications, so we’re very excited to have, Dr. Dustin Sulak, Dr. Bonnie Goldstein, we have, pharmacologist Linda Klumper is joining us. And then, other pharmacists, doctors — and, everyone we have is physically practicing in their field, which I think also helps the attendees really learn from the experts.
So after this 16 hour accredited conference, you can get continuing education credit for it. There is an optional certificate exam, so we’re very excited. More information is available on our website, cannabispharmacist.org. And then in the top toolbar, you’ll see Clinical Cannabinoid Pharmacy Conference 2020.
Michael: Well, thank you so much for taking the time to speak to us.
Dr. Kane: Absolutely. Thank you, Michael.
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