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November 12, 2019

Medical Marijuana

Reuel S. Amdur

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Medical marijuana is in an ambiguous position. Its products lack DIN drug identification numbers. As a Health Canada web site explains, "A DIN uniquely identifies the following product characteristics: manufacturer; product name; active ingredient(s); strength(s) of active ingredient(s); pharmaceutical form; route of administration." And, "A drug product sold in Canada without a DIN is not in compliance with Canadian law."

All very interesting, but cannabis products are legal yet have no DIN.  In order to get a DIN, it appears that questions including strength and efficacy would need to be established, and extensive double-blind testing would need to be done.  So cannabis products are in something of a grey area.

Because of lack of a DIN, these products have a difficult time getting coverage under drug insurance plans, though some plans do cover them.  They are not covered under Ontario’s formulary for social assistance recipients, but neither are some medicines with a DIN.

No medicines are magic bullets.  Medical practice is both art and science.  Medicine X will help patient A, hurt patient B, and have no effect on patient C.  Side effects will vary.  That is true even of successfully tested drugs.  The same is true of cannabis products. 

Medical cannabis products are expensive.  Let us look at problems faced by a couple of users, Chris and my son Martin.  Chris has a variety of non-physical problems for which he takes marijuana:  attention deficit hyperactive disorder (ADHD), obsessive compulsive disorder, and depression.  His obsessive compulsive disorder makes his home look like a maximum security prison, with locks and cameras.  He is on the Ontario Disability Support Program.  As noted, cannabis products are not covered under Ontario’s formulary for social assistance.  His monthly supply runs him over $1000.  How can he manage?  He is fortunate to have a mother who can pony up.  Otherwise, he would be out of luck.  His doctor says he is functioning much better with cannabis than with previous medicines.  Without, it is likely that he would have more serious health issues costing the system much more.

Then take the case of my son Martin.  He is prescribed a  variety of cannabis products for his conditions.  He has kidney stones due to a condition known as medullary sponge kidneys.  (“I have around 10 stones in each kidney.”)  He also has diverticular disease, migraines, and narcolepsy.

He finds real benefit from his cannabis.  “During my last kidney stone attack I was able to halve my usual Percocet for all but the most acute part. My MD was thrilled.”  Percocet is a highly addictive opioid.

Because of the cannabis drugs, he has cut down or eliminated Percocet, codeine, acetaminophen, ibuprofen, and sleeping pills. He is prescribed but does not take sleeping pills.  This effect of cannabis is desirable because “the drugs being replaced are physically addictive and hard on the liver and kidneys, except the ibuprofen and acetaminophen which are not addictive but are hard on liver, kidneys, stomach.”

His prescription is for 3.5 grams of cannabis a day, at a cost of $12 a gram. Half to one gram is in liquid form, “mostly taken at bed time.” The law allows him to grow four plants himself without prescription, but he has a prescription for 11. He also takes CBD oil and CBD/THC oil. Cost of cannabis comes to $900 a month. CBD oil is $86 a bottle. “Apparently Ontario is the most expensive jurisdiction in the world to buy CBD oil.” He needs two bottles a month, as well as one bottle of CBD/THC oil, at $78 a month.

“The CBD is believed to be an anti-inflammatory, which supposedly makes it easier to pass stones. Since I have started the oils my incidences of kidney colic (stones) has decreased noticeably. Since being on medical cannabis oil I’ve had about one migraine a year, down from seven or eight. This represents six or seven times I didn’t need to take Tylenol 2’s or 3’s. It also means less ibuprofen, which gives me wicked heart burn. I now need to take pantoloc to control stomach acid when I take ibuprofen or naproxen.”

$900 a month for cannabis, plus the oils, is a heavy burden on the family budget, even with the reduction made possible for the four plants.  He contacted the nurse practitioner working for the marijuana firm that supplies him, asking her to prepare the necessary forms to allow him to grow up to 11 plants.  She refused, saying that the paper work to do so would be too onerous.  He wonders if the real reason might be that the company has a vested interest in him having to buy from them. 

What can Martin do?  He is trying to find another authorized medical practitioner to complete the necessary paper work to get him authorization to grow 11 plants.  His partner, who works for a university, might lobby her employee association to seek cannabis coverage in the next collective agreement.  And he might complain about the nurse’s refusal to the College of Nurses of Ontario.

The bottom line: cannabis may make a real difference in the health of some people. It is expensive, and getting the products needed can be complicated. We need more testing of cannabis products so that they can get DINs and find their way into the general medical formularies.

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