As Canada edged ever closer this year to making it legal for any adult to buy marijuana, Dr. Hance Clarke noticed a surprising phenomenon.
At his Toronto pain clinic, Clarke encountered more and more people eager for him to prescribe medical cannabis, though they could soon buy the drug without anyone’s approval. The trend has continued and today he estimates that 15 of every 20 of his patients seek pot as a treatment.
Logic suggests the newly legalized recreational weed business — which makes purchasing cannabis about as difficult as ordering a bestseller online — would render the rest of the market irrelevant.
But patients, doctors and industry representatives say the more cumbersome medical system – rather than melting away — is actually gaining in popularity.
And it’s happening despite caution from experts that the evidence of marijuana’s therapeutic benefits falls well short of the considerable hype.
I don’t see companies that are satisfied with being the best Canadian (medical) cannabis companies. I see companies that want to be the best global cannabis companies
“Recreational cannabis will lead to the demise of medical cannabis? It’s actually been the opposite,” said Clarke, director of pain services at Toronto General Hospital and a University of Toronto professor. “Canadians … want guidance, they want to know how to navigate this stuff.”
Not only are many patients still anxious to involve a physician in their therapeutic use of the drug, he and others say, the tidal wave of publicity around the recreational change has peaked interest in using it as a treatment.
In apparent recognition of that interest, Shoppers Drug Mart, the country’s biggest pharmacy chain, is poised to become a major retailer of medical weed, and is already promoting it to doctors.
Industry executives acknowledge that recreational marijuana buyers — “adult-use consumers” in the sector’s jargon — are for now an exponentially bigger pool in Canada than medicinal users. But they insist they will keep making patients a priority, and say growth potential is huge in the dozens of other countries that have recently opened the door to medical use, yet still ban recreational consumption.
“I don’t see companies that are satisfied with being the best Canadian (medical) cannabis companies. I see companies that want to be the best global cannabis companies,” said Allan Rewak of the Cannabis Council of Canada. “They’re looking big, and they are going to win. We are the global leader.”
It was, of course, the medical cannabis stream that gave birth to that industry, and to the government-approved “licensed producers” (LPs) of marijuana that are now also branching out into the recreational market.
Health Canada says it will review the medical system within five years, but has no immediate plans to end it.
That’s a relief to Rob Frid, one of the 330,000 medical users registered with Health Canada as of this June, along with 21,000 authorized to grow a limited amount of pot for themselves or someone else.
Patients under the program must obtain a doctor’s authorization to use marijuana for medical purposes, which is then registered with a specific producer. Recreational users, by contrast, merely have to order their pot online, or buy it at bricks-and-mortar stores.
But there’s more at stake for patients than just convenience, says Frid, a spokesman for advocacy group Medicinal My Way who uses cannabis to treat symptoms of his early-onset Parkinson’s.
He also takes prescription drugs and says he wouldn’t want to add pot to the mix without medical advice.
“You get rid of the medical side … and you’re running into potentially some serious issues,” Frid said.
Still, as the medical stream continues to draw in more patients, questions remain about what exactly it is selling.
You get rid of the medical side … and you’re running into potentially some serious issues
Though he is heavily involved in cannabis-related research, Clarke warns that the industry and its promotion of pot’s health benefits has surged way ahead of the empirical evidence. The potential is exciting, he says, but the proof is largely still to come.
“We’re moving to the drum of the venture capitalist, not the scientist,” Clarke said. “We have something being claimed to have medical efficacy, without the data to support it…. It is the utopia of our society, it’s solving all evils by the magic CBD (Cannabidiol) oil that will fix everything for you.”
Indeed, his research suggests many patients don’t know what they’re ordering, or how to make it work for them. A study of 1,000 medical users that he and colleagues presented at a recent conference found that 75 per cent of the patients had stopped using the drug after six months.
As for the product sold by LPs, the quality varies widely, Clarke said. Another study of his in the works found that some contained no activated cannabis at all, suggesting a lack of any clinical value, he said.
Still, Clarke believes physicians should educate themselves and, as much as possible, help patients keen to use marijuana, at least to avoid the alternative: unguided self-medication.
The Canadian Medical Association – the country’s largest professional group for doctors — does not agree. It actually urged the federal government to end the medical-cannabis stream when it legalized the drug, so physicians would no longer be involved.
“What we need as doctors is more of the evidence, with large trials, larger numbers of patients, rigorous research methodology,” CMA president Dr. Gigi Osler said in an interview. “Right now, you probably won’t find many doctors whose comfort level with authorizing cannabis will change.”
So what does the evidence to date say about cannabinoids — the active compounds like CBD and THC found in the plant?
The most rigorous science supports marijuana’s use for treating pain, especially neuropathic pain — related to nervous-system damage, said Clarke.
The first drug extracted from the cannabis plant to be approved by the U.S. Food and Drug Administration — Epidiolex — targets rare forms of pediatric epilepsy, and is backed up by phase-three clinical trials.
There is some evidence of value for treating nausea from chemotherapy and spasticity in diseases like multiple sclerosis, while proponents tout its application to a range of other ailments, from insomnia to Alzheimer’s.
With researchers now able to readily buy cannabis and not worry about criminal sanction, conducting studies to test those claims should become easier, said Lynda Balneaves, deputy director of the Canadian Consortium for the Investigation of Cannabinoids.
But the University of Manitoba nursing professor complained that most of the public funding handed out so far has focused on studying the consequences of legalization — not the medicinal uses that many Canadians already embrace.
“The horse is out of the barn,” said Balneaves. “We have patients who have shared with us in our research that this allows them to live, this allows them to participate at work, in their life, with their families.”
The industry itself recognizes the evidence is limited and is willing to help change that, perhaps by pooling together funds that could be used by scientists to conduct studies with no strings attached, said Rewak.
Such research would presumably help everyone in the industry.
But the business brass ring is something different: creating a medicine extracted from cannabis that could be patented and receive approval from regulators.
We’ve made a decision as an industry to remember where we came from
That would transform the business from one where dried cannabis becomes a relatively low-priced commodity sold to masses of people, to one with fewer customers but far higher margins, said Khurram Malik, an analyst with Jacob Capital Management, and CEO of producer Biome Grow.
“You can sell $ 7-a-gram recreational product in larger volumes, which is great,” or win approval for a unique cannabis-derived medicine, and charge $ 200 a gram, said Malik.
Indeed, Epidiolex for pediatric epilepsy, the pioneer, is priced at about US$ 32,000 per year.
Rewak of the Cannabis Council suggests Canada’s greatest success will come from looking globally, to the 31 countries that have recently or are about to legalize cannabis for medical purposes, a potential $ 75-billion market.
In the meantime, as patients at home complain that the surging recreational business is creating shortages for them, Rewak insisted that medical users will always be the companies’ first priority.
“We’ve made a decision as an industry,” he said, “to remember where we came from.”