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Private cannabis clinics offer patients access

 

By Shannon Lough

National Access Cannabis CEO Gulwant Bajwa says “We don’t want people to go to the street. We want them to get the medicine from a legal source supply,”

 

There’s a budding business in the medical marijuana industry lurking between pot dispensaries and doctor’s offices. Cannabis clinics connect people with physicians willing to prescribe legal access to medical marijuana — for a fee, of course.

The “prescription” is actually a  Health Canada form that has to be filled out by a physician, but many doctors resent being gatekeepers to what they consider to be an unproven drug.

At least 25 clinics have sprung up in British Columbia, Alberta, Quebec, Ontario and possibly elsewhere. For people who qualify for medical marijuana and want to try it, these businesses claim to be the missing link in the system. Membership fees range from $99 to $300.

At National Access Cannabis in Ottawa, marijuana-savvy staff wearing black scrubs welcome clients to a facility that is decorated with the crisp simplicity of an Apple store: hardwood floors, white walls, white tables with green accented chairs, information boards and a glass case displaying a collection of vaporizers.

In the back corner are two private rooms enclosed by glass and hidden behind blinds, where the telemedicine conferences take place between the clinic’s members and physicians who decide if the patient qualifies for the medical declaration to access marijuana as per Health Canada’s Medical Marijuana Purposes and Regulations (MMPR).

National Access Cannabis CEO, Gulwant Bajwa, was the former manager for Health Canada’s Marihuana (sic) Medical Access Regulations who left after that program became invalid in March 2014. He says his business is “educating people on the use of cannabis so that they can make safe, and informed, and most importantly a responsible decision.”

Members get access to the staff “pharmacist” — actually an international medical graduate — who asks them to provide medical documents including a letter of diagnosis from a physician, and copies of prescriptions and hospital records before arranging a telemedicine conference, for an additional $150, with a physician. If the physician prescribes access to medical cannabis, the clinic staff help the member select the best strain for their condition from those offered by Canada’s 19 licensed producers. They also instruct members on ways to consume the drug, and uses a software system to monitor the drug usage and interaction with other prescriptions.

“We don’t want people to go to the street. We want them to get the medicine from a legal source supply,” Bajwa says. He says his business is not commercially linked to any of the licensed producers.

There appears to be a growing demand for these businesses. As of March of this year, Health Canada reported that more than 18 500 people had legal access to medical marijuana, but that doesn’t include people grandfathered in through the previous medicinal marijuana program. The number of people with access is expected to reach 500000 in the next few years (Int J Drug Policy 2015;26:15-19).

In a needs assessment survey by mdBriefCase, an online continuing medical education provider, 321 family doctors were asked how likely they are to prescribe access to medical marijuana: 8% say they currently prescribe, 32% say they might, 60% say it is unlikely they will prescribe.

This is where the middleman approach comes in. Physicians willing to prescribe can provide services to clinics like National Access Cannabis either via telemedicine or off-site at their own clinic. To encourage more physicians to become familiar with the alternative treatment, National Access Cannabis has paid $995 for 300 placements for the online Advancing Practice Medical Cannabis Certificate Program, which is accredited by the Canadian Council on Continuing Education in Pharmacy.

“We actually want to work with Health Canada and we want to work with the regulatory agencies to give them an alternative. Come and have a look at our model, maybe this will work,” Bajwa says.

Many of the clinics have opened in the year since the MMPR came into effect and each operates differently depending on provincial college policies.

In Ontario, for example, health practitioners must follow the College of Physicians and Surgeon’s policy on prescribing medicinal marijuana, which approves of telemedicine as long as the physician complies with the policy. But as for charging patients for a consultation, Ontario college spokesperson, Kathryn Clarke says the policy is clear: “Physicians must not charge patients or licensed producers of dried marijuana for completing the medical document, or for any activities associated with completing the medical document.” According to Bajwa the fee charged by his clinic for the physician consultation goes to National Access Cannabis, not the physician.

Other clinic owners say that some doctors charge a “risk compensation.” Recently, the College of Physicians and Surgeons of Manitoba began investigating reports that a doctor is charging $300 a note to buy medical marijuana at a Winnipeg dispensary.

Other provincial colleges appear to be more concerned about the use of telemedicine than payment.

In British Columbia, the college’s new rules around when telemedicine is appropriate, stipulate that the physician must have a long-term relationship with the patient, or be in direct communication with another physician or nurse practitioner who has such a relationship. The registrar for the College of Physicians and Surgeons of BC, Dr. Heidi Oetter says “our caution around doing it by telemedicine simply reflects the fact that we think it’s a service that’s best provided face to face.” She adds, “It’s the one-offs that we’re concerned about.”

Prince Edward Island’s college also prohibits physicians from prescribing the medical document for marijuana through telemedicine. Dr. Cyril Moyse, the registrar of the PEI College of Physicians and Surgeons says “one of the issues is that you have to continue to monitor the patient for effectiveness.”

Not all the cannabis clinics use telemedicine. Pauline Garrard, the CEO of Canna Relief Consulting Canada in Mississauga, Ont. says she found it unreliable. “We want to stay on the straight and narrow and doing all the required things that keep the doctors safe and that keeps us safe. We just want to make sure we do the right thing for patients.”

At her year-old clinic, staff educate and help clients sort their documents. If a member’s physician will prescribe the drug, membership costs $150; if not, the fee is $300, which includes finding a physician who will meet the client at an off-site clinic.

“The whole obstacle is that Health Canada has put the burden on doctors to prescribe and most of them are not willing to prescribe because they don’t have the information. So patients are the ones who lose because they don’t have access,” Garrard says.

In Vancouver, the Medicinal Cannabis Resource Centre, which opened in 2010, claims to be the first such clinic.  It offers a hybrid of telemedicine and off-site clinics. The annual membership fee is $275, walk-in appointments at an off-site clinic are $275, and Skype consultations cost $375.

CEO Terry Roycroft says “Physicians that have entrepreneurial spirit are looking at it as a new way to create a specialty line.”  — Shannon Lough, CMAJ

Originally published on July 28/2015 in the Canadian Medical Association Journal

DOI:10.1503/cmaj.109-5119

[Editor’s note]

This is part one of a two-part series on medical cannabis clinics. Coming up: another clinic model is emerging that won’t cost the patient a dime.

The cannabis doctor is in

 

By Shannon Lough

Dr. Danial Schecter, co-founder of the Cannabinoid Medical Clinic says his clinic has already received close to 2600 referrals from other doctors.

 

Doctors can become subspecialists in fields such as cardiology, gynecology, or neurology, but what about cannabinoidology? Just over a year after new federal regulations made physicians the gatekeepers for prescribing access to medical marijuana, a handful are focusing on cannabis as a therapeutic agent and carving out a new subspecialty.

Cannabis clinics have so far taken on two distinct forms in Canada. With the membership-based clinic, patients pay a fee to be educated by nonmedical staff and connected with knowledgeable physicians willing to prescribe legal access to medical marijuana.  The second model is a more traditional medical clinic staffed with physicians, all, in this case, with expertise in prescribing cannabis. Patients are referred for a consultation and are not charged; the doctor bills provincial health systems. It’s not known how many such clinics exist.

One in Ottawa’s north-east began accepting patients by referral in May. The Canadian Cannabis Clinics, one of six in Ontario, is situated on the fifth floor of a medical building with only the acronym — CCC — in sight. The clinic is bare bones, no messaging, no chic design; it looks like any other clinic.

Inside, an administrator welcomes patients and gives them a 12-page form to fill out in the bright waiting room. Magazines stacked on the table include the National Geographic special on “Weed: The New Science of Marijuana.” There are two exam rooms for physicians: one works Tuesdays at the clinic; the other works the first week of the month. In a third room, a counselor meets with patients who have received a prescription to access medical marijuana.

The counselling is paid for by CanvasRx, a commercial resource site that helps patients chose a strain from among the 19 Health Canada-approved licensed producers that sell cannabis. CanvasRx keeps counsellors informed about the producer’s products and which companies offer compassion pricing plans for low-income patients on disability assistance.

Most patients use this service because they’re “cannabis naïve” and have many questions about a drug that has been prohibited for decades, says CCC’s medical director Dr. Barry Waiglass, who works at the company’s St. Catharines clinic.

Waisglass was a family doctor for over 40 years before taking on this new role. “My motivation is harm reduction.” He views cannabis as an alternative to potentially more hazardous pain medications, such as opioids. He cites a 2014 study published in Addiction that showed that one to two people die every day in Ontario from accidental opioid overdoses.

After prescribing, Waisglass has regular follow-ups with patients for as long as they use cannabis for therapy. Before each visit, patients have to give a urine sample; Waisglass doesn’t want to see opioids or cocaine present when the patient says he or she is only taking Advil for pain. It’s an attempt to prevent marijuana misuse among patients.

“I’m not rubber stamping some stoner getting street weed that this is a proper medical assessment and a consultation was done in keeping with OHIP [Ontario Health Insurance Plan] regulations.” Since the first clinic opened in Sept. 2014, Waisglass has seen an increase in referrals from other physicians.

Elsewhere in Canada, complementary counselling services are not always offered, but physician consulting fees are covered by provincial health insurance.

In Montréal, a marijuana dispensary turned semi-private clinic has a team of seven doctors seeing referred patients on site. “Access to doctors is a major problem in Quebec. We had an opportunity to do something completely new,” the founder of Santé Cannabis, Adam Greenblatt, says about the transition. Consultations are free, but if the patient qualifies to access medical marijuana, there is an annual membership fee for uninsured services of $250; $200 for low-income members.  Greenblatt says he had the fees looked over by the College of Physicians and Surgeons in Quebec, which didn’t take issue with the model.

The college CEO Dr. Charles Bernard says they inspect all clinics when they open. “We want the physicians in those clinics to respect the rules and we don’t want to them to be part of a gimmick.”

Ontario’s first referral clinic, which opened in July 2014, assesses a patient’s suitability for cannabinoid medicine, including herbal cannabis and the two pharmaceutical options. Dr. Danial Schecter co-founder of the Cannabinoid Medical Clinic says the clinic has already received nearly 2600 referrals from family physicians and specialists across Ontario. “That just goes to show the need for other physicians who feel that cannabinoid therapy may help their patients but they’re just not comfortable doing it themselves.”

By Shannon Lough

Physicians who prescribe medical cannabis often encourage patients to use inhalers or vaporizers instead of smoking.

Two physicians work full-time at Schecter’s Toronto clinic. He also offers a training program for physicians looking to join the team and develop a subspecialty in cannabinoid therapy.

All services are covered by OHIP and Schecter is vocal about his distaste for clinics that charge patients. “A majority of the patients we see are on disability and are already suffering with chronic illness. By charging some kind of access fee, or a user fee, goes absolutely against the Canada Health Act and it’s not right.”

Schecter says physician’s attitudes toward prescribing cannabinoids as a therapeutic option may change over time, especially after the Supreme Court ruled in July that other forms of medical marijuana, not just the dried bud, should be available to patients. New government regulations allow licensed producers to sell cannabis oils, which means patients will be able to ingest the drug in exact doses, much like the pharmaceutical variety.

“To be honest my real dream is there won’t be a need for cannabinoid clinics and that every family physician and specialist will be comfortable prescribing it as part of their day-to-day practice,” Schecter says. — Shannon Lough, CMAJ

This story was originally published on August 6/2015 in the Canadian Medical Association Journal

[Editor’s note]

This is the second part of a two-part series on medical cannabis clinics.

DOI:10.1503/cmaj.109-5121

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