This is not my writing
I wish it was
It is a reprint
of
A Jan 2012 PubMed Commons Article
I am reprinting it here because I want all of my friends and followers to find out just who we are as Customers relating to Health Canada and how as a group in 2007-8 we were utilizing and obtaining our cannabis supply.
It’s just a snapshot in time but it’s sad to see things are even more complicated after 7 more years of Government interference and Physician obstruction but remarkably SameOh! SameOh!
I should warn all you potential readers that it is a long read of many pages but reading it is well worth the effort. Fortunately it is broken into shorter segments that stand individually and I learned a lot I was ignorant of in the utilization of the HERB.
Abstract
The Quality of Service Assessment of Health Canada's
Medical Cannabis Policy and Program
BACKGROUND:
In 2001 Health Canada responded to a series of Ontario court decisions by creating the Marihuana Medical Access Division (MMAD) and the Marihuana Medical Access Regulations (MMAR). Although Health Canada has conducted a small number of stakeholder consultations, the federal government has never polled federally authorized cannabis patients. This study is an attempt to learn more about patient needs, challenges and experiences with the MMAD.Methods
Launched in the spring of 2007, Quality of Service Assessment of Health Canada's
Medical Cannabis Policy and Program pairs a 50 question online
survey addressing the personal experiences of patients in the federal cannabis
program with 25 semi-guided interviews. Data gathering for this study took
place from April 2007 to Jan. 2008, eventually garnering survey responses from
100 federally-authorized users, which at the time represented about 5% of the
patients enrolled in Health Canada's program. This paper presents the results
of the survey portion of the study.
Results
8% of respondents report getting their cannabis from
Health Canada, while 66% grow it for themselves. >50% report that they
frequent compassion clubs or dispensaries, which remain illegal and unregulated
in Canada. 81% of patients would chose certified organic methods of
cultivation; >90% state that not all strains are equally effective at
relieving symptoms, and 97% would prefer to obtain cannabis from a source where
multiple strains are available.
Of the 48 patients polled that had tried the Health
Canada cannabis supply, >75% rank it as either "1" or
"2" on a scale of 1-10 (with "1" being "very
poor", and 10 being "excellent").
Discussion
72% of respondents report they are either
"somewhat" or "totally unsatisfied" with Canada's medical
cannabis program. These survey results and relevant court decisions suggest
that the MMAR are not meeting the needs of most of the nation's medical
cannabis patient community. It is hoped this research will help inform policy
changes that will better address the needs of Canada's critically and
chronically ill medical cannabis patient population, including the integration
of community-based dispensaries into this novel healthcare delivery model.
Background
According to
the United Nations Office for Drug Control and Crime Prevention (2001) cannabis
is the most popular illicit substance in the world. Despite the high rate of
recreational use and over 5000 years of medical use, there has never been a
substantiated case of death resulting from cannabis overdose. However, the
therapeutic use of cannabis remains highly controversial, and only a few
Western nations have introduced policies or programs to allow legal access to
medical cannabis.
Initially
established in response to patient needs and ineffective or non-existent
federal medical cannabis policies, community-based medical cannabis
dispensaries have become the main suppliers of medical cannabis in both Canada and in many of the 14 U.S. states that have legalized the medical
use of cannabis. In Canada, community-based dispensaries,
otherwise known as "compassion clubs" currently supply over 30,000
critically or chronically ill Canadians with medical cannabis.
Although
Canadian dispensaries continue to operate without legal sanction or protection,
recent research suggests that this patient-centered healthcare delivery model
builds social capital and provide patients with a safe supply of cannabis
within a supportive environment that's conducive to healing.
A Brief History of Cannabis as a Medicine
The medical
use of cannabis can be traced back at least 5000 years. The oldest reports
originate in China and Egypt. It appears in a medical context in
the Vedas, India's oldest religious text, and there
are reports of its use as a medicine from fragments of Assyrian texts dating
back to 700 B.C. The famous Chinese doctor Hua T'uo (approx. 100 A.D.)
reportedly made use of a wine and cannabis mixture as an anaesthetic for
surgical operations.
By the late 19th Century, cannabis-based preparations were manufactured and marketed by Burroughs-Wellcome & Co. In England; and Bristol-Meyers Squib, Parke-Davis, and Eli Lilly in North America. The development of vaccines to prevent the spread of common infectious diseases, the increased use of opiates (with the introduction of the hypodermic syringe), and the discovery of aspirin at the end of the nineteenth and early twentieth century resulted in cannabis-based medicines losing their prevalence in the market place and Western pharmacopoeia.
In Canada, the non-medical use of cannabis was outlawed as part of the Opium and Narcotics Drugs Act of 1923, largely based on a series of misleading articles written by Emily Murphy for MacLean's Magazine in the early 1920's which claimed cannabis turned people into raving, blood-thirsty lunatics. The US Pharmacopoeia listed Cannabis until 1941 and stated that cannabis can be used for treating fatigue, coughing, rheumatism, asthma, delirium tremens, migraine headaches, and the cramps and depressions associated with menstruation.
Although
modern research into therapeutic applications for cannabis has been seriously
stymied by its prohibition in most of the Western world, extensive anecdotal
reports and a growing body of laboratory and clinical research suggest that it
may have many medicinal uses, including hunger stimulation for wasting
syndrome; anti-emetic and anti-nausea properties in AIDS or cancer
chemotherapy; anti-spasmodic properties for MS, epilepsy and other neurological
dysfunctions; reducing intra-ocular eye pressure in glaucoma; and analgesic
properties in a large number of chronic pain conditions. Recent research has
found that cannabis can reduce the use of pharmaceutical drugs and even be an
effective treatment for addiction.
Medical Cannabis Access in Canada
Although the
Canadian Addiction Survey suggests that about 1 million Canadians use cannabis
for medical purposes, as of January 2010 the MMAD had only authorized 4884
people in Canada to use cannabis legally.
Additionally, the federal supply of cannabis produced by a company called
Prairie Plant Systems since 2000 remains highly problematic due to a lack of
strain selection, controversial production methods, and patient concerns over the
quality and safety.
According to this report, one of the main reasons for the small number of applicants to the program is reluctance by physicians to act as gatekeepers to medicinal cannabis. Citing a perceived lack of information on dosage, side effects, and alternate routes of administration to smoking, both the Canadian Medical Association and the Canadian Medical Protection Agency (which insures nearly 95% of Canada's physicians) have warned against the therapeutic use of cannabis, and have recommended that doctors not participate in the federal program.
For example, a CMA press release dated July 9th, 2003, declares:
The CMA has consistently raised concerns about the lack of evidence-based decisions to support the Medical Marijuana Access Regulations," said Dr. Dana Hanson, President of the CMA. "Our unease over use of medical marijuana has been ignored in this new policy. Physicians should not be the gatekeeper for a substance for which we do not have adequate scientific proof of safety or efficacy.
Such warnings have been a particular deterrent for medical specialists, whose support was initially necessary for all applicants to the program that were neither terminally ill nor likely to die in the next 12 months, such as those suffering from MS, HIV/AIDS and hepatitis C (terminal patients only required the support of a single physician). In addition, specialists were simply not available in many smaller rural communities. When compounded by the bureaucratic hurdle of filling out a 29-page application that sometimes took in excess of 12 months for Health Canada to process, the challenges to participation in this program ranged from onerous to impossible for many potential applicants.
Health Canada officially amended the MMAD
application process in 2005 to remove the requirement of a supportive
specialist under most circumstances. However, the new "simplified"
application form was now 33 pages long, and potential applicants continue to face
resistance from the medical community. The burden of this difficult application
process is apparent in comparing the MMAD with the state-run Oregon Medical
Marijuana Program (OMMP), one of twelve state-administered medical cannabis
programs in the U.S. Although both programs originated
in 1999 and have similar medical requirements for registration, Oregon's simple
two page application process has led to the registration of 23,873 participants
as of October 2009 (as compared to just over 4000 in Canada during the same
period) - despite having a population one-tenth that of Canada.
Community-Based Dispensaries
Community-based
medical cannabis dispensaries, also called "compassion clubs", supply
cannabis for therapeutic use upon a valid recommendation or confirmation of
diagnosis from a licensed healthcare practitioner, and reflect a
patient-centered response to the suffering of critically and chronically ill
Canadians who might benefit from the medical use of cannabis.
In Canada, a
loose network of community-based dispensaries provide over 30,000 critically
and chronically ill Canadians access to a safe supply of cannabis within an
environment conducive to healing. Although Canadian dispensaries continue to
operate without legal sanction or protection, communities, law enforcement, and
criminal courts across Canada have shown support and tolerance
for compassion clubs that self-regulate to ensure their services are strictly
for medical purposes
Quality of Service Assessment of Health Canada's Medical Cannabis Policy and Program
Although
Health Canada hosted a stakeholder consultation
in 2003 to address some of the early constitutional and bureaucratic
deficiencies of the MMAR, the opinion of patients registered with the MMAD has
never been officially polled by the federal government in any systematic
manner. This survey is an attempt to address the dearth of information about
actual patient experiences with medical cannabis and Health Canada's program.
The 50 item self-administered survey combines multiple choice and open-ended questions, and includes items informed by validated questionnaires like the Short-Form Patient Satisfaction Questionnaire (PSQ-18) and a 2005 questionnaire designed by Belle-Isle and the Canadian AIDS Society to identify barriers to medical cannabis experienced by Canadians affected by HIV/AIDS. In addition to basic socio-demographic data, survey questions generated by the researcher to address the history of involvement and experiences with the federal program, cannabis use patterns, and specific symptoms and conditions that cannabis has relieved.
For privacy
reasons Health Canada does not make a list of federally authorized medical
cannabis patients available to the public, so recruiting for this study was
conducted through online and hard mail outreach to medical cannabis patient
internet discussion groups and community-based dispensaries. In order to ensure
that survey participants were federally authorized patients, respondents were
asked to type in a specific word only found on the authorized user ID card
supplied by Health Canada as a password to access the online questionnaire.
Although the identity of survey respondents will be kept completely anonymous,
participants were also asked to supply the registration number from their
Health Canada medical cannabis ID card to allow for future
verification/authentication if necessary.
Demographic Data
Study
participants were > 78% male and 20.4% female, and > 87% were 35 or
older. Over 93% report that they are Caucasian, with 3 participants identifying
as First Nations, 2 as Metis, and 1 as "black" (n = 97). In terms of
income 36.8% make less than $20,000, and > 61% make less than $30,000, so
this is a group that is well below the medium income in Canada, which may be the result of
physical disabilities stemming from serious and/or chronic medical conditions.
Although a medical expanse income tax claim can be filed for the cost of
cannabis purchased from the government, or produced by individuals or their
designated grower, there is currently no reimbursement of the actual costs of
medical cannabis. In light of these findings, it is unsurprising that 46.3% of
respondents state that they can "never" afford enough cannabis to
relieve their symptoms. Despite the low-income levels, 77.8 had graduated from
high school, and 22.3% had a university degree. According to Statistics Canada,
this is slightly higher than the Canadian average; the 2006 Census found that
just over 76% of Canadians had graduated from high school, and that 18% had a
university degree equivalent to a Bachelor's or higher.
Demographics of
Federally Authorized, Medical Cannabis Patients
Although there is no way to
verify that this limited sample is representative of participants in the MMAD,
a recent study by Reinarman et al assessing population characteristics of 1746
California-based medical cannabis patients offers some useful comparisons.
Reinarman et al found that 72.9% of their sample was male, with the researchers
theorizing that the under representation of women may be related to the
gender-distribution of certain kinds of sports or workplace injuries, as well
as the "...double stigma women face in seeking MM (medical marijuana) -
for using an illicit drug and for violating gender-specific norms against
illegal behavior in general".
Additionally,
Reinarman et al found this population to be of slightly higher education levels
than the general population, with 93.1% reporting at least high school
graduation, and 23.8% having a post-secondary degree, which is also similar to
this Canadian survey.
Patient Use Patterns and Preferences
While the
overwhelming majority of participants reported using cannabis recreationally
prior to their medical use, > 20% were cannabis-naïve prior to using it
medically (n = 89). The average years of medical use is just over 10 years,
which may be reflective of the older patient profile and additionally suggests
that many patients have been using cannabis for far longer than Health Canada's federal program has been in
existence.
When asked
to check off all the major symptoms for which they used medical cannabis, most
cited multiple symptoms: 84.1% cited pain relief, 78.4% cited relaxation, 61.4%
cited appetite stimulation, 60.2% cited anxiety reduction, 58% cited
depression, 56.8% cited nausea reduction/vomiting, 55.7% cited mood
improvement, 43.2% cited desire to manage/gain weight, 42% cited reduction in
spasticity/tremors, and 23.9% cited side-effects of other medications. Of
interest is the high number of individuals using cannabis for relaxation,
anxiety reduction, depression and mood improvement, suggesting that patients
with physical health conditions may also be self-medicating for mental health
issues and/or general improvements in their quality of life.
Major
Symptoms. Bar
graph of self-reported major symptoms treated with cannabis by survey
participants (n = 88).
In terms of personal use
patterns, over 94% stated that they use it every day, which is considerably
higher than the 67% reported by Reinarman et al from their California patient survey. Over 88% smoke
cannabis, and 71.6% report that they eat it. Over 52% have used vaporizers,
18.2% use tinctures and, unlike Europe, less than 4% mix it with tobacco. While the rate of
smoking is similar to the Reinarman et al sample, which found that 86.1% smoke
cannabis, the comparatively higher use oral ingestion/edibles (71.6% v. 24.4%)
and vaporizers (52% v. 21.8%) in the Canadian sample may suggest a greater
level of concern and mitigation for potential health impacts associated with
smoking within the Canadian patient population. This health awareness may also
explain why 80.7% of respondents prefer to use cannabis grown using certified
organic cultivation methods, whereas 19.3% either don't care (14.5%) or prefer
non-organic cultivation (4.8%).
Methods
of Ingestion.
Bar graph of self-reported methods of cannabis ingestion reported by survey
participants (n = 88).
In terms of patient
preferences and treatment efficacy, 90.9% report that not all strains are
equally effective at relieving their symptoms. As a result, 97.6% would prefer
to obtain cannabis from a source that offers a "large selection of
different strains" rather than 1 or 2 strains, and over 90% would prefer
to have access to raw cannabis as well as other methods of ingestion like baked
goods, tinctures, and hashish, compared with 9.8% who would prefer a
cannabis-only outlet. This creates a stark contrast between access through Health Canada and through community-based dispensaries. While Health Canada offers a single strain of raw cannabis and no alternatives to smoking, dispensaries make multiple strains and methods of ingestion other than smoking available to patients, including edibles, oils, tinctures, salves, and even oromucosal sprays.
When asked
about other cannabinoid-based pharmaceutical medicines like Marinol (dronabinol),
Cesamet (nabilone) and Sativex, 34.9% had tried Cesamet, 33.7% had tried
Marinol, and 14% had tried Sativex. 43% had not tried any of the above, and
81.5% stated that didn't use any of these pharmaceuticals on a regular basis.
Patient Access to Medical Cannabis
When asked
how they obtain cannabis, only 8.2% of respondents report getting their
cannabis from Health Canada (although nearly half state that
they have tried the federal supply), while 80% grow it for themselves or have
it grown for them by a Designated Producer. Over 50% report that they frequent
compassion clubs or dispensaries, 38.8% report getting it from a friend, and
> 22% get their medicine from street dealers.
Access
to Cannabis.
Bar graph showing how survey participants access medical cannabis (n = 85).
When asked how they would
rank the quality of the cannabis from their regular source, 87.8% rank it as 7
or above in a scale of 1-10, with 1 being "Very Poor", and 10 being
"Excellent". By comparison, of the 41 patients who have tried the
federal cannabis supply, over 75% rank it as either 1 or 2 on a scale of 1-10.
While 3 respondents ranked it as either a 6, 7, or 8, no one ranked it any
higher.
When asked
what their single preferred source for medical cannabis would be, 65.1% stated
that they would like to grown their own, 24.1% cited dispensaries, 6% would
like to get their medicine from a pharmacy, 4.8% would like to get it from a
friend, while neither street dealers nor Health Canada were cited by a single
patient as their preferred source. This is highly relevant since Health Canada's proposed regulatory changes
include removing the right for individuals to produce their own cannabis, despite
this being the preferred option cited by most study participants and the option
chosen by the majority of patients in the federal program.
As of January 2010
(the latest statistics available on the Health Canada website) 3576 out of 4884
- or over 73% - of federally authorized patients chose to produce their own
medicine or to have a Designated Producer do so for them. If Health Canada
intends to make this program more patient-centered, removing the right for
patients to produce their own supply does not appear to reflect current patient
needs, and as such this proposed significant amendment to the program should be
highly controversial, and will likely lead to further court challenges by
patients wishing to control the cost and quality of their supply of medicine.
Patient Experiences With Health Canada Marihuana Medical Access Division
Of study
participants, nearly half (49.3%) became federally authorized patients in 2004
or later, while 50.7% joined the program prior to 2004. When asked if they had
difficulty finding a physician to support their application, exactly 50% said
"yes", and 50% answered "no", reflecting the diversity and
unpredictability of medical support available throughout Canada.
In terms of
processing applications, 35.3% had theirs completed by Health Canada within 2-4 months, and 29.4% state
that it took 60 days or less. However, 35.2% of participants suggest that it
took over 4 months, with 17.6% citing that they waited over 12 months for their
application to be processed. This suggests that for those suffering from
serious or terminal conditions, processing times would be a significant concern
and may not be quick enough to allow some
patients to legally use cannabis in
end-of-life situations.
In addressing the statement "I find the application for a federal authorization simple and uncomplicated", only 21.8% "agreed" or "strongly agreed", while 71.2% "disagreed" or "strongly disagreed" (42.5%), suggesting that for most patients the federal application process is onerous and challenging.
When asked to comment on the statement "Employees at Health Canada's MMAD act too businesslike and impersonal towards me", 54% "agreed" or "strongly agreed", while 28.7% "disagreed" or "strongly disagreed".
In regards to the statement "I am dissatisfied with the service I receive from Health Canada in regards to my use of medical cannabis", 68.9% "agree" or "strongly agree", while only 18.3% "disagree" or "strongly disagree".
However, when asked if "Employees at Health Canada's MMAD treat me in a friendly and courteous manner", respondents were split, with 35.6% "agreeing" or "strongly agreeing", 27.6% "uncertain", and 36.8% "disagreeing" or "strongly disagreeing".
When the statement "I have full confidence in the ability of the Health Canada employees that administer this program" was put to patients, 76.8% "disagreed" or "strongly disagreed", with only 5.9% "agreeing" or "strongly agreeing" with the statement, and 17.4% stating that they were "uncertain".
Finally, when asked "I am able to get help from Health Canada in regards to my medical use of cannabis whenever I need it", 8.2% "agreed" or "strongly agreed", while 70.6% "disagreed" or "strongly disagreed", with 21.2% uncertain.
The final question of the survey asked participants to rate their overall satisfaction with Health Canada's medical cannabis program, and 15.1% of patients state that they are "completely" or "somewhat satisfied", 12.8% uncertain, and 72.1% either "somewhat" (20.9%) or "totally unsatisfied" (51.2%).
This suggests a very poor patient perception of the service quality at Health Canada Marihuana Medical Access Division, with many potential improvements in application processing times, cannabis selection and quality and overall responsiveness to patient queries and concerns.
Overall
Satisfaction with Health Canada Medical Cannabis Program. Bar graph of overall level of
satisfaction with Health Canada's medical cannabis program reported
by survey participants (n = 86).
Thousands of seriously ill Canadians must therefore choose between breaking the law to use the therapy of their choice, or going without, which in many cases compromises their well-being and quality of life.
The results
of this federally authorized medical cannabis patient survey support the
findings of the CAS study and other research into the MMAR/MMAD.
Discussion
Creating
policies and procedures for safe patient access to medical cannabis has proven
to be a challenge in Canada and around the world. In the U.S.,
the 14 states that allow for the legal use of cannabis continue to struggle to
protect patients, address access issues, and mitigate community concerns, all
of which is made all the more complicated by ongoing resistance and active
legal threats by the federal government.
In Canada, patients face multiple challenges
to safe access:
1) resistance from the medical community to act as gatekeepers
to the program;
2) an onerous application process;
3) a very limited and
much-criticized cannabis supply;
4) limited income and a lack of national
cost-coverage; and
5) ongoing social prejudice against the use of medical
cannabis.
Results from this survey suggest that reducing bureaucratic obstacles
while increasing patient options for access would result in greater levels of
patient participation and overall satisfaction with the federal program.
The high bureaucratic burden on both patients and physicians is reducing participation in the program, so allowing healthcare providers to treat cannabis like any other medicine would likely improve uptake and might also alleviate some of the social stigma associated with the therapeutic use of cannabis. Since this study and Health Canada's own statistics show that the majority of participants in the Canadian federal program chose to produce their own medicine, policies and procedures should be put in place that maintain the option of personal production while also ensuring that both patients and communities are protected from the dangers of poorly-cultivated cannabis.
This could range from basic information from Health Canada on safe production practices to electrical inspections at the municipal level. Additionally, with over half of respondents currently accessing cannabis through dispensaries and growing evidence that these organizations build social capital and provide an environment that is conducive to health and healing, the federal government should work with dispensaries to develop regulations that would incorporate this community-based model of access into Canada's medical cannabis program.
Finally, many of the challenges faced by the MMAD could have been addressed or avoided through a more robust and active strategy for patient engagement and involvement. Although there are many stakeholders directly or indirectly affected by the federal medical cannabis program - municipalities, police, physicians, etc. - the key stakeholders are the Canada's critically or chronically ill who could or do benefit from the use of cannabis. Unfortunately, the short history of the MMAR/MMAD shows that the needs and concerns of patients has all too often been ignored or overshadowed by other interests and concerns.
The future success of this cutting-edge program will depend largely on the willingness of the federal government to create a truly patient-centered approach to medical cannabis access, including active and ongoing engagement with end-users, support for research into the potential harms and benefits of medical cannabis, and increased options for patients, potentially through the regulation of community-based dispensaries.
There are a
few limitations to this study. Although participants represented about 5% of
the patient population in the program at the time of the survey there is no way
to know how representational this cohort is to the rest of the participants in
the MMAD since Health Canada has never released any demographic information
about federally authorized users. Additionally, since recruiting was largely
done online and through medical cannabis patient lists and groups, it is possible
that this more active population has a higher level of dissatisfaction with the
federal program.
However, the
general demographics of participants in this study is similar to those
identified by Reinarman in a recent U.S.-based study, and many of the patient
needs and challenges that came to light in this survey support previous
research on Canada's medical cannabis population and associated federal
program. It is hoped that this survey, which represents the first polling ever
conducted solely on federally authorized patients in Canada, will assist policy-makers here and
abroad develop more patient-centered strategies for safe access to medical
cannabis.
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Too Bad They Didn't Finish This
A Hell Of A Lot Sooner!
Blaine Barrett
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