As medical cannabis use grows, pharmacist involvement is essential.
This color-coded map of the United States illustrates the dynamic patchwork of cannabis legality. The map was last updated in December 2022, and since that time there have been changes in Delaware, Ohio, and Minnesota, which all voted to legalize adult-use cannabis. The evolving legal landscape for cannabis reflects the shifting attitudes, regulations, and state policies. Image sourced with permission from The Cannigma.
Representing Europe’s legal cannabis landscape, this map illustrates widespread medical adoption across the European Union (EU). This map was last updated in December 2022, and the most significant change since then is Germany’s legalization of adult use cannabis in April 2024. The evolving regulatory landscape in the EU mirrors shifting attitudes and policy frameworks across the continent and globe. Image sourced with permission from The Cannigma.
Pharmacist-led care models for medical cannabis are emerging as a critical component of ensuring safe and effective use of cannabis-based therapies. These models integrate the expertise of pharmacists into the management of medical cannabis, focusing on patient education, therapy optimization, and monitoring for adverse effects (AEs). Cannabis is becoming increasingly more accepted both medically and socially worldwide (Figure 1 and Figure 2); however, approaches to regulation and patient care remain highly variable. From the Americas to Europe and beyond, different jurisdictions have implemented diverse models for the production, manufacturing, distribution, and use of medical cannabis, varying widely from highly restrictive to loosely regulated. Many medical cannabis initiatives around the globe have opted to highlight the pharmacist as the primary mode of distribution, ensuring safe and effective medical cannabis management.1
No Pharmacist Involvement (eg, California, Colorado, and Canada)
In Canada and multiple states in the United States, where governments adopted cannabis laws early on in the wave of cannabis legalization, medical programs have mostly consolidated with adult-use programs and operate without any pharmacist involvement. Aside from a medical provider writing a cannabis recommendation, these states rely on a dispensary model utilizing a budtender as the cannabis medicine expert for patients seeking medical use. Given budtenders’ highly variable prerequisite training, this opens them up to field complex medical questions for which they have no formal training to respond to.2
Mandated Health Care Professionals in Dispensaries (eg, Pennsylvania)
Pennsylvania legislation mandates the presence of pharmacists or physicians in medical cannabis dispensaries, ensuring that patients have access to medical expert guidance and counseling on medication use. These health care professionals verify that patients have up-to-date medical marijuana certifications, screen for potential drug interactions, and offer counseling to patients on dosing, titration, and AEs.3
Mandated Pharmacist Consultant (eg, Arkansas)
In Arkansas, although pharmacists are not required to be physically present in dispensaries, they are mandated to be readily available to serve as consultants, providing expertise and guidance (at least remotely) to both patients and dispensary staff.3
Distribution Centers Staffed by Trained Health Care Professionals (eg, Connecticut, Minnesota, and New York)
Some states have established medical cannabis distribution centers, which are essentially dispensaries staffed by a pharmacist or another health care professional, such as a physician, or sometimes by a physician assistant or nurse practitioner.3
Sale of Cannabis via Specialty Pharmacies (eg, Louisiana)
Unlike most other medical cannabis programs, the medical marijuana dispensaries in Louisiana are a subcategory of pharmacy licensure, with regulations set by the state board of pharmacy. This model inherently integrates pharmacists into both the business and clinical framework via a limited number of specialty pharmacy licenses throughout the state.3
The Sale of Cannabis via Licensed Pharmacies (eg, US State of Georgia, Denmark, Italy, and Netherlands)
In certain European countries, such as Italy, Netherlands, and Denmark, medical cannabis is sold directly through pharmacies, allowing patients to access their cannabis medication alongside traditional pharmaceuticals.4 This system integrates the medical cannabis system into the typical pharmacy model, affording patients a more familiar and comprehensive medical experience.
In a similar strategy, the US state of Georgia passed legislation in 2023 to establish its low-tetrahydrocannabinol (< 5%) medical marijuana program within independent retail pharmacies for registered patients. In response to this, the Drug Enforcement Administration (DEA) distributed a memo to Georgia pharmacies essentially reminding them of the federal Schedule I status of marijuana and warning them of the potential legal ramifications if they enact this practice. The conflicts between the state and federal laws put these pharmacies in a difficult position that is yet to be resolved.5
In 2021, California took a groundbreaking step by allowing terminally ill patients in health care facilities to use medical cannabis (excluding inhalation/smoking). This marked a significant shift, as detailed in the Pharmacy Practice in Focus: Health Systems article “Ryan’s Law Is a Monumental Opportunity for Pharmacists,” written by the Pharmacists’ Cannabis Coalition of California—but the evolution did not stop there.6 Just 2 years later, California expanded the law, extending access to include all patients older than 65 years with a medical marijuana certification within health care facilities.7 The dramatic increase in potentially eligible patients using cannabis in the institutional setting highlights the urgent need for comprehensive education and support.
This rapid policy shift that opened institutional use of cannabis to exponentially more patients is likely a harbinger of changes across the country. To ensure safe and effective implementation, it is crucial that health care professionals be prepared to provide value when these changes occur. Pharmacists, with their expertise in medication management and drug interactions, are uniquely positioned to lead the charge on educating patients. Their involvement can empower patients with knowledge, streamline dose titration, and ultimately improve patient outcomes.
Pharmacists Are Too Expensive, Right?
The high cost of a pharmacist is a common argument made by parties concerned about the bottom line in the tight-margin cannabis industry. Although pharmacists may add expense to the overall budget of a dispensary, they also add great value by helping patients with dosing and avoiding AEs. Putting a price on safety is a challenging problem without a simple solution, but it may be worth considering alternative ways to bring down the cost of cannabis medicine rather than simply scrapping the supporting role of the pharmacist.8
It is worth noting that many healthier patients may not need formal help with these processes, and models like Arkansas’ may be a good balance between cost and availability of a pharmacist.3 Moreover, once insurance companies begin to see regulated and FDA-approved cannabis products—which could happen in the next few years if cannabis is rescheduled per the request from the US Department of Health and Human Services to the DEA in January 2024—then it is reasonable to think that pharmacist support could be a cost-effective and value-additive component of the medical cannabis model.9
Patients with complex needs often require comprehensive medication management that considers potential drug interactions and susceptibility to AEs. Pharmacists, with their expertise in pharmacology and drug interactions, are uniquely positioned to provide valuable insights and guidance in medical cannabis therapy.10 Offering patients the option to consult with a pharmacist can significantly enhance outcomes and improve safety, and there is very little downside in offering the service to patients with complex and chronic conditions and who need more in-depth support than a budtender could be expected to offer.
Of course, the value of a pharmacist in a dispensary hinges on their ability to provide quality education and information about medical cannabis to the patient. Most data suggest that pharmacists remain concerningly unprepared for these real-world conversations. Likewise, pharmacy students report feeling underprepared for the incoming wave of patients seeking medical cannabis, with concerns dating back nearly a decade.11
With the landscape of medical cannabis continuing to evolve, the potential role of pharmacists in patient care cannot be overstated. With proper education, both at universities and on a personal level, the integration of pharmacists can undoubtedly enhance the medical cannabis care model. On the flip side, pharmacists must show initiative and provide value or risk being rejected and replaced for more affordable service providers. Certain states like Virginia and Ohio started their medical cannabis programs under the board of pharmacy but are now shuffling those responsibilities to other state-run regulatory bodies.
Pharmacists’ Cannabis Coalition of California (PCCC) is a nonprofit organization established in 2020 to provide evidence-based education about cannabis to health care professionals and the public. PCCC looks to integrate the pharmacist more fully into the cannabis patient-care model for the betterment of patient health and health outcomes.
As medical cannabis continues to gain acceptance and utilization increases, pharmacist involvement will be essential in ensuring its safe and effective integration into patient care. However, developing the role of the cannabis pharmacist will require universities to engage in training about cannabis medicine and require that pharmacists engage in cannabis-focused continuing education. By championing the integration of pharmacists into medical cannabis care models and advocating for more pharmacist-oriented education, policy makers can help ensure safe and effective medication management while promoting patient wellness. Collaborative efforts between health care stakeholders, including physicians, pharmacists, nurses, and academia, are essential to harnessing the full potential of medical cannabis and improving patient outcomes and quality of life.
