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Pharmacare…Long Overdue

By: Lorian Hardcastle

PDF Version: Pharmacare…Long Overdue

Matter Commented On: Interim report from the Advisory Council on the Implementation of National Pharmacare

Canadian Medicare has traditionally focused on hospital and physician services due, in large part, to the fact that the Canada Health Act, RSC 1985, c C-6, provides for federal/provincial cost-sharing for these services. The exclusion of pharmaceuticals made sense at the inception of Medicare in the 1950s, as there were few effective drugs at the time. However, the ensuing decades have seen a proliferation of new drugs that significantly reduced morbidity and mortality. For example, statins, which lower cholesterol and decrease the risk of heart attack by approximately 25%, came into clinical use in the late 1980s. They are now taken by millions of Canadians and represent the second largest category of pharmaceutical spending (after certain types of cancer drugs). The increasing prevalence and efficacy of pharmaceuticals and their growing costs have led to calls for universal pharmaceutical insurance (referred to as pharmacare).

On Wednesday, the federally-appointed Advisory Council on the Implementation of National Pharmacare released their initial recommendations. Notably, they recommended that “Canadian residents have access to prescription drugs based on medical need, without financial or other barriers to access.” Universal pharmacare would make Canada’s health care system more equitable and prevent needless morbidity and mortality. It would also bring Canada in line with other countries. According to a recent report, “every developed country with a universal health care system provides universal coverage of prescription drugs—except Canada.”

Decriminalization of Cannabis and Canadian Youth

By: Lorian Hardcastle

PDF Version: Decriminalization of Cannabis and Canadian Youth

Legislation commented on: Cannabis Act, SC 2018, c 16

In a previous blog post, I summarized the new federal, provincial, and municipal laws pertaining to cannabis. One of the key policy issues for all three levels of government is the impact that legalization will have on young people. For example, the federal Cannabis Act has as two of its stated purposes to “protect the health of young persons by restricting their access to cannabis” and to “protect young persons and others from inducements to use cannabis” (section 7). In furtherance of these goals, the federal law decriminalized cannabis possession for individuals who are 18 years of age or older, with an exception for young people in possession of small quantities. All provinces other than Quebec and Alberta have increased this age to 19, which corresponds with provincial laws respecting alcohol consumption. However, Quebec’s incoming government recently promised to raise its legal possession age to 21.

The Future of Medical Cannabis

By: Lorian Hardcastle

PDF Version: The Future of Medical Cannabis

Legislation commented on: Access to Cannabis for Medical Purposes Regulations, SOR/2016-230

The recent decriminalization of recreational cannabis, which I explored in an earlier blog post, has led some to question whether Canada still requires a separate legislative scheme for medical cannabis users. On the one hand, some argue that health professionals should not spend their time writing prescriptions for something that can now be purchased in stores, particularly given the mixed evidence in support of medical cannabis. In stark contrast, others argue that a single regulatory regime would affect the rights of medical users and hinder their ability to access cannabis products.

Medical Cannabis in Canada

Canadians who currently wish to consume cannabis for medical purposes must first obtain what is referred to as a “medical document” from a health care professional (a physician or nurse practitioner). They may then purchase cannabis from a federally-licensed producer, register with Health Canada to produce a limited amount of cannabis for their own medical purposes, or designate someone to produce this supply for them.

According to data from Health Canada, in June 2018 alone (the most recent month for which data is available), Canadians purchased 2,103 kilograms of dried cannabis and 4,124 kilograms of cannabis oil for medical purposes, licensed producers made 135,062 cannabis shipments to Canadians, and 3,836 health care practitioners provided medical documents for patients registered with licensed producers. As of the end of June 2018, there were 21,521 active Canadian users registered with a licensed producer, 20,346 users who produced their own cannabis for medical purposes, and 1,195 who had designated someone else to produce it for them.

At this time, Health Canada has decided to retain this separate medical cannabis regime. In other words, while medical users can continue to purchase cannabis in the same manner as they had prior to decriminalization of recreational cannabis, they can also forego the need to obtain medical documentation and purchase these products from provincial or territorial retail outlets.

The Role of Health Professionals in Medical Cannabis

Perhaps the loudest and most prominent opponent to retaining the dual recreational and medical cannabis regimes is the Canadian Medical Association (CMA). It has recommended phasing out the medical cannabis regulations, noting that there is “no need for two systems” as cannabis “will be available for those who wish to use it for medicinal purposes, either with or without medical authorization, and for those who wish to use it for other purposes.”

The CMA’s position is that they are concerned “about the lack of clinical research, guidance and regulatory oversight for cannabis as a potential medical intervention.” Furthermore, they note that many physicians are uncomfortable “prescribing a substance that hasn’t undergone the same regulatory review processes required for all other prescription medicines”, which result in comprehensive information for prescribers relating to clinical indications, dosages, and potential interactions with other medications. One St. Albert doctor controversially went so far as to say “I can’t prescribe alcohol, I can’t prescribe trips to Hawaii, and so I don’t prescribe marijuana… [I’m] not saying it doesn’t make people feel better, but it’s not a medication.”

There is support for the CMA’s position that there is a lack of high-quality evidence respecting the medical efficacy of cannabis. For example, a recent guideline published in Canadian Family Physician, a peer-reviewed medical journal, involved a detailed systematic review of the evidence on medical cannabis use. The authors recommended limiting medical cannabis due to a concern with a lack of evidence, apart from a small subset of medical conditions: neuropathic pain, palliative and end-of-life pain, chemotherapy-induced nausea and vomiting, and spasticity due to multiple sclerosis or spinal cord injury. A recent review of the medical cannabis literature by University of Calgary researchers concluded that “there is only low to moderate quality evidence to suggest that cannabis is an effective treatment for most medical conditions.”

In response to the CMA’s position, it could be argued that a lack of high-quality evidence on medical cannabis supports more involvement by health professionals rather than less, in order to ensure that patients are properly informed of these evidentiary limits and that they are using cannabis appropriately. Divorcing themselves from informing patients about a product with potentially significant health implications is arguably an abdication of their responsibilities. In this regard, the College of Physicians and Surgeons of Alberta has stated that physician responsibilities include, “providing objective, evidence-based information to patients seeking medical cannabis to support informed decision-making.” If patients self-prescribe cannabis for their medical conditions and purchase it from recreational retail outlets, they will not receive potentially important information about its efficacy for their particular conditions, alternative medical treatments, or potential medication interactions.

In contrast to their physician counterparts, the Canadian Nurses Association has said that it is in favour of retaining a separate system for medical cannabis, worrying that a single recreational legislative scheme may result in patients not talking with health care providers about cannabis use.

The Concerns of Medical Users

Medical cannabis users and advocacy groups argue in favour of retaining a separate legal regime for a variety of reasons. Some fear that producers may be encouraged to focus their efforts on more economically viable recreational products over the existing medical products that users have come to depend upon. Other users argue that patients may not feel confident talking with health professionals if cannabis is perceived as a recreational rather than medical product. In an article in the Canadian Medical Association Journal, Cairns and Kelly argue that “having only one stream continues to fuel the stigma surrounding cannabinoid-based therapeutics and delegitimizes patients who state that they use these drugs out of necessity rather than choice.” Many medical users struggle with the cost of cannabis, due to a lack of insurance coverage. Although an increasing number of insurers are covering medical cannabis for certain conditions, progress could be halted with the abolition of the medical cannabis regulatory scheme.

Creating a single recreational cannabis regime may also raise human rights concerns. Provincial laws protect those who use cannabis for medical purposes related to a disability from discrimination in the context of employment, housing, and other areas. For example, a landlord has a duty to accommodate the consumption of medical cannabis by a tenant up to the point of undue hardship. If existing regulations are abolished and doctors no longer provide medical documentation to patients who use cannabis for their health conditions, these patients may have difficulty establishing their disability-based claims for accommodation.

Health Canada’s Approach

Health Canada has stated that it plans to review whether there is an ongoing need for separate sets of medical and recreational cannabis regulations within five years. In the meantime, policy-makers have taken several steps to improve the evidentiary basis for medical cannabis, which will enable them to make a more informed decision about whether to keep the medical regulations. For example, the Canadian Institutes of Health Research have earmarked specific funds for cannabis research in urgent priority areas. The Cannabis Regulations, SOR/20180-144, which recently came into force, were designed to encourage research by including a specific category of license for those seeking to conduct research on cannabis (in addition to those licenses relating to cultivation, production, etc.). However, research on cannabis can be challenging. Compared to pharmaceuticals, which are synthetically manufactured in near-identical conditions in factories, the composition of even genetically-identical cannabis plants can vary due to environmental differences in soil and lighting, resulting in study design challenges.


This post may be cited as: Lorian Hardcastle, “The Future of Medical Cannabis” (October 18, 2018), online: ABlawg, http://ablawg.ca/wp-content/uploads/2018/10/Blog_LH_Future_of_Medical_Cannabis_Oct2018.pdf

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A Primer on Cannabis Regulation

PDF Version: A Primer on Cannabis Regulation

By: Lorian Hardcastle

Legislation Commented On: Cannabis Act, SC 2018, c 16; Cannabis Regulations, SOR/2018-144; Gaming, Liquor and Cannabis Act, RSA 2000, c G-1; Gaming, Liquor and Cannabis Regulation, Alta Reg 143/996

Legal changes that decriminalize recreational cannabis come into effect today, with 17 Alberta stores set to open their doors to the public. This is a complex area of the law that involves all three levels of government (see Figure 1).

(Figure 1)

In addition to legal changes, scores of other organizations have developed or adapted policies to address cannabis, such as condominium corporation bylaws preventing cannabis consumption within their complexes, workplace policies addressing cannabis use by employees, and university policies governing cannabis on campus. This blog post, which is the first in a series relating to cannabis, describes the key features of federal, provincial, and municipal laws.

No Discrimination Against Long-Term Care Residents in Elder Advocates of Alberta Case

By: Jennifer Koshan and Jonnette Watson Hamilton

PDF Version: No Discrimination Against Long-Term Care Residents in Elder Advocates of Alberta Case

Case Commented On: Elder Advocates of Alberta Society v Alberta, 2018 ABQB 37 (CanLII)

Our colleague Lorian Hardcastle recently posted a comment on the Elder Advocates of Alberta Society case, where a class of long-term care residents brought a claim against the Alberta government challenging its ability to charge accommodation fees in their facilities. As she noted, the plaintiffs were unsuccessful in their claims of unjust enrichment, negligence, and contract. The plaintiffs also argued that the accommodation charges were discriminatory on the basis of age and mental / physical disability, contrary to section 15 of the Canadian Charter of Rights and Freedoms. Justice June Ross also dismissed this argument, and her reasons on the section 15 claim will be the focus of this post.

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