Although medical cannabis has been used successfully as a palliative therapy in patients with cancer, it is still stigmatized because of its illicit scheduling. However, as research on cannabis use in oncology matures and the stigma begins to fall away, more states are allowing for pharmacist oversight of this product, and its legalization continues to spread.
Compelled by the current lack of standardization, the International Society of Cannabis Pharmacists (ISCPh) was founded to recognize the legitimate use of medicinal cannabis and unify the pharmacy profession on this topic to support public health. With an ever-growing membership of approximately 300 licensed pharmacists, medical professionals, and industry leaders in the United States and abroad, the ISCPh seeks to advance cannabis education and collaboration and empower pharmacists to responsibly administer cannabis to appropriate patients. According to Jeffrey Lombardo, PharmD, BCOP, Secretary of the Board of Directors of the ISCPh, it is becoming increasingly important for pharmacists to educate themselves on the medicinal use of cannabis in oncology.
In an interview with The Oncology Pharmacist (TOP), Dr Lombardo discusses the mission of the ISCPh, and provides details on the organization’s inaugural meeting scheduled for later this year.
TOP: What is the mission of the ISCPh?
Dr Lombardo: Our mission is education, centering around the role of the pharmacist as it relates to the management of cannabis as a medication. As a pharmacist and a researcher, I am concerned about safety first and efficacy second. There is credible evidence that certain drug–drug interactions can lead to serious adverse events. For example, Epidiolex is a pure cannabidiol (CBD) isolate and the first FDA-approved prescription cannabinoid medication for the treatment of 2 forms of epilepsy. Safety data from studies have shown that this drug has the potential for causing elevated liver enzyme levels and could be hepatotoxic at higher doses. Therefore, careful monitoring of the patient is a clinical function that should be done by the pharmacist over time while patients are receiving this medication.
We need to set level expectations up front. At the end of the day, cannabis can be associated with certain side effects, and the product is not effective for everyone who tries it at the initial starting dose. Like other medications, medical cannabis needs to be titrated to a desired effect while keeping a close eye on potential side effects. When cannabis is combined with a patient’s established medication regimen, there can be a synergistic effect, both positive and negative.
TOP: What is the role of the pharmacist in this area?
Dr Lombardo: Each state has its own protocol for a medical marijuana program, and in some states, pharmacists are not even involved in the process. In New York State, the process relies heavily on pharmacist input. For instance, a medical provider can give the patient a recommendation for cannabis, but if the provider does not specify, the pharmacist may select the product and dosage for the patient, and then provide the necessary education on its use. As a result, although the physician makes the initial recommendation, he or she may not know what the patient actually ends up receiving.
I believe the pharmacist’s primary role is to perform a drug–drug interaction check and look for potential clinical contraindications to the product, followed by a discussion with the patient around the evidence-based literature and the therapeutic benefits of cannabis, as it relates to the patient’s specific qualifying condition.
I spend 1 day every other week working in a dispensary in New York, because I am interested in knowing which questions patients have about dosing, how they respond to the products, and how we are following up with them. This has allowed me to create a program where relevant clinical information is communicated back to a select group of medical providers. This is truly a multidisciplinary approach and has resulted in a program that benefits all parties involved. As I previously stated, not all patients respond positively to cannabis and you need to know when to move on to another form of therapy. However, in the oncology palliative care community, I have seen many patients benefit from cannabis treatment to the point where they can state their quality of life has improved.
TOP: What is the goal of the upcoming ISCPh inaugural meeting?
Dr Lombardo: The meeting is really focused on awareness, education, and networking. For example, labeling standards are a big focus for us as an organization. Not every state provides the same clear, concise information on its product labels. When patients with cancer ask for information about cannabis, some providers may not be equipped to answer these questions. We plan to initiate discussions and form a national working group that focuses on what needs to be studied over the next year in relation to research, policy, and clinical practice.
Clinical research on cannabis has increased since the passage of the 2018 Farm Bill (which transformed federal hemp policy in the United States and took CBD off the shelf as a Schedule I classification), and we are working on bringing individuals with regulatory knowledge and experience to the meeting to comment on this bill. I will be moderating a session on the future of cannabis pharmacy. A panel of physicians, researchers, and pharmacists will discuss what needs to be done collaboratively as we move forward.
TOP: Why is it crucial for providers to be informed about cannabis?
Dr Lombardo: Patients are trying it, they are using it, and it is everywhere. They are more open to alternative medicine and state regulations are changing to allow it. If you look at the number of growers, processors, and distributors within the CBD market alone, it has increased exponentially in recent years. I work very closely with patients enrolled in palliative care programs and have done so for more than 20 years. Cannabis does help some of these individuals, and for some, it has helped tremendously.
I know that most of this information is currently not evidence-based; however, in my daily contact with patients, I have seen cannabis help with symptom control in numerous individuals with cancer. However, for patients on active treatment, it can be a different story; you need to look at potential drug–drug interactions and the possibility of increased toxicities associated with potent anticancer medications. Therefore, providers need to have a strong information base to keep their patients safe.
TOP: Which safety issues need to be considered when prescribing cannabis?
Dr Lombardo: Cannabis is metabolized through the liver, as are many other FDA-approved drugs. A pharmacist needs to obtain a complete medication history from the patient, and a plan should be put in place to monitor for potential side effects.
For example, a patient who obtained a certification for medical cannabis via the Internet recently came into the dispensary. This individual was seeking relief for general pain syndrome. During my interview with him, I discovered that he was taking an immunosuppressant medication and was also a kidney transplant recipient. Some of his medications would have directly interacted with CBD, so I did not dispense a product to him that day. Instead, I provided education, along with a strong recommendation that he speak to his local transplantation physician and tell him what he wanted to do regarding cannabis therapy. If they decided as a team that it was okay for him to try it, his monitoring regimen would have to be vigorously modified for a potential fluctuation of his immunosuppressant levels that were keeping his body from rejecting the transplant.
In certain subsets of patients, we need to carefully consider the risk–benefit ratio and determine whether there are other options for pain relief. There are also specific medical conditions for which cannabis use would not be recommended (eg, patients with a history of schizophrenia or cardiac disease [specifically arrhythmias], or those on certain medications for bipolar disorder).
TOP: How will the increasing use of cannabis in oncology affect providers, policymakers, and payers?
Dr Lombardo: Providers need to be engaged because patients with cancer are using alternative medications, cannabis included. They need to develop a better understanding of cannabis and its treatment options. As usage continues to evolve, policymakers need to clarify their stance on the state and federal laws. Their constituents may begin to demand changes to current laws, and they will need to be open to renegotiating some of the current procedures as patient treatments change. Again, people are still trying to understand the complexity of the Farm Bill. Currently, cannabis is not FDA approved and as such, treatment is not covered. I do not see that changing until the FDA begins approving more treatments.