This is an excerpt from Second Opinion, a weekly roundup of eclectic and under-the-radar health and medical science news emailed to subscribers every Saturday morning. If you haven’t subscribed yet, you can do that by clicking here.
« Shoppers Drug Mart presents: ‘Medical Cannabis: The Future is Now.' »
That was the notice sent to Canadian doctors who were invited to register for « an exciting educational event » that would give them tools « to capably and confidently authorize medical cannabis for your patients. »
Interested doctors could sign up for one of four sessions being held across Canada.
Why is Shoppers Drug Mart holding education sessions for doctors on how to prescribe cannabis for their patients?
« Somebody has to do it, » said one family doctor on his way into the Vancouver event on Thursday evening. « On the whole for me I am confused. Who do I listen to? Who do I send my patients to, because I know I do not have adequate knowledge? »
Who should train doctors on prescribing medical cannabis?
But Toronto family doctor Sharon Cirone questions whether this medical education should be offered by a drug store chain that wants to get into the business of selling medical cannabis.
« It’s not appropriate and it’s not necessary » she said, adding that there are resources being developed by the College of Family Physicians of Canada, and other medical associations that don’t have a vested financial interest in cannabis.
The issue brings into sharp focus two increasingly controversial questions — how should a product that has not been approved through the normal drug approval process be used in medical practice? And who should be selling it?
Some doctors say they have no idea how to properly prescribe a product patients ingest though smoking. (Livia Manywounds/CBC)
Right now, pharmacies are not allowed to dispense medical cannabis. Instead patients must get it through the mail, after first getting authorization from a doctor and then registering with a licensed producer.
(Last week CBC News reported that medical cannabis users are facing supply disruptions in the first rush to supply newly legalized recreational market.)
National pharmacy chains are lobbying for legislation that would let them sell medical cannabis.
« This is basically the only product for medicinal purposes that does not go through a pharmacy, » said Justin Bates, CEO of The Neighbourhood Pharmacy Association of Canada which represents major drugstore chains and large retailers with in-store pharmacies.
The Canadian Pharmacists Association (CPhA) said patients would be better served if pharmacists were the ones dispensing medical cannabis.
« Typically the patients who are using cannabis for medical purposes are not using it as first line, » said CPhA spokesperson Shelita Dattani. « They’re on other medications which may have drug interactions with cannabis, they may be experiencing adverse effects, and we’d like to make sure we’re helping to keep patients safe. »
Lack of evidence still a concern, says CMA
But the professional pharmacist licensing agencies are not as keen for their pharmacists to jump into the medical cannabis field. The National Association of Pharmacy Regulatory Associations outlines that hesitation in a position statement.
There is similar hesitation from the Canadian Medical Association about doctors embracing cannabis use in their practices.
« The CMA remains concerned about the lack of clinical research, guidance and regulatory oversight for cannabis as a potential medical intervention, » the CMA states on its website.
« Physicians [are] being asked to prescribe something that is not approved, and that is largely ingested by smoking, » said Cirone. « Physicians have never been put in the position to prescribe a smoked product before and expose the lungs to disease. »
Right now, some doctors avoid dealing with the problem and instead direct patients to the recreational cannabis market, even though medical users might have different medical cannabis needs, such as achieving pain relief without getting high.
Canada has two separate cannabis markets— recreational and medical. (CBC)
Is there a conflict of interest?
« Now with it being legal, many patients are going forward and getting a product and asking afterwards for guidance on how to use it, » said Winnipeg oncologist Dr. Paul Daeninck. He routinely gives talks to doctors about his experience using cannabis to treat cancer pain and other palliative conditions. He’s one of the panelists involved in the Shoppers Drug Mart seminars.
Is there a potential conflict of interest?
« I feel that a company or a group that’s providing education and trying to do it in an unbiased manner is really doing the right thing, and bringing in experts to talk about it is important, » Daeninck said.
This is the first step in our journey to provide medical cannabis to our patients, »– Catherine Thomas, Loblaw Companies Limited
« The sessions, developed and presented by key opinion leaders from top Canadian universities and hospitals, cover the most up to date information about research into medical cannabis, including its use for a variety of disease states, » said Catherine Thomas, spokesperson for Loblaw Companies Limited, which owns the Shoppers Drug Mart chain.
In September, Shoppers Drug Mart received a licence from Health Canada to purchase and store pre-packaged cannabis products from existing licensed producers.
« This is the first step in our journey to provide medical cannabis to our patients, » Thomas said in an email.
Health Canada confirmed that Shoppers Drug Mart pharmacies cannot sell cannabis even through the mail, until the company receives a second Health Canada licence.
« There is no licence under the Cannabis Regulations that would allow Shoppers Drug Mart, or its subsidiary companies, to sell cannabis in its stores, » Health Canada spokesperson Tammy Jarbeau said in an email.
A decision is expected Tuesday in the case of a woman who, the Crown and defence agree, was not criminally responsible for fatally stabbing 28-year-old Rosemarie Junor in a Shoppers Drug Mart.
In the brief trial last week, forensic psychiatrist Dr. Ian Swayze testified Rohinie Bisesar, 43, was in a state of severe psychosis, experiencing hallucinations, delusions and disorganized thinking when she bought a knife from a Dollar Store and stabbed Junor in the heart on Dec. 11, 2015.
Junor was a “victim of (Bisesar’s) illness,” Swayze testified. He said the horrible tragedy for everyone involved would not have happened if Bisesar had been in treatment.
He diagnosed Bisesar with schizophrenia, suffering from fixed beliefs that external forces had placed an implant or device into her body and were controlling her movements.
Junor, a newlywed ultrasound technician, had popped into the drugstore in the underground PATH system on an afternoon break, court heard. She was on the phone with a friend when, according to an agreed statement of facts read in court, Bisesar walked up to her and stabbed her. Bisesar put the knife on a cosmetics display and left immediately.
The women were complete strangers to each other, court heard.
According to Swayze’s report, made in a court exhibit, Bisesar told Swayze that on the day of the incident, she heard the voice in her head say: “what is the worst thing you can do.”
She said the voice commanded her to buy a knife. “The voices, communication and movements made me sit up, turn, walk straight into the Shoppers fast… I was not an agreeable participant.”
She said she approached Junor without hesitation. “The voice said, if you mean to do it, do it,” she told Swayze. “The voice and movements raised my hand, pushed forward…it was like the knife was sticking to my hand and couldn’t be dropped.”
Junor was rushed to the hospital, but died four days later.
Junor’s death has been “unbearable” for the close-knit family, her cousin Denise Sagar wrote in a statement given to reporters Friday. Sagar said Junor dedicated her life “to the care and treatment of people who are ill.” Sagar said her worry is what happens should Bisesar stop taking her medication again in the future.
“I hope my fears are unfounded,” she wrote. “I don’t know which is worse, the loss of my cousin or my fear that another family will suffer the loss of a loved one because someone simply decides to stop taking their medication.”
The case has taken nearly three years to conclude because Bisesar was repeatedly assessed and eventually found unfit to stand trial in December 2017 because her continued delusions impaired her ability to instruct her lawyer. She consistently refused treatment for a mental illness, instead claiming there was an implant in her body controlling her, which should be a matter of national security. She also suggested she did not believe Junor was dead, but rather hiding.
After her arrest Bisesar was held at the Vanier jail, though she was briefly transferred to hospitals on four occasions out of concern for her declining physical condition, including weight loss and facial lesions from her picking at her face. She was forced to receive treatment after being found unfit to stand trial. Her symptoms are now almost entirely in remission, Swayze testified at her fitness hearing last week after which a jury found her fit to stand trial. She is now consenting to treatment, he said.
Bisesar’s lawyer Robert Karrass argued in his closing address that she should be found not criminally responsible because, while she committed the physical act, her ability to think rationally was so impaired by her mental disorder at the time that she did not know what she was doing was legally and morally wrong.
If she is found not criminally responsible, Bisesar would be sent to a forensic hospital for an indefinite period of time.
Swayze’s report recommends Bisesar continue to be held at the women’s secure unit at the Centre for Addiction and Mental Health where she is responding well to treatment and has been granted staff-accompanied community passes.
Bisesar’s release would be controlled by the Ontario Review Board, a five-person panel usually including psychiatrists, a lawyer and a member of the public.
In annual hearings they determine whether individuals found not criminally responsible (NCR) should continue to be detained in the hospital, given a conditional discharge which could allow the person to live in the community while subject to certain requirements, or an absolute discharge which is a full release with no further supervision.
A detention order is not intended as a punishment, like a prison sentence.
Instead the paramount concern of the Board is whether the person poses a significant risk to the safety of the public, said mental health lawyer Anita Szigeti who is not involved in the case.
“Just because someone is found NCR doesn’t mean they are in any way dangerous,” she said. If the person is found to be a significant risk, the board will consider other factors — most importantly the protection of public from dangerous persons, as well as the re-integration of the person into society and the liberty interests of the person.
They have to choose the “least onerous, least restrictive” disposition possible, she said. “They can’t take away more liberty than is neccesary.”
However, it is definitely not a “get-out of jail free card,” she said. “The ramification of coming under the review board’s jurisdiction is potentially indefinite detention in a maximum secure psychiatric facility setting, some of these facilities are very similar in their layout and security to high-security prisons.”
Victims can make victim impact statements at the annual Ontario Review Board hearings, Szigeti said. However, that process — which is often emotional and difficult for both the victims and the person found NCR — can give victims the “unfair and wrong impression” that their statements can influence the board’s decision, Szigeti says.
Unlike in a sentencing hearing, the statements do not have any impact on the decision the board makes which is based on the person’s current level of risk to public safety, she said.
Alyshah Hasham is a Toronto-based reporter covering crime and court. Follow her on Twitter: @alysanmati