Finding Your North Star: A Cannabis Alternative in Pain Management in Canada

Cannabis Patient Care, March/April 2021, Volume 2, Issue 1

Dr. Julie Hildebrand, Dr. Peter Blecher, and a medical cannabis patient share their insight into medical cannabis as a treatment for pain management in Canada through the help of WeedMD and others.

If you asked Georges Theriault what pain feels like, he’d tell you about a day he sat alone in his garage. Unable to walk, barely able to stand, he recalls the moment he realized he had become a shell of his former self.

“When you’re sick, you can’t believe what your life has become,” said Theriault, a 63-year-old Canadian Forces and Royal Canadian Mounted Police (RCMP) veteran, who was diagnosed with diabetes in 2012.

Before his diagnosis, Theriault rarely sat still for long. He qualified for pre-Olympic boxing, ran sled dogs in Alaska, worked as a ski patroller in Europe and, before retirement, led an executive security firm protecting top Canadian politicos. After retiring and relocating from Ontario to New Brunswick, his health quickly and steadily declined; before long, the effects of the illness required the replacement of one hip and both knees.

After three surgeries and four years of physiotherapy and conventional opioid-based narcotics, as well as naproxen, Theriault still hadn’t recovered. “At the very end, I was in the hospital for eight days and the doctor looked at me and said, ‘I can’t do anything else for you,’” he shared.

Theriault’s story is all-too-common in Dr. Julie Hildebrand’s practice. In her 30 years of biomedical research and patient experience, she has met many patients like him, caught in a pain management symptom-prescription loop.

“As physicians, we do not like to start treatment for pain with narcotics, though it is, unfortunately, where many patients end up,” Hildebrand said. “We usually start small—with anti-inflammatories and massage—and augment progressively if symptoms do not abate. But once a patient starts with opiates, treatment can spiral as the body develops a tolerance—after that, there is very little left in terms of conventional treatment. Cannabis has given some of my patients new hope, however.”

Hildebrand is a New Brunswick-based physician published in papers and publications on cannabis medicine as a new therapy, effects of opioid addiction, methadone treatment, analysis, and mental health. She works closely with Starseed Medicinal, the medical division of Canadian licensed cannabis producer WeedMD Inc., to provide cannabis counseling and treatment options for patients in the country’s Atlantic-area provinces.

A general practitioner, Hildebrand began prescribing cannabis to patients in 2014. She became interested in learning more—a lot more—about cannabis medicine after seeing significant improvement in patients suffering from chronic pain. Over the following seven years, Hildebrand became the Atlantic region’s foremost expert physician prescribing medical cannabis.

Theriault, a 40-year military and RCMP veteran, had never tried cannabis in any form before. Through a series of referrals, he connected with Dr. Hildebrand, who prescribed the drug in an oil format, high in both tetrahydrocannabinol (THC) and cannabidiol (CBD). Within a year, he had transitioned off all narcotics for cannabis, and today, he says he is pain-free.

“The (hospital’s) doctor couldn’t believe it. I can ride my motorcycle, I can walk. I went from using a walker to having a new life,” said Theriault.

Like Theriault, many of Hildebrand’s patients find cannabis as a third or fourth-line treatment option for conditions, ranging from post-traumatic stress disorder (PTSD) to fibromyalgia. And like Theriault, who is now a medical patient of a local New Brunswick-based licensed producer, most have gone down traditional pharmacological treatment paths with little success and turned to cannabis when all else failed.

“Patients would come to me and say ‘cannabis works.’ I wasn’t comfortable with the idea of patients buying it on the street, so I started to study the phenomenon from a clinical perspective, travelled and met experts, and read all I could that was available to offer treatment and counseling. I was quickly overwhelmed with both the demand and the impact of this medicine. It opened up a new era of treatment for me,” said Hildebrand. “As a physician, it is gratifying to see results after so many failed attempts.”

Medical Cannabis in Canada

Canada’s medical cannabis landscape has grown exponentially in recent years. Regulation was established by the country’s national health authority, Health Canada, in 2001. The change stemmed from a decision by The Ontario Court of Appeal, which ruled prohibition unconstitutional, as it didn’t allow exemption for medical use. The country’s initial legislation allowed for approved patients to grow their own plants, or to acquire their medicine from a designated grower.

Legislation was modernized in 2014 to allow patients to purchase products directly from a licensed commercial producer such as WeedMD, which received its initial licensing in 2016.

Medical authorization from a licensed health care practitioner is required for Canadian patients to purchase medical cannabis, many of whom say they use it to treat a variety of ailments, from chronic pain to PTSD. Once authorized, patients may register with a licensed producer of their choice and buy direct. According to Hildebrand, the average amount generally prescribed is 2 grams per day, though her patients often experiment with dosage under her supervision until the optimal dose is found.

“The efficacy of cannabis medicine is still being studied and while the endocannabinoid system isn’t taught in medical school anywhere near as extensively as it should be, we are seeing the results for ourselves in our clinics,” said Hildebrand.

In 2018, cannabis was legalized for both medical and recreational adult-use under a combined legislation, The Cannabis Act, replacing the medical cannabis framework legalized in 2001. Under the legislation, adults are permitted to purchase cannabis at licensed retail locations (subject to laws on possession limits and consumption), though provisions around access, taxation, and possession exist for medical patients.

“Despite cannabis’ recreational legal status, many patients opt to remain registered in the medical system,” said Dr. Peter Blecher, Starseed Medicinal’s Chief Medical Officer who helped set up the Starseed Medical platform and benefits reimbursement structure back in 2014.

Medical producers can guarantee access to medical-grade cannabis products such as high-CBD flowers, gel caps, oils, and sprays formulated for precise, metered dosing; and patients can receive one-to-one specialized care from select producers who offer such support. Additionally, medical cannabis is considered a medical expense and can be claimed on an individual tax return, provided it has been authorized by a healthcare professional and is purchased directly from a licensed producer.

“While many producers turned their attention to the recreational market, we doubled-down on our efforts to care for patients,” Blecher said. “We began working with a growing number of practitioners and enhanced our patient program with simple onboarding, education, and a pharmacy approach to ordering and fulfillment. We wanted to make sure no patients were left behind.”

Medical Cannabis Research

Emerging research continues to validate patients reported success with cannabis, and it is being shown to be an effective treatment for many who suffer from pain. Dr. Blecher has spent more than 15 years working in the field of chronic pain management, treating complex pain through a combination of interventional, pharmacotherapeutic, as well as guided mindfulness and self-management approaches. In the 2000s, he was witness to the rampant over-prescribing of opioids for chronic pain, and consequent issues of addiction, distress, and societal costs this left in its wake. His personal observations and subsequent investigations into the science of cannabinoids led him to become an ardent advocate for the use of cannabis as an opioid displacement strategy. He developed his proprietary TOP-CART program (Tapering of Opioid Prescribing with Cannabis As Replacement Therapy), and ultimately assembled and trained the team of medical experts that came to be North Star Wellness, and recently started working with Hildebrand to expand care into Atlantic Canada.

A 2021 study published in the Canadian Journal of Anesthesia (1) that followed 1000 patients using cannabis for chronic pain found that, among those who remained on medical cannabis for six months, pain intensity and pain-related interference scores were reduced.

In addition to her practice, Hildebrand is the medical director of the Methadone Maintenance Therapy Program at Saint Joseph’s Hospital in Saint John, New Brunswick. She often observes comorbidity of anxiety disorders and opioid addiction in methadone patients.

“Anxiety and pain are mechanistic,” she said. “I wondered, what if we try to treat both the pain and anxiety with cannabis? I noticed the people who were using cannabis on the side were doing better. They were sticking to their methadone treatment better than those who weren’t. Now what if those patients who had been originally prescribed opiates for pain chose cannabis instead? Because we’re complex beings, it’s rare someone only suffers from pain. The beauty of cannabis is that it can address many health problems at one time.”

In the Canadian Journal of Anesthesia study, the proportion of studied individuals who reported using opioids decreased by half. Furthermore, in a 2020 survey from Medical Cannabis Canada (2), 72% of medical cannabis patients revealed that cannabis decreased their reliance on traditional medication. According to the survey, 1 in 4 reported decreased reliance on opioid pain relievers, but 36% of these patients reported that barriers to accessing cannabis led them to return to those medications.

Patient Access

The results point to a greater need than ever for patient access and physician support for cannabis as an opioid exit therapy, explained Max Monahan-Ellison, a medical cannabis consultant and board member with Medical Cannabis Canada.

“Survey research indicates a good portion of patients are treating for chronic pain, and observational studies have highlighted that cannabis can be an effective option to help reduce opioid dependency,” said Monahan-Ellison. “The challenge is that cannabis is still primarily seen as a second or third-line treatment option by prescribers.”

He added that for insurance providers, most of whom don’t recognize medical cannabis, this treatment option is something of a regulatory oddity. In Canada, medications approved for specific indications are issued a drug identification number (DIN). Excluding pharmacological cannabinoid drugs such as Sativex and Nabilone, cannabis in any format has not received a DIN from the regulator.

Without a DIN—and despite necessary medical authorization—cannabis generally isn’t considered or regulated as a traditional pharmaceutical medicine, nor is it covered by any public health drug plans. Yet, many carriers including Sun Life, Canada Life, Green Shield, and Medavie Blue Cross cover medical cannabis as an insured drug, with limitations.

“The key point here is that despite the fact that carriers have created coverage options, there has been low uptake from employers and other payors to include cannabis on their formularies because cannabis has to be added as a paid benefit,” said Blecher.

Often, standard extended benefits will cover the drug when prescribed to treat specific conditions, such as epilepsy and multiple sclerosis, that have a greater body of clinical evidence for cannabis efficacy. However, those policies tend to exclude the majority of the patient population and businesses typically have to buy into them as part of their benefits packages.

Many of the plans seen today resulted from external pressure and demand from plan sponsors (employers, union groups, and so forth) looking for medical cannabis options, Monahan-Ellison explained, adding he has heard from the insurance sector that uptake of these programs is low.

“Insurers develop benefits offerings based on the needs of customers, the employers who purchase group plans for their staff—and they emphasize that if the demand isn’t there, the benefits won’t be there either,” he said.

“At the same time, as plans expand their coverage to other indications, they will be relevant to a broader group of employees. Continued research is essential for building the case for private insurers to expand covered indications and public payors to consider reimbursing the treatment option. It will take a coordinated effort of government, industry, and advocacy groups to push forward change in this category and expand access,” said Monahan-Ellison.

WeedMD includes cannabis coverage as a drug benefit in its employee insurance plan, should an employee use cannabis for medical purposes. The company built its Starseed medical platform to bridge the gap between patients and insurers through a "virtual pharmacy" model. 

Today, the company is Canada’s leading licensed producer in the paid benefits arena. In addition to its work with four of Canada’s major insurers, its offering has been embraced by union groups, who offer reimbursement for Starseed Medicinal cannabis products to qualifying members. The company holds a partnership with Labourers’ International Union of North America (LiUNA) the largest construction union in Canada with a number of Ontario-based locals signed. In January 2021, the company signed its sixth LiUNA local and first in Manitoba, to the Starseed medical program.

“We wanted to build a program that, for the first time, could really bring insurers and employers together to provide insured patients with an alternative to other covered drugs, like opiods and benzodiazepines,” Blecher said. “We know all the too well the stories about the ripple effect of opiate drugs and addiction. While those pain medications are relatively inexpensive to pay for up front, the percentage of patients who develop dependency, in turn, run into a host of other issues: a decline in job productivity, more time off the job, slower return-to-work, mental health and addiction issues, and new expenses such as dental care or long-term methadone treatment, all of which cost insurers far more in the long run.”

Starseed works directly with insurers on their patients’ behalf to ensure medication is paid for in the background as patients focus on their treatment. The only other group that receives a comparable level of coverage are Canada’s veterans. In fact, many licensed producers work with veteran groups to provide advocacy and education to those with medical cannabis coverage, reimbursed by Veterans Affairs Canada. 

While national registered patient counts dipped following legalization, data shows patient counts are once again rising steadily. Today, according to Health Canada, roughly 375,000 patients are registered with federally licensed producers, while 43,000 are registered for personal or designated production.

Canada’s cannabis industry has grown exponentially in recent years. Pre-recreational legalization on October 17, 2018, 125 producers were licensed. Today, more than 570 producers are licensed for various activities, including cultivation, processing, sale, research, and testing.


Paving the Way Forward

In Hildebrand’s practice, the rates of new patients signing up for medical cannabis—particularly seniors between the ages of 70 and 90—are on the rise. Cannabis is talked about in retirement-age communities as a safer treatment option, and pain sufferers are interested in trying it more than ever, she explained.

“Considering cannabis is legal for purchase in-store, now when a patient reaches out, I know they are serious,” said Hildebrand. “They need professional advice on how to consume, how often, and whether there are any contraindications—you can’t get that at a recreational shop. It is vital that practitioners are ready and able to support them, but there are still many barriers to access.”

Though cannabis is legal in Canada, many physicians are still reluctant to prescribe because they are not sure about dosing and which formats to prescribe—they simply don’t know enough about it, Hildebrand noted. Most patients find her by referral, or through their own research after their requests for medical cannabis are rejected by their own physician.

“It happens a lot. I often hear that physicians are only willing to try medical cannabis after all else has failed. My message to other doctors is that we don’t have to wait until all other avenues have been explored, especially opiates,” she said. “In medicine, we learn a great deal from books, black and white. But when we get in front of patients, most conditions often fall in a grey zone. Though sticking to outlined criterions are important and useful, the really good doctors also follow their intuition and are willing to think outside the box.”

Data from Health Canada suggests that in some provinces, fewer cannabis prescriptions are being issued. Between September 2019 and March 2020, Alberta, Newfoundland, and Ontario saw fewer healthcare practitioners associated with registrations, leading to the assumption that many people could be self-medicating by accessing cannabis through other means.

The regulator’s 2020 Canadian Cannabis Survey (CCS) reported that 14% of Canadians aged 16 and older indicated they used cannabis for medical purposes. The report found that just over 20% of medical cannabis patients access treatment with a medical document, which means the rest are purchasing their medicines from either the recreational or the illicit market.

In addition, Medical Cannabis Canada’s 2020 survey found that among medical cannabis patients, 50% reported that it’s hard to find a healthcare practitioner to speak with about obtaining a medical document and 83% reported that the stigma about medical cannabis use exists among medical professionals.

The optics of cannabis use—smoking, rolling, pipes, and bongs—and antiquated, prohibition-era ideas about the drug contribute to its limited acceptance in the medical profession, Hildebrand explained. The plant’s legal status in much of the world and consistency through batches has made clinical research challenging, and the availability of verifiable data hasn’t kept pace with patient demand.

“Dealing with pain or struggling with a chronic health condition can be very isolating. Worrying about securing medication and paying out-of-pocket only adds to the stress of illness, and can compound symptoms,” Blecher said. “In many cases, cost is the single-largest barrier for patients, and the reason why they revert back to cheaper, covered, and often more dangerous and addictive medications.”

But many producers are providing ample support for their patients—both insured and uninsured. In the case of Starseed, it offers compassionate pricing for low-income patients, first responders, veterans, and seniors, including full, complimentary access to virtual medical consultations with it suite
of professionals.

Blecher added: “The cost of cannabis has long been a huge barrier for patients, as it isn’t regarded in the same way that traditional pharma is—there is no government reimbursement, with the exception of veteran coverage, so it’s up to private insurers, employers, union groups, and licensed producers to step up and affirm their core commitment to patient care.”

Hildebrand confirms many of her patients reporting the greatest improvements are those who are supported, monitored, and following a thoughtful treatment plan designed for the individual—not only the disease or condition.

“Medicine is both an art and a science. Many doctors forget about the art and the intuition in our practice—balancing both and really caring for our patients gives them the best chance at recovery.”

As for Theriault, nowadays when in his garage, he is definitely not sitting around anymore. Instead, he is grabbing a shovel to clear snow, or gathering landscape tools to prune hedges, or mowing the lawn—returning to a life full of simple moments that remind him that life is indeed back to normal.

References

  1. H. Meng, M.G. Page, P. Ajrawat, A. Deshpande, B. Samman, M. Dominicis, K.S Ladha, J. Fiorellino, A. Huang, Y. Kotteeswaran, A. McClaren-Blades, L.P. Kotra, and H. Clarke, Can. J. Anaesth. doi: 10.1007/s12630-020-01903-1 (2021) https://pubmed.ncbi.nlm.nih.gov/33469735./.
  2. https://www.patientaccess.ca/survey/.

Read this article in Cannabis Patient Care's March/April 2021 digital edition.