There is variability in comfort regarding marijuana counseling and education. Pharmacies often have internet restrictions in place that prohibit access to numerous clinical resources outside of what has been approved for the pharmacy. This may lead to some discomfort in counseling when the only available resources are those specific to FDA approved medications. If an individual is interested in using a marijuana edible for a sleep-aid, data from Epidiolex^® or Sativex^® pharmacokinetics will not be applicable. Currently, known side effects/precautions are based on clinical data from pharmaceutical products such as Epidiolex and Sativex, which vary significantly from the formulations available in medical marijuana dispensaries (or recreational marijuana dispensaries). For example, Epidiolex is an oral solution containing only one cannabinoid, cannabidiol. The cannabidiol is provided in a 100 mg/mL solution that comes with two 5 mL measured oral syringes. Dosing is determined based on the weight of the patient, and alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin levels are required to be drawn prior to the administration of this drug due to the risk of hepatocellular injury.⁷ Cannabidiol formulations in dispensaries may or may not include other cannabinoids. Oral solutions in marijuana dispensaries come with varying administration devices, including “droppers” which lack consistency in dosing. Sativex is a combination product of dronabinol and cannabidiol in doses of 2.5 mg ad 2.7 mg per 100 microliter buccal spray, respectively.⁸ The consistency of the doses provided in Epidiolex and Sativex enable providers to determine appropriate dosing and response, whereas the dosing variability in dispensary products leaves a large area of gray in determining patient response and appropriate dosing.

It is evident that the longer the pharmacist had been in practice, the more likely they would be comfortable counseling, or at least, discussing marijuana with their patients. This highlights that without a patient sharing that they are using marijuana, it may not come up in conversation with a pharmacist. It is common practice for many pharmacists to ask if a patient uses tobacco. Is adding marijuana use to that common question the next step for holistic care? In the study surveying primary care providers, 38.7% of the providers reported a belief that marijuana interacted significantly with medical therapies.²¹ This report provides insight that providers are aware of the possibilities of interactions, but the medical and pharmacy community will need to work together to document suspected interactions and/or side effects that may be occurring with the use of the non-regulated marijuana products. Determining interactions will be crucial when patients are using non-FDA products for indications outside of those studied in clinical trials. Considerations to ensuring that a marijuana discussion occurs for the majority of patients may be to include a marijuana section on all intake forms. Currently, intake forms may have a section for stating the use of marijuana, but it is following the question pertaining to the use of “illegal substances.” This provides stigma and may create a barrier to patients honestly documenting their use of marijuana.

Physicians, pharmacists, physician-assistants, nurses, and all allied-health clinicians must consider the marijuana discussion with patients. There may be a conflict between evidenced-based medicine and the use of marijuana in some patients, but the importance of documentation and counseling remains. Regardless of one’s personal views on the use of marijuana, marijuana products are widely available, and consumers are using them. Counseling and confidence in initiating the discussion is necessary to ensure patient safety.

As the majority of Colorado community pharmacists surveyed do not feel comfortable answering questions about recreational marijuana, and slightly more than half feel comfortable answering questions about medical marijuana, an emphasis should be placed on continuing education (CE) for marijuana. This is an unprecedented setting because pharmacists are trained to provide evidenced-based care, and marijuana products available to the public are lacking in clinical research and the safety and efficacy data that support evidenced-based care. It makes complete sense why pharmacists may be wary to take part in providing counseling for marijuana. This creates a community pharmacy setting that acts as one of many pseudo-clinical trials of unregulated products. Regardless that the use of marijuana for the general patient population is unprecedented, it is time to modify the standard of care so that pharmacists can, at least, be accessible healthcare team members that will promote the safest use of these products as possible. Pharmacists that are placed in the role of dispensing marijuana in the states of Connecticut, Minnesota, and New York may be excellent resources in learning how best to care for patients, evaluate and monitor those utilizing these marijuana products that have not been studied in clinical trials. Although the trial by error is not ideal, it is reassuring to know that medical professionals are a requirement in the dispensing of these unknown products. It is likely there will be a lot to learn from these pharmacists in the years to come. The Connecticut Pharmacists Association offers a “Medical Marijuana Academy” for pharmacists, and the state of New York requires that pharmacists complete a state-approved course before they are allowed to counsel on medical marijuana.^{26bibr27-2050312120938215–28} New York has two approved courses.^27,28 These education opportunities require registration, but they may provide pharmacists with additional concepts to navigate caring for patients considering marijuana outside the context of pharmaceutical, clinical-trial drugs. In addition, New York has a marijuana adverse event reporting system.²⁹ This adverse event reporting system is a valuable tool for practitioners to update what the medical community knows of patient adverse events related to marijuana. Hopefully, the New York pharmacy community in roles of dispensing will add to medical literature, as they will be able to report adverse events, in the context of knowing more about the patient’s condition, what they are using the product for, as well as what other medications the patient may be on. This will be valuable information.

Based on the results of our study, pharmacist education should emphasize the importance of asking about marijuana use with all patients, what efficacy information is available, and what interactions are possible. These findings are applicable to all healthcare providers, as there are many gaps of knowledge to fill in determining safe practice in the utilization of these new and unregulated products.

Recognizing resources available to stay up-to-date in the changing climate of marijuana accessibility is an important step in staying informed. The National Conference of State Legislatures (NCSL) website provides valuable information regarding state versus federal laws.³ According to federal law, marijuana remains classified as a schedule 1 substance. Federal law prohibits prescriptions for class 1 substances, so a prescriber cannot truly write a prescription for marijuana. In December 2018, the Farm Bill was signed into law.²⁵ The Farm Bill removed hemp and its constituents from the definition of marijuana in the Controlled Substance Act.²⁵ Cannabis sativa L. with no more than 0.3% tetrahydrocannabinol (THC) is no longer defined as marijuana, however that does not enable it to be used as a dietary supplement.³⁰ Subsequent to this bill, CBD products are now available in grocery stores, spas, coffee shops, and so on, regardless that it is still considered illegal on a federal level.

In Colorado and other states that have approved marijuana for medical purposes, the terms used in statutory language (propositions, amendments, measures, etc.) varies from prescriber “certifications” to “recommendations”; the recommendations/certifications given to a patient are not truly “prescriptions” since marijuana remains a schedule 1. With regard to the marijuana products, there is no difference in the state of Colorado between “medical marijuana” and “recreational marijuana.” Therefore, counseling and education points may be similar, regardless if the patient is using marijuana medically or recreationally. The difference between medical marijuana and recreational marijuana in the state of Colorado is the amount of marijuana purchased at one time, the cost, and the legal consequences if found in possession. However, it is important to recognize that there may be differences in marijuana “medical products” versus “recreational products” in other states. This article focuses on the marijuana experience where marijuana is determined state-legalized for both medical and recreational purposes. The states of Connecticut, Minnesota, and New York have language requiring pharmacists to be involved in the dispensing of marijuana, and this changes the experience significantly.

Variability exists in possible interactions based on the cannabinoids present in the marijuana product being utilized, the concentration of each cannabinoid, and the dosage form. Individuals may use predominately CBD products due to their lack of psychotropic activity, but the possibility of drug interactions is not benign for CBD products, and should be evaluated carefully. As a reminder, Table 1 provides examples of CYP activity based on cannabinoids most heavily studied and understood in marijuana. Please note there are many other compounds found in marijuana. This table is designed to act as a reminder of the importance of having ongoing discussions with patients about marijuana use. Asking patients if they are using marijuana, either for medical or recreational reasons, is important in order to ensure patient safety, and to enable documentation of adverse reactions, side effects, and drug interactions that may be occurring or impacted as a result of the marijuana product.