Canadian children can access medical cannabis (MC) by their parents or caregivers obtaining an authorization from a licensed health care provider (HCP)—either a physician or nurse practitioner. Specific requirements for HCPs to authorize MC are determined by their respective provincial or territorial regulatory bodies (1). Despite this, many parents face significant barriers to accessing MC for their children. We discuss these barriers and explore ways in which decision-makers, the medical community, and licensed cannabis producers (LCPs) can facilitate access. This commentary builds on our recent article in the Canadian Medical Association Journal with recommendations for addressing regulatory deficiencies that negatively impact paediatric patients (2).

Most children obtain MC as whole plant extracts containing a wide spectrum of cannabinoids including cannabidiol (CBD) and tetrahydrocannabinol (THC) and biologically active terpenes. MC in the form of purified CBD products makes up a very small minority of products available in Canada. Except for several studies assessing purified CBD to treat several forms of paediatric drug-resistant epilepsy (DRE) (3,4,5,6), evidence supporting the use of MC products for other paediatric indications is sparse and founded on non-randomized open-label studies and case series. These indications include spasticity, pain, and nausea associated with malignancy and chemotherapy, behavioral issues in autism spectrum disorder, and symptom management for children requiring palliative care (7,8,9,10,11). Despite limited evidence, many families of children with complex medical needs use or seek access to MC to treat symptoms not sufficiently addressed by conventional medical therapy (12).

In 2019, Elliott et al. identified barriers Canadian parents of children with DRE faced accessing MC for their children using semi-structured qualitative interviews of 19 parents of 19 children with DRE who had accessed MC. The parents expressed a desire to work with their child’s healthcare team in pursuing MC. Just over half successfully obtained MC authorizations from their child’s neurologist. The remainder sought authorizations outside of the child’s normal circle of care (e.g., from a specialized MC clinic) (13). This coincides with the experience in a Canadian tertiary care paediatric hospital, where MC authorizations largely came from outside of the patient’s regular care team (14). Social media and advocacy groups have become prominent information sources for parents regarding the use of MC but may promote misinformation about its benefits (15). When no support or guidance is provided by a child’s HCPs, some parents may prepare homemade cannabis extracts or turn to other cannabis providers, including the illicit market (8). This has the potential to cause harm to the child from drug–drug interactions, impurity, lack of standardization, unintentional overdosing, and intoxication (16,17,18,19).

A disconnect between a parent’s wish to access MC for their child and the apprehension from HCPs regarding the use of MC in children may lead to tensions, distrust, and fragmented patient care if the parent seeks MC elsewhere. This apprehension in HCPs may be perceived by families as an unwillingness to help or as withholding a potentially beneficial treatment. The paucity of high-quality evidence assessing the safety, efficacy, appropriate dosing, and long-term neurodevelopmental impacts are all reasonable reasons why HCPs are reluctant to authorize MC, even if they believe it could be beneficial (20). This, combined with a lack of formal training about MC in Canadian medical schools, residency programs, and continuing professional education activities has contributed to discomfort with discussing and/or authorizing MC to paediatric patients (21). In fact, Canadian paediatric neurologists report reliance on self-education prior to authorizing MC (22). This shortage of educational opportunities has resulted in a small group of paediatricians and paediatric subspecialists with sufficient clinical expertise to be comfortable authorizing MC to their complex needs patients.

The prohibitive cost of MC is another major barrier. Products without a Health Canada Drug Identification Number (DIN) such as MC are not covered through provincial or territorial drug formularies. Private insurance coverage for MC varies greatly, with many plans providing no coverage at all. Some parents have reported spending over $1000 (in Canadian currency) per month for their child’s MC (13). Despite compassionate pricing programs offered by several LCPs, the use of MC places a substantive financial burden on families already struggling to afford the cost of caring for a child with complex medical needs (23,24). With the introduction of the Cannabis Act, MC became subject to provincial and federal taxes making it even more cost prohibitive for families. Parents can claim MC as a tax-refundable medical expense; however, a family earning $50,000 per year spending $12,000 per year on MC can only claim an annual federal tax credit of $1575 and a provincial/territorial tax credit ranging from $420 to $1134 (25). This tax benefit is not nearly enough to support these families. Cost concerns can result in parents administering doses to their children lower than those recommended by their HCPs (8,13).

MC products used by children are plant-based and subject to variations in the strain of cannabis and extraction techniques used resulting in considerable variation in concentrations of active ingredients. Many formulations are available reporting similar ratios of THC and CBD on their labels but having their own unique concentrations of minor cannabinoids and terpenes (2). This compounds product shortages that LCPs are not required to report to patients or HCPs as would be expected for other Health Canada approved drugs (13). LCPs are currently not mandated to provide a certificate of analysis (CoA) to parents or healthcare providers confirming the full profile of each MC product batch, which causes undue stress for parents and HCPs searching for a comparable formulation when shortages occur.