As a Cannabis Pharmacist & Dispensary Manager, Clinical Pharmacist, and Community Pharmacist, Dr. Rony Sinharoy has had a busy year in Ohio. He has served on panels discussing medical marijuana for the Ohio State Bar Association and American College of Healthcare Executives and presented on the topic for the Ohio Pharmacist’s Association.
Dr. Sinharoy’s clinical focus shifted solely to cannabis therapy after interacting with patient advocates as a member of Americans for Safe Access (ASA) and National Organization for Reform of Marijuana Laws (NORML) in Washington, D.C. He currently advises on product development for a medical cannabis processing facility and helps manage an Ohio dispensary.
MedicateOH sat down with Dr. Sinharoy to learn more about what he’s doing to help Ohio patients. The interview below has been lightly edited for length and clarity.
MedicateOH: You came to the Ohio cannabis industry through your work as a pharmacist. Can you tell us how that transition happened?
RS: Sure. I was working as pharmacist in Columbus when I began to take an interest in healthcare policy. It was in Washington, D.C. where I really began learning about cannabis from both a regulatory and clinical standpoint. I found there are a handful of states that require pharmacists to dispense medical marijuana, so this enabled me to dip my toe in the industry and see the positive impact on patients first-hand. That experience made it easy for me to return home and make the leap into cannabis.
MedicateOH: Ohio is unique in that the Board of Pharmacy partly controls the operation of the state’s medical marijuana program. What are some of the advantages and disadvantages to the state treating cannabis as though it were a pharmaceutical drug?
RS: To be clear, the Board of Pharmacy controls the operations of dispensaries and aspects as it relates to patients, not the whole program.
The advantages lie mostly with safety and security. Surveillance requirements, inventory controls, record-keeping, lab testing, product recalls, purchase limits, labeling, advertising restrictions, unproven medical claims, employee badging requirements, and education requirements are all examples. And then these factors tie into addressing public health concerns as well.
The disadvantages are that marijuana is not a pharmaceutical drug. While the state classifies marijuana as Schedule II, it cannot be treated as such in every aspect of the dispensing process by statute due to the nature of the product and lack of a framework federally. Marijuana is in a gray area which makes it extremely challenging to regulate. You have the industry pulling in one direction and regulators pulling in another. Add on the fact that culturally marijuana is viewed quite differently than how the State sees it being a medical program.
The State is coming from a medical perspective attempting to govern an industry coming from a commercial perspective. Having to reconcile that difference with limited resources and black and white policies doesn’t sit well, because everything from costs, to patient count, to program satisfaction is affected.
MedicateOH: How does a doctor’s cannabis recommendation differ from a doctor’s prescription? Do patients find this confusing?
RS: A prescription — for a prescription drug — is a specific set of instructions for the use an FDA approved medication, authorized by a qualified healthcare professional. Everything from the quantity, the name of the medicine, and dosing and administration information must be on the order. A prescription also allows for third-party reimbursement.
A cannabis recommendation is a physician exercising his first amendment right within a regulatory framework set up by the state. The doctor is simply stating his medical opinion that marijuana can benefit the patient.
I do believe it is confusing for the patient. Because marijuana is federally illegal (thus no FDA approval), it cannot be prescribed. Without FDA approval, dosing guidelines, standardization … all the elements which make something legitimate medicine — as we have come to define it — are missing. The burden of knowledge rests on the patient and sales staff, not the physician, which is often unexpected. Couple that with the way recommendations in Ohio are set up — by breaking it into 90-day periods and utilizing traditional terms such as refill — the confusion is compounded. To simplify, I explain to patients that a prescription is written for a specific medication, whereas a recommendation is written for a specific time frame.
MedicateOH: Earlier this year, The board of pharmacy enacted several coronavirus-related measures to help medical marijuana patients access their medicine more safely and efficiently during the pandemic. In addition to adding TeleMed visits for doctors to virtually approve medical marijuana recommendations, dispensaries were permitted to add curbside pick-up but not delivery. What do you think about curbside and delivery options for patients?
RS: I support any policy change that improves accessibility without having a negative impact on public health and safety. To this point, curbside pickup has been relatively smooth — depending on how the dispensary implements the service.
Delivery, however, is different. While I support the option, particularly for certain population groups, the way the rules are written with regards to how transactions must be conducted by dispensaries and how product is tracked by the state, it requires much more effort to implement from a regulatory standpoint. At this time, delivery is not very likely to happen.
One concern which arises with improved accessibility, is a potential shift by doctors and dispensaries to make these changes the primary option available to patients. There was already a large void in education and interaction. Many patients are not adept at telehealth and online ordering. The menus are confusing, disorganized, often times inaccurate, and do not include a lot of the relevant information needed to make the best decisions. While the majority of patients will appreciate the changes, if the industry makes a major push to prioritize convenience for the sake of efficiency, it will likely alienate a subset of patients that this program is also meant to serve.
MedicateOH: Another key way that the OMMCP altered its rules post-coronavirus was to move from a 90-day rolling period for patient product limit to a somewhat simpler 45-day product limit cycle. How do you feel about this change as a pharmacist? Do these limits help patients or hurt them?
RS: Compared to the previous method of calculating a patient’s purchasing power, the new method is an improvement, particularly for dispensary staff. It is easier to understand conceptually for employees and the new calculation requires less reliance upon the state database, which never functioned as intended with the 90-day calculation.
As far as limits, the new method does not really help or hurt. While it allows for patients to make purchases in a way which may reduce the number of visits they make to the dispensary, the underlying issues with respect to purchasing power, particularly flower, are not addressed.
MedicateOH: The state still does not provide patients with their day supply via the registry, and patients are relying on dispensaries to calculate their supplies. What effect does the 45-day limit have on patients? What could be done to improve this system?
RS: Again, if a patient utilizes flower as their primary method of consumption, the 45-day limit is restrictive because of the way purchases of flower count toward allotments. I do believe some of the concerns will be alleviated soon once the State revisits the issue. Then the focus will likely become the limits themselves, instead of how purchases count toward them.
You already mentioned that patients do not have access to their purchase history via the registry. That would be one improvement, or at least accurately calculating how many “days-worth” a patient has purchased within a given timeframe. Other improvements circle back to simplifying the way purchases of flower are calculated. Such as day units of flower accounting for a single day and removing the “tier” and “terminal diagnosis” distinctions.
MedicateOH: What would you tell a new patient who was reluctant to switch to marijuana from another medication?
RS: There isn’t a simple answer to that question. It depends on two broad factors: one, which medication the patient is on or seeking a substitute for; and two, the primary reason(s) a patient is reluctant.
If the prescription medication is working for a particular condition or symptom without negative effects, it may be better just to remain on it. Not all prescriptions are “evil” as some would like to portray and marijuana is not a medical panacea simply because it is “natural”, as many cannabis enthusiasts claim. Also, if reluctance is due to work-related factors such as drug-testing or being on the road for extended periods of time, THC products should also be avoided.
However, if the reluctance is due to stigmatization, a lack of education concerning the products, or safety concerns; that is where an experienced healthcare practitioner can really help ease those fears. The points I try to emphasize are the safety profile of cannabis when dosed appropriately, my experience working with patients and the successes they have achieved, and focusing on more “socially acceptable” product forms available.
MedicateOH: How does MyMedicine counsel patients who are transitioning to marijuana from opioids?
RS: The key point to emphasize is that the two are not mutually exclusive — unless the patient is in the unfortunate circumstance where their physician is not supportive of the combination. The dose of opioids, how the pain presents and the location of the pain, the diagnosis, and other patient factors all play a role when transitioning. But the simple answer is slowly introducing marijuana at doses and combinations which do not cause side effects and monitoring the level of relief. At that point, the patient may be able to pull back on their dose of opioids. This process can then be further refined under the guidance of a pharmacist or physician to find the best regimen. Whether that means opioids and marijuana in conjunction, or solely marijuana, is highly patient-specific.
MedicateOH: What is the greatest challenge you’ve seen with helping patients to select methods and strains that work effectively for their condition? What do you tell patients who become frustrated?
RS: Generally speaking, the greatest challenges to overcome are lack of research and cost. Without data or standards of care, dosing and ratios remain a challenge to pinpoint for a given set of patient factors. On top of that, until insurance begins to cover medical marijuana in some form, the correct regimen may be too costly for a patient to sustain. There is only so much THC a patient can take before side effects arise. High doses of other cannabinoids, such as CBD, are needed to realize a therapeutic response and the price is prohibitive to reach those levels on a consistent basis.
While at the dispensary, the challenge is time and access to resources. Hence why I started MyMedicine. Helping some patients select the right product(s) requires a significant amount of interaction. As it stands, the dispensary environment doesn’t lend itself to really sitting down and working with the patient without severely impacting workflow and wait times. Also, there are so many different strains, it becomes difficult to distinguish the nuances without accessible, organized, and reliable product information. And this information is what should be utilized when making a selection for a particular condition.
I preface every consult by prioritizing safety over effectiveness. ‘Do no harm’ is the guiding principle. I would rather a dose be too low and ineffective than overdoing it and having a negative, potentially harmful experience. Patience and managing expectations are key. Even prescription medications need to be adjusted. I avoid using the term “trial and error”, because any information is useful. But if a particular plan or protocol is put in place based on the evidence and preliminary guidelines available, it allows for maximizing wellness, even if initial purchases are ineffective.
MedicateOH: What products do you find you’re recommending a lot? What have patients told you they’ve had success with?
RS: The patients I personally work with are not indicative of the preferences of the market as a whole. While I believe every patient can benefit from a quick consult with a healthcare professional that is knowledgeable about cannabis medicine and the products, the reality is pharmacist services are typically only provided to highly medicalized patients with several clinical considerations, or patients without much cannabis experience who are looking for a substitute to prescription medication. Their needs are much different than the average patient. I find myself recommending tinctures and higher CBD edibles and vape pens. Rarely is flower preferred with the patient population I counsel.
In terms of success stories, there isn’t a specific category or type of product that clearly lends itself to more success that I have identified. Because of the highly varied patient population and symptoms, I could find a success story for every type of product on the market.
MedicateOH: What can patients or prospective patients do to learn more about MyMedicine and/or the Ohio medical marijuana program?
RS: The website, mymedicinellc.com, is fairly comprehensive. Not only with respect to the services offered by MyMedicine, but some helpful resources for Ohio patients as well.
To learn about Ohio’s program, most dispensaries and recommending physician practices will give general information in a simplified manner. But the state’s website is the best place for learning about the program in detail.
MedicateOH: What are the key challenges and opportunities you see ahead for both your own business and for the state program?
RS: I think the biggest challenge for my business is getting the word out that MyMedicine provides a valuable service to both the industry and patients without stepping on any toes. MyMedicine is not meant to be a substitute for physician and dispensary staff advice, but rather complementary to allow everyone to focus on what they do best. There are plenty of instances where I have relied on my co-workers for information. Too often pharmacists in this industry rest on their title.
MyMedicine counselors need to be just as versed in the cannabis industry and cannabis medicine as they are with traditional medicine and medical conditions. This allows cannabis pharmacists to play a unique role in the industry with respect to patient care, particularly if the market transitions to adult-use. The focus will invariably change for the industry, yet medical patients will still have a resource for guidance in a traditional way. Not only does this benefit active patients but serves to reduce the stigma surrounding cannabis medicine and opens the market to a larger demographic.
For the state, the challenge and opportunities are essentially the same; working with the industry to find compromises that make the program more business and patient-friendly, without sacrificing health and safety. There needs to be mutual understanding that the two sides have entirely different backgrounds when developing policy. Those in the industry have little to no healthcare experience, while regulators have been immersed in medical oversight and understand those nuances quite well. And vice versa, policymakers do not have much experience with cannabis and the cannabis industry.
Understanding and clearly communicating the rationale of each other’s perspectives will go a long way. What comes naturally or is common sense to one person, may not be the case with another. This has been an added benefit of being a pharmacist in medical marijuana in that it is much easier to wrap my head around both sides of a particular issue.
Developing and simplifying policy, and allocating resources to realistically implement those policies, while keeping public health at the forefront, should be done utilizing subject-matter expertise from all parties involved.
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