The ACS believes that cannabis dispensaries play a vital role in providing care and products to patients.  Ideally, dispensaries provide access to high-quality, regulated, and tested cannabis in appropriate forms and for use in appropriate routes of administration to meet patients’ medical needs.

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It is well understood by good dispensaries, however, that neither they nor their employees are qualified to provide medical advice, despite often being called upon by customers to provide exactly this sort of information. Therefore, it is to the benefit of both dispensaries and customers to clarify the role(s) of dispensaries and dispensary workers, and provide both groups with a proper understanding of what to do or say when confronted with questions that, while reasonable to ask, are not within the bounds of dispensaries expertise.

Many of the answers to these situations can be drawn from the experience and regulation of pharmacies – a highly regulated system that has honed best practices over the past hundred plus years. It is neither beneficial nor practical to reinvent the wheel for dispensaries. Dispensaries, again like pharmacies, ultimately bear responsibility to customers for both the products that they sell and the advice that they give.

Adhering to state or federal regulations for the safety of product is paramount and protects dispensaries from liability. So, too, maintaining the following personnel best practices intend to protect against general and malpractice liability.

Roles

Patient Service Advocates

Clearly define the roles of Patient Service Advocates (aka budtenders). This job, in general, is a combination of cashier and sommelier. The job entails finding product for customers, describing the product to customers within certain bounds, and completing the sale.

However, in no case should any information be imparted to customers regarding the medical benefits or other medical considerations of such products. This must be the case for all interactions with customers, regardless of whether specifically for recreational or medical use.

PSA should not give advice on types of products, methods of use, or dose. In no case should they contravene the advice of medical professionals, nor sell products other than those recommended by that customer’s clinician. In the event that a customer asks medical questions, that customer should be referred to their clinician, or if they haven’t one, to one.

Ancillary Medical Professionals

In certain jurisdictions regulation requires dispensaries to have on staff pharmacists or nurses. These professionals should be available to answer deeper questions about the products, or routes of administration. They are certainly encouraged to help patients feel confident in the medicine. However, on-site professionals must be cognizant that they do not interfere with the patients’ therapeutic plan as outlined by their clinician.

Further, on-site professionals have an inherent financial conflict of interest, and must refrain from changing or initiating a medical plan for a customer or patient.

Appropriate SOP

Dispensaries should have written SOP that are disseminated to all customer-facing personnel with regard to questions posed by customers. These must include:

• All medical questions should be referred to customers’ clinicians.

• If customer does not have a clinician, they should be encouraged to engage one.

• Not having or not wanting a clinician is not reason to provide medical advice.

• Questions or concerns about a customer’s therapeutic plan should be addressed to the customer’s clinician, in real-time if necessary.

• Questions that constitute medical advice include questions about: potency, dose, route of administration, efficacy, side effects, risks, or benefits.

• No product should be sold for any medical purpose without a clinicians’ therapeutic plan.

• A clinicians’ plan must include product description, dose, route of administration, frequency, and purchase amount.

• No amount greater than that recommended by customer’s clinician should be sold to patient, regardless of higher limits provided by local regulation.

• Use of linguistic tricks to avoid definitive statements are not acceptable. For examples: “this product ‘may’ do X” or “’patients report’ that this product helps with Y”.

Appropriate Medical Cannabis products

Ideal medical cannabis products support consistent, reproducible dosing, safe ingestion, and do not foster medical harms in other ways. Further they should not lead to confusion for consumers.

Presently, most medical dispensaries make products for the medical market that do not meet the above ideal. Lack of consideration of uniformity of product, consistency of availability, and effects on overall health, lead to consumers having difficulty getting medicine that they can rely upon.

To ameliorate these problems, the ACS has outlined below a range of product types that are inherently useful in treatment of patients, and has also outlined products that have no medically appropriate use.

Oral

Products should be:

• Discrete items – each dose should be its own object. E.g. each 5mg dose is one gummy or lozenge. Objects should not be multi-dose like a cookie or candy bar that must be cut to size.

• Range of doses – each type of product should be available in a range of doses that are useful for medical treatment.

• Useful dose ranges – 1mg, 2mg, 5mg, 10mg, 20mg

• Liquid items – such as tinctures or “oils” should be used for either very low dose or very high dose products.

• Range of doses – each type of product should be available in a range of doses that are useful for medical treatment.

• Dose must be specified as a concentration, mg of cannabinoid per drop or per mL of liquid. Any other method of description is inadequate. Use the scientifically defined drop: 20 drops per mL.

• Useful dose ranges – 1mg per drop (20mg per mL), or 2mg per drop (40mg per mL).

• Products should be sold in appropriate sized bottles to fit patient needs (eg: 1 month supply) and appropriate measuring tool included (dropper or mL measuring cup).

• Informative and consistent dose information – packaging and online information must provide clear indication of product content. Labeling must describe the content of each piece or object, and if packaged with more than one piece, describe the number of pieces in the package. E.g. each gummy contains 5mg THC, each package contains 30 gummies.

• Dose information must specify the amount of each major constituent – an object containing one or more major chemicals should be labeled with the amount of each chemical. Major chemicals should be defined as greater than 5% of the total chemical content. E.g. an object containing 5mg THC should be labeled 5mg THC, an object that is 1:1 ratio of THC:CBD should be labeled with the amount of THC and CBD each, not total. For example 5mg THC and 5mg CBD, but not 10mg total.

• Allowable variation – no piece should vary more that +/- 15% from the stated amount

• Meaningful precision – doses should be represented as integer numbers only with standard rounding applied. E.g. an object measuring 4.92mg should be properly labeled 5mg, an object measuring 4.43mg should be labeled 4mg.

• Low calorie, low sugar options for patients with other comorbidities

• 30 day supply packaging or the option to “fill” a prescriptive dose.

Inhaled

Products should include:

• Safer vaporizer pen systems – must be able to set and maintain a consistent 350’F via measured temperature, not simply timed.

• Clean concentrates free of thinning agents including terpenes.

• Dosed options, much like a metered dose inhaler, to allow patients to take uniform and measured doses and then have the machine turn off.

• Pre-ground homogenized flower – this is a better way to ensure proper potency and safety testing, as well as improves ease of use for patients who have mobility and dexterity concerns.

• Consistent availability of flower in the 15-20% THC range - this offers patients access to medical grade cannabis that suits the needs of new users and low dose users.

What Patients Don't Need

The following are products and dispensary behaviors that are CONTRARY to patient’s needs:

• High dose edibles and high sugar content edibles such as sugar, honey, cooking oils, and sauces. As these products cannot be specifically dosed, and are not safe for obese or diabetic patients, they have no role in medical treatment.

• Rick Simpson Oil. True RSO is contains too many contaminants to be recommended as medicine. Cleaner concentrates should be available to patients in a form that is easily measured in mL, with clear concentrations marked on the bottle. Viscous concentrates in syringes are not titratable with precision. “A grain of rice” is not an appropriate way to dose medicine.

• Topical lotions and patches for transdermal use. There’s little evidence of absorption of cannabis through the skin. Without evidence of efficacy, these products should not be offered.

• “Dabbing”, High dose, unmeasured inhalation is unsafe for many patients, and growing evidence indicates that prolonged exposure to these levels can create harmful structural brain changes.

• Low dose CBD. Research on CBD effectiveness consistently demonstrates the necessity of high doses of 10-20mg/kg/day. Offering products that cannot meet the dose necessary for real effect is confusing to patients and providers.

• Sales, discounts and offers which incentivize purchasing for recreation to patients who are there seeking medical cannabis only. Discounts for seniors, veterans, or low-income should be available constantly with fixed, published amounts.

It is the ACS’s goal to have guidelines in place to ensure safe and uniform cannabis for medical patients. These options should be offered at every medical dispensary, regardless of whether recreational sales are allowed. Products that fit with this guideline will allow dispensaries to meet the needs of medical patients and their clinicians.

It is our hope that dispensaries and product manufacturers will find this guideline helpful in creating new viable medical options, as well as how to better train their staff to address medical patients. If there are further questions of concerns, the ACS is available to offer guidance in setting up medical options, training staff and more.