The Challenges Ahead for MED, with Patient Advocates Hilary Black, Stephanie Lake, and Jonathan Zaid

When Hilary Black founded the BC Compassion Club Society in 1997, medical cannabis was still illegal. It was three years before R. v. Parker determined Canadians have a constitutional right to MED, and during that time Black routinely risked jail to provide MED to patients.

Like most cannabis veterans, Black is happy to see the end of sweeping prohibition. But like many other patient advocates, she has a variety of concerns about the way physical access to MED treatment options will evolve—and the spaces devoted to MED communities will change—with legalization.

“My focus is always on patient issues,” said Black, now Canopy Growth’s director of patient education and advocacy. The compassion club she founded 22 years ago has been continuously in operation ever since, and has long been one of the few Canadian cannabis hubs that everyone could agree on. Throughout its 22 years, the BCCCS has focused on treating the extremely sick and the extremely poor, providing a suite of holistic treatments including massage, counselling, and nutritional advice free of charge alongside its 60-to-90-minute intake and education sessions for new patients explaining how to multiply MED benefits while reducing risks and avoiding negative reactions. The BCCCS has become, in Black’s words, “the sweetheart of the Senate and Health Canada.” Not only have politicians and report-writers embraced the BC Compassion Club Society, but Black herself received the Queen Elizabeth Diamond Jubilee Award for her service to the suffering.

“Yet there is no licensing provision, either federally or provincially, that would allow that organization to do what it does legally,” she stressed. MED stores are not allowed under the Cannabis Act, even if they have the long roots of the BCCCS, so the MED stream is being shunted into the hands of LPs and away from what Black calls the principles of “very pure, very compassionate medical access.”

The present MED system requires patients to purchase cannabis through the mail, though in January it also became available in Ontario via Shoppers Drug Mart pharmacies. Shoppers plans to expand its MED coverage to other provinces shortly.

“But we are forgetting about the true bricks and mortar medical cannabis organizations that need to be grandmothered into the regulations,” Black said.

Many now consider MED a resolved question, but for Black it’s still a system that needs to be shaped to best serve patients’ needs. While it’s convenient to order their MED products online, that mode of delivery ignores many of those whom the Compassion Society always prioritized.

“People who are marginalized and living in poverty, they often don’t have credit cards,” Black said. “Sometimes they don’t have fixed addresses or access to a computer…. Sometimes people will go and pick up recycling, cash in their $8, and come and buy a portion of a gram. And that’s the thing that they use for those couple of days.”

Black was pleased Health Canada overrode the recommendation of the Canadian Medical Association and chose instead to continue the MED stream. But the system as it stands—with no provisions for physical MED dispensaries—feels unfinished to her. Community, she said, is critical to health, while having a place to go where a person is recognized can improve stress levels and limit related illnesses.

By comparison, she acknowledged MED patients can pick up a phone and speak with knowledgeable people available through their assigned licensed producers. “But there’s something about face to face contact,” she said, “about somebody that knows your name, and knows that your dog was sick last week. There is a real sense of community that happens when you have bricks and mortar access.”

Stephanie Lake, a PhD candidate in population and public health at the University of British Columbia, shares many of Black’s concerns. Her research—associated with the BC Centre on Substance Use—focuses on cannabis use by those who use other illicit drugs, and in particular explores the role of cannabis in mediating the opioid crisis.

Like Black, Lake expressed concern about the small number of places in which marginalized people can buy legal cannabis. At the time we spoke in mid-January at the Lift & Co. 2019 Expo, Vancouver had just opened its first two REC stores, in which products were limited and expensive.

“We’re working with people who are living with substance use disorders, living in a lot of poverty, coming from poverty and trauma,” she said. “Legalization is an access issue for these folks. Is it going to be harder for them to access cannabis now that it’s legal and probably more expensive? How are they accessing cannabis now that it’s legal? Are they continuing to access through other [illicit] outlets because that’s more accessible to them financially?”

Lake has found drug users on opioid-agonist therapy (such as methadone and buprenorphine) who also used cannabis daily were likelier to still be using opioid-agonist therapy six months later rather than returning to unchecked opioid use.

“That’s something we’re interested in investigating a little bit further,” Lake explained. “What is it about cannabis that’s helping people retain on opioid agonist therapies and helping with symptoms of withdrawal, nausea, and things like that?”

One role cannabis plays in the lives of opioid users is medical, but it’s also a financial engine, and Lake says researchers need to understand how legalization will change the way homeless and marginally housed people who might have previously sold cannabis will now earn a living.

“Are they turning to other illicit means of generating income, like sex work or dealing other kinds of substances as a result of this new legal framework for cannabis?” she asked. “When they make something legal, it sounds nice, but we have to think about all the ways it’s actually going to create possibly more harms and criminalization among people who are already on the margins of society.”

Like Black, Jonathan Zaid has made the jump from non-profit patient advocate to the world of LPs. Zaid founded Canadians for Fair Access to Medical Marijuana in 2014 when he was a 20-year-old using MED for New Daily Persistent Headache, frustrated with the difficulty of accessing MED under the MMAR. Last spring, he joined Aurora Cannabis as director of advocacy and corporate social responsibility.

“I still think excise tax is the most unjust thing that could be applied on medical cannabis.” he said, noting Canadian physicians give patients authorization for up to a certain amount of cannabis per day.

“Medical cannabis is not a product where the government should be trying to restrict access to reduce consumption,” he said, “If a physician is prescribing a certain amount of cannabis, then a patient shouldn’t be further restricted from that access because of an arbitrary sin or excise tax on it. It’s quite unjust and beyond that it doesn’t really reach the policy objectives, either. It makes patients go towards the black market more if they can’t afford it.”

What concerns Zaid is that many MED LPs—like his own—have stepped in to cover excise tax for patients, which may make the issue appear resolved to MED users no longer saddled with the duty. He’s happy that companies are moving to help shoulder the tax burden, but he stressed this should only be a stopgap until MED is no longer taxed at all.

“I think [LPs covering excise tax] also means patients don’t understand that it’s still having an effect on their products,” said Zaid. “And beyond that it is fundamentally an unjust tax. I think that that’s a persistent issue that we really need to continue raising our voices on.”

Zaid identified the upcoming federal budget and, following it, the October general election as pressure points when activists and industry could push the government to end the excise tax. He and CFAMM hope to build on previous lobbying successes—their Don’t Tax Medicine campaign helped lead to the federal government not charging excise tax on CBD products.

“While that’s a positive step, there should’ve never been tax on medical cannabis to begin with,” Zaid said with understated emotion. “Coming into 2019, we have a real opportunity. The industry, the community needs to come together and continue. It’s still a political issue at the end of the day and elected officials represent their citizens. And I don’t think the general public in Canada supports applying a sin tax onto patients’ medicine.”