Is Canada really the Wild West for Cannabis Marketing to Medical Professionals?
A recent story from Global news covering how cannabis producers in Canada pitch to the medical community generated a stir on social media, mainly regarding a quote from Dr.Sarah Giles comparing Cannabis to Oxycontin.
As responsible advocates it’s important to put Dr.Giles comments in the proper context, the full quote from her bases this comparison on the ‘cannabis as a panacea’ phenomenon which is an accurate depiction of some messaging for how cannabis should be used therapeutically, and the negative reaction is to the implied comparison from the headline of the article between the effects of cannabis and the opioid crisis.
The issue I would like to focus on in this piece, however, is something else Dr.Giles mentioned regarding a change in ‘rules’ about what doctors can and cannot receive, being largely limited to food. You likely have the same question that I did, ‘What are the rules?’
The ‘rules’ comprise federal, provincial, and industry association regulations. While Health Canada is designated as the regulatory body overseeing pharmaceuticals in Canada, in practice regulation is delegated to provincial colleges of medicine, and to non-governmental bodies such as Innovative Medicines Canada. In 2017, then Minister of Health Jane Philpott commented that jurisdiction largely falls to her provincial counterparts.
Health professionals themselves are governed by organizations referred to as ‘Colleges’, which are essentially professional regulatory bodies based in each province, similar to provincial regulatory bodies for other professional disciplines such as engineering and law. Since these organizations exist at the provincial level, specific policies may differ from province to province. In general, the issue of pharmaceutical inducements is covered under conflict of interest, and is resolved on a complaint basis within College review boards.
The federal association governing physicians in Canada, the Canadian Medical Association does also have a brief section in their policy document for medical professionals, albeit one that is very broad:
44. Practising physicians should not accept personal gifts of any significant monetary or other value from industry. Physicians should be aware that acceptance of gifts of any value has been shown to have the potential to influence clinical decision making.
Innovative Medicines Canada is comprised of 45 member companies including familiar names such as Glaxo-Smith-Kline and Pfizer, and has a code of conduct for those member companies to follow, referred to as the IMC Code. There is a similar association for the generic drug industry known as the Canadian Generic Pharmaceutical Association with their own code of conduct, similar to the IMC Code.
The rules Dr.Giles refers to are likely the provisions regarding meals and refreshments , and prohibited activities in the IMC Code :
Occasional reasonable meals/refreshments may be offered in connection with promotional presentations by Member employees to Health Care Professionals and other Stakeholders attending the presentation.
Member employees should not participate in activities such as but not limited to golf, hockey, theatre and spa in interactions with Stakeholders outside of the limited exceptions as described in Section 12.2.2 or as part of congresses/symposia that are incidental to these events and which are not organized by Member companies.
Dr.Giles is correct in saying that the ‘rules’ have been updated, but the details of how those rules are applied is where the nuance on this issue exists. These rules are imposed by an industry organization, in effect the industry is largely self-regulated when it comes to promotional activities. Member companies of the IMC must submit a yearly declaration that they are compliant with the code, but without more oversight it is largely a complaint-driven process.
Harsh financial penalties and publication of non-compliance exist as possible consequences for non-compliance, but this complaint system exists outside of the patient to physician relationship which may lead some patients to be skeptical of the true efficacy of this regulatory ecosystem. Also of note is that sales reps from member companies of the IMC must undergo an educational course within 2 years of being hired, with a maximum of 9 months or 300 hours of pass/fail coursework based on scientific, regulatory and sales related material.
A 2016 study by Habibi et al concluded that the regulation of pharmaceutical promotion in Canada is largely self-regulated, and also pointed out that according to a 2004 report, Health Canada has levied no fines in the past 25 years. This report pre-dates the opioid crisis, but seems to indicate that the government is not likely to levy fines on issues related to pharmaceutical promotion.
Turning to the current state of the cannabis industry in Canada, there are strict regulations regarding what producers of cannabis may include in advertisements to customers in government legislation, whereas the pharmaceutical industry turns to another non-governmental body, the Pharmaceutical Advertising Advisory Board to approve marketing communications. Given some recent alleged misconduct on the part of producers of cannabis on the marketing front however, it is definitely within the realm of possibilities that the government may turn to a similar method to ensure compliance.
In terms of the producer to physician relationship however, the industry lacks a code of ethics similar to the IMC Code. The Cannabis Council of Canada is arguably the cannabis industry version of the IMC, but does not publish a code of ethics which member companies are required to follow. Interesting to note is that an earlier incarnation of an industry organization, the Canadian Medical Cannabis Council did publish a code of ethics. Despite cannabis being used as medicine, it is largely not considered medicine in the same way other pharmaceutical products are, leading to some of the divides between the pharmaceutical regulatory apparatuses and those for cannabis products.
Dr.Giles is quite correct in pointing out that cannabis producers are not beholden to the same rules as pharmaceutical companies, however it remains unclear how a non-pharmaceutical company would become an IMC member, so this criticism is somewhat shallow. The impact of self-regulation that the pharmaceutical industry employs is up for debate, so I would disagree with the position that the cannabis industry is the wild west when compared to the pharmaceutical industry.
Provincial colleges have employed strict guidelines with regards to prescribing cannabis, that some would argue are more strict than those for prescribing opioids, so it is difficult to reconcile the wild west metaphor on the side of regulations that medical professionals are bound to. On the side of industry, the situation is that of self-regulation to an industry published code of ethics versus no industry regulation. In light of the opioid crisis, instead of holding up the pharmaceutical model of self-regulation as a gold standard, we should seek more transparency and better oversight on both fronts. At a bare minimum, cannabis industry associations should be at least as accountable as their pharmaceutical counterparts in publishing a code of ethics.
I reached out to Dr.Sarah Giles, as well as Cam Battley and Allan Rewak of the Cannabis Council of Canada via Twitter, but did not hear back by the time of publication.