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March-April 2018

Medical cannabis users cannot afford the weed that’s keeping them healthy—and legalization won’t help

These patients are among the country’s sickest, its poorest, its most opiated. But as the country lurches toward legalization, the patients who most rely on cannabis are still struggling to pay for it

Kieran Delamont@k_delamont

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On a mild February afternoon in 2014, a pastor named Chris from the Maritimes sat outside his Jeep in a park near his home by the water, and smoked a joint. There was a sense of experimentation, curiosity even. Having never smoked weed as a teenager, Chris barely knew what he was doing. He got his hands on his first quarter ounce of weed less than two weeks earlier, and was still looking for the answer to a question: What did cannabis have to offer?

“I was sitting outside and smoking it, and running through my mind was, ‘I really want this to work,’” he says. “‘Please let this work.’”

Chris drove a minute or two down the road back to his house, and got out of the car. For any other pot smoker, on any other day, the act of getting out of your car and walking is entirely unremarkable. Remarkable, though, were the things left behind: a cane, left sitting in the front seat of his Jeep. The constant, debilitating pain in his back, resulting from seven herniated and two compressed discs that had left him bedridden and opiated for the better part of the past decade, had for the moment disappeared. (Chris has asked This Magazine to withhold his last name and the city where he resides, since not everyone at the church and in his community knows he uses cannabis.)

“Instantly, I could feel relief in my back,” he says. He made a decision: “I’m willing to do this. It seems to be working.”

It was an easy choice, because the alternative was so awful. The number of different medications he was on at one point or another stretched well into the double digits, and Chris can’t even remember how many he tried.“I was on fentanyl. I was on OxyContin,” he recalls. “It wasn’t actually doing anything for my pain, it was just numbing my brain.” At one point he was put on six opiates at the same time.

Chris is religious, a literal Man of the Cloth, a minister and technical director for a small church out east. The metaphors that come to mind—a come-to-Jesus moment, a revelation, an epiphany—seem to ring hollow. But the cannabis-induced relief in his back did show him that there was a way out of the heavy cocktail of opioids and chronic pain that had consumed his life. “Within a month, I had stopped taking almost all the other medications [my doctor] had me on,” he says.

The thing most cannabis patients have in common is that they are, in some fashion or another, always fighting: fighting illness and chronic pain; fighting a Byzantine system of medical administration; fighting to be taken seriously as medical patients. In just about every way, Chris could be the poster child for the possibilities of medical cannabis, but that realization meant he would need to fight for it. He had to detox, spending a week on the bathroom floor, when “every bone in my body felt like it was breaking,” as his body suddenly came back online after years of opiated numbness. These fights are tolerable, because many patients are getting so much back. Not long after he had smoked his first joint, cannabis had “given me my life back, given [my wife] her husband back, and given my kids their father back,” says Chris.

But four years later, Chris can barely afford it. Nearly two decades after medical cannabis was first legalized in Canada, and months before it will be legal for all adults, many medical cannabis patients still struggle to pay for weed. Many are out of work or, like Chris, can only work limited hours, and have to buy their weed out of pocket; those who can work rarely have their medication covered by drug benefit plans.

Medical cannabis patients are among the country’s sickest, its poorest, its most opiated. As the country lurches towards the dawn of legalization, the patients who most rely on cannabis are still struggling to pay for it. And there doesn’t appear to be any help on the way.

***

Medical cannabis, which has been legal in Canada since 2001, has always come with a steep price tag for patients. For many years, the fight was for access to weed; affordability was an afterthought. It was difficult to get the medical exemptions required to buy and use cannabis, and possession remained illegal. Affordability for medical patients, however, has emerged as a major concern in recent years, particularly as a result of major overhauls of the system at the federal level.

In medical cannabis’ original iteration—a program called the Medical Marihuana Access Regulations (MMAR) scheme—patients could buy their pot for $2 to $5 per gram. In 2013, that single-source system was overhauled, and the Marihuana for Medical Purposes Regulations (MMPR) scheme was introduced, allowing patients to purchase their cannabis from licensed producers (LPs). (The system would be further updated after the 2014 Allard v. Canada court challenge, which loosened restrictions around growing your own cannabis. The system is now known as the Access to Cannabis for Medical Purposes Regulations, or ACMPR.)


Were Chris a cancer patient, or had he suffered a broken leg, his care would likely be paid for by our system of socialized medicine. But weed comes with a sticker price


The new system improved access—a 33-page medical document was replaced with a two-page form, and a growing number of licensed producers meant that patients had far more selection when it came to what strain they could use—but hurt affordability in the process. The move to the private market, albeit a highly regulated one, meant that prices increased, getting closer to matching the established street price of about $10 per gram. Prices rose to their current level, with the average gram costing patients about $8.40.

The wide variation within the prices means that patients often find themselves on a sliding scale where the quality of their medication depends largely on how much they are willing to pay for it. The Markham, Ont.-based LP MedReleaf, for instance, sells a strain called Rex at $17.50 per gram, while some of the weaker strains from other LPs go for around $4 or $5 a gram. “Even at some of the crummier strains, I’m at $900 to a $1,000 [a month],” says Chris. Which end of the spectrum you end up on depends largely on what costs you are willing— or able—to bear.

As a result, “some patients have to choose between continuing to take their opioids, which are often covered by insurance, and pursuing medical cannabis as an alternative or supplementary medicine, which is not covered but might be more effective for their needs and have less negative side effects than traditional medicine,” writes Bryan Hendin, president of Apollo Cannabis Clinics, a medical cannabis clinic in Toronto, in an email statement. From a medical and health care standpoint, this kind of system creates other stressors that can exacerbate health problems. “Even for patients who can technically ‘afford’ medical cannabis, we’ve seen how the financial decision to pursue medical cannabis versus traditional medicine covered by insurance can even exacerbate symptoms related to pain, such as anxiety and poor sleep,” Hendin adds.

It can be hard to tease out the source of cannabis’ price. Despite costs being fairly low to produce—Aphria, another LP in the country, has brought their cost per gram under $2—prices soar. Few major LPs see massive profits (or any profits) at the end of the fiscal cycle, with most of their revenues going back into expanding their production capacity, both for existing medical demand and in anticipation of recreational legalization. Patients are but one part of a much larger industry, and the costs they bear will help finance the recreational market.

***

For many patients in Canada, cannabis is their saving grace. It has given Chris his life back—but getting there hasn’t been an easy process. Were he a cancer patient, or had he suffered a broken leg, his care would likely be paid for by our system of socialized medicine. But for Chris and those like him, it comes with a sticker price.

At the same time, the federal government is actively taking steps to make medical cannabis less affordable when legalization comes into effect by applying a $1 per gram excise tax to all cannabis, including medical weed. For patients, that amounts to a steep price hike for their medication.

Sarah Colero, a medical cannabis patient from Toronto, pays $864.45 every month for her cannabis. Two consecutive strokes when she was five years old left her with damage to her frontal lobe. She also suffers intense migraines. She began treating both with cannabis three years ago, after years on opioids.

But her illness means she can’t work. She receives $1,151 every month in disability payments—most of which is chewed up by the cost of cannabis, the only medication that lets her function properly. “No insurance companies cover it,” she says. The excise tax proposal will tack on an extra $90 to her monthly bills—about one-third of what she has left over each month. “Once I found out that the taxing was going to happen I totally broke down. What am I going to do?” she said. “My dad wants to retire, obviously. I don’t want to be reliant on him all my life, and obviously this isn’t working.”

When asked if Health Canada, who are responsible for the administration of the ACMPR system, would be taking steps to alleviate affordability concerns, spokesperson Andre Gagnon declined This’s request for an interview, but said in a statement that “costs of cannabis will be determined by the market.”

Stories like Colero’s are illustrative of a system that critics say favours the revenues of large cannabis producers over the well-being of patients. The country’s LPs—many of whom have seen major increases to their valuation in the stock market over the past year—acknowledge that affordability is top of mind for many customers. But they are also businesses, first and foremost, and balancing the demands of shareholders with the needs of patients is a challenge. Affordability is “a huge factor,” says Jordan Sinclair, a spokesperson for Canopy Growth, the country’s largest LP. “As Canadians, I think we’re lucky that most of the health care system is free, and pharmacare is mostly covered if you have a plan,” Sinclair says. “[But the cost of medical] cannabis falls outside of all of that.”

Canopy Growth was the first licensed producer in the country to introduce a compassionate pricing program. Customers who earn less than $29,000 a year get a 20 percent cut on the cost of their weed. That sort of scheme is more or less standard in the industry now, with most LPs offering some sort of compassionate pricing for people on low incomes. But even at discounted rates, the patient is paying for a hefty markup. According to recent financial filings, the all-in production cost for Canopy was $2.73 per gram, while the lowest you could buy it for is $4.80. Even that price is below what they could be selling it for, says Sinclair.

The industry is trying to avoid a race to the bottom. Driving prices down below sustainable levels will ultimately hurt patients, goes the theory, because without major companies to lead production, there simply won’t be anyone left to sell the weed. “It’s not a problem that can be explained away,” Sinclair says. “There is that reality that’s hard to escape—there’s a correlation between people who are using medical cannabis and people who tend to have a lower income.”

***

Few existing mechanisms by which medication and medical services are made affordable are available to patients who require medical cannabis. No provinces offer coverage for pot in their health or pharmacare plans, and none of the country’s major insurance providers—Manulife, and Desjardins, for example—cover medically prescribed cannabis as part of their standard package. “In terms of benefit plans, which are usually offered [by] a union or an employer, the decision really comes down to the plan sponsor,” explains Jonathan Zaid, co-founder of Canadians for Fair Access to Medical Marijuana (CFAMM).

Battling with administrators to try to get your pot covered is a battle that Zaid knows well. In 2014, he fought for his insurance provider at the University of Waterloo, where he is an undergraduate student, to directly cover the cost of his pot, which he used to treat a condition known as new daily persistent headache. When the insurance provider denied the claim—which almost always happens, since cannabis lacks what’s called a Drug Identification Number (DIN) from Health Canada that allows them to process claims—he went to his student union and asked for coverage.

That, he says, wasn’t easy. “That process still took eight months and a huge amount of deliberation on everyone’s side,” he says. In doing so, he became one of the first Canadian medical cannabis patients to have his medication covered by a private insurance plan.


Chris has to fight: to pay the bills, to afford his medication. He must grapple with policies that don’t always feel like they take his health seriously


Even in cases where an employer is open to covering the cost of an employee’s cannabis, it can be difficult to navigate. “That process is stressful and personal for many patients,” says Zaid. “The usual response is usually rooted in stigma. It’s about the fear of people getting high at work, employers not seeing it as a legitimate medicine, and so on.”

Patients, then, are sometimes put in the position where they not only have to advocate for the cost of their pot to be covered, but for medical cannabis patients to be taken seriously in the first place. The onset of legalization will leave the way the insurance industry handles medical cannabis claims more or less unchanged.

On February 15, Sun Life announced that it was changing its policy and would begin covering medical cannabis for patients whose plan sponsor is willing to include it in their benefit plan. The coverage will be available for specific ailments and symptoms, such as for those with cancer, rheumatoid arthritis, and multiple sclerosis.

***

More than two years after I first spoke to him about his cannabis use, Chris’s back pain is getting better—or at least more manageable. “The great thing is that it seems I haven’t had a lot of flare-ups,” he says. None of that was an easy fight; for cannabis patients, it never is. Doctors at first refused to prescribe him medical cannabis, forcing him to buy it off the street until he found a doctor who was willing to help him. Now, he is completely opiate-free. The pill bottles, the four years he spent on a fentanyl patch, and the week he spent on the bathroom floor toughing out his detox are now all behind him.

The beating heart of the fight for cannabis affordability is the people who have better lives because of it. It is an elemental fight for a form of health justice often ignored, cast in different language and different terms. Chris has to fight: to pay the bills, to afford his medication. He must grapple with policies that don’t always feel like they take his health seriously. But the fight to make medical cannabis more affordable underscores a deeper, more foundational problem for medical cannabis patients: The industry is becoming dominated by large corporations who serve a different master in their shareholders, and are increasingly serving as the main advocate for patients’ rights.

The degree to which the government is in the pocket of Big Weed is likely overstated by the industry’s critics, but its influence over policy can’t be denied, either. Without the successful development of an infrastructure that served medical cannabis patients from the private market, and without the flourishing of a regulated production model, it’s unlikely the legalization of cannabis would’ve ever gotten off the ground.

But then, the patients like Chris probably have a point: The launch and growth of the LP system has made millionaires of many people. Medically speaking, few of them have much in common with Chris and those like him.

Facing a multi-billion-dollar industry can feel, for patients, like a titanic problem, with their health and well-being hanging in the balance.

“Greed does what greed does,” says Chris. “It comes back to that almighty dollar…. It’s just a money business for them. At the end of the day, it’s about the dollar.”


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