In the Hands of the Budtender: Dispensary Staff Education and the Future of Medical Cannabis.

By Mary Clifton, MD

drmaryjanemd.com

A physician writes a prescription. The patient walks into a dispensary for the first time. What happens next varies wildly and has an enormous impact on patient outcomes.

Imagine for a moment…

You’ve been suffering with chronic pain for nearly a decade. You’ve tried everything. It’s wreaking havoc on your everyday life.

You’re open to trying anything, and your doctor suggests a drug that you’ve heard a lot about…mostly within the context of recreational use with a heavy association with a decline in motivation and productivity, and an unfortunate stigma that will create judgment amongst loved ones, friends and colleagues.

This drug can’t be picked up at your local grocery store pharmacy where you’re familiar with the staff, and it won’t be a 30-day supply of pills in a ubiquitous orange plastic bottle to carry with you. In fact, you bear the responsibility of choosing what form of the drug will work best for you, learning how to dose, and making your own dosing adjustments to determine the best timing and intensity for you.

You walk out of your doctor’s office with the familiar prescription, but your next stop is wholly unfamiliar: a dispensary that solely specializes in that drug — the one that carries a stigma, such that anyone you see or interact with there will undoubtedly know what you are there to obtain.

When it’s your turn, you step up to a dispensary staff person unsure of protocol, unsure of what’s available, what it looks like, what you need. You don’t even know what questions to ask.

How are you feeling? Anxious. Hopeful. Fearful. Confused. Curious.

For many patients, beginning medical cannabis treatment is more of an initiation than a simple errand while picking up bread and milk. And the next steps after they get home with their prescription represent an entire additional induction experience, mostly relying on trial and error and self-taught understanding gleaned from Google searches.

Now add to that emotional experience the knowledge that your dispensary technician may or may not have ANY professional training.

Thirty-one states have now legalized the medicinal use of cannabis, and with more than 2,000 dispensaries across the country, this critical interaction between patient and budmaster or budtender, as the dispensary staff are often called, is taking place thousands of times each day.

Patients are navigating a very new experience, often with minimal research or understanding of their own to help guide them. They are in the hands of a budtender.

The constraints that have been unjustly placed upon research and usage of cannabis for decades have constipated the entire system: education, research, development, and marketing.

As state by state has rallied for legal use of a drug that can literally save lives, the market has not only opened, but exploded. We now need to clean up the subsequent mess, before we have an even bigger one that could take the entire country backward.

Every single patient, at every step of the process, needs to receive accurate, clinically-informed support and education about the different species and strains of cannabis, delivery methods, safety, common adverse effects, potential drug interactions, and more.

Federal law maintains the use of marijuana as illegal, even if states legislated otherwise, so the stigma continues, backed by decades of media indoctrination around marijuana as a recreational drug, and the users as potheads who eat cheeseburgers and fail in life.

Marijuana is still currently classified as a Schedule 1 drug, lumping cannabis in with heroin, LSD, and ecstasy as substances with no currently accepted medical use, which tragically leaves many patients behind, for fear of the legal or social consequences.

The Drug Enforcement Agency (DEA) refuses to acknowledge the medical benefits and the low potential for abuse, all while permitting pharmaceutical companies to sell the synthetic version of THC (the psychoactive cannabinoid found in cannabis) for over 30 years.

As states take matters into their own hands, the success of these programs is not only vital to the health and wellbeing of the individuals currently walking through the doors of the operating dispensaries, but also the ability to keep these facilities in existence and demonstrate the wide-scale public health benefit of medical cannabis.

Dispensary staff members are a pivotal lifeline to the patient standing at the counter, and to the future availability of cannabis as a treatment option.

We are in the middle of an opportunity to either validate the clear and long-fought argument on behalf of millions of patients suffering with chronic pain or a host of other unnecessary symptoms proven to be alleviated by proper application of cannabis treatment, or to let it all slip away.

Dispensary staff are a frontline linchpin in the future of medical cannabis.

While many patients may be relatively healthy, coming to the dispensary to be treated for one condition, chronic headaches for example, others will be dealing with many overlapping health issues. Perhaps rheumatoid arthritis and PTSD. Ovarian cancer and clinical depression. Chronic back pain and Crohn’s disease.

We also know that patients aren’t likely to share their entire medical history with dispensary staff, often only disclosing a primary complaint. Therefore, training must be broader than the dispensary owner might consider at the outset.

On-the-job training, when dealing with a wide array of complicated medical conditions, is not exactly “best practice” — if it happens at all.

The consequences are significant.

That new patient that walked in the doors of the dispensary for the first time will walk out with either the right product for their unique needs, or the wrong one — representing a delay in their treatment success at the least, and the potential for a serious adverse outcome at the worst.

This hit-or-miss patient experience plays out for thousands of patients each day, placing the entire medical cannabis industry in the same precarious situation.

At best, we are delaying the acceptance, research and education that will continue to open access and improve patient care across the country. Without a shift, the worst case scenario undermines the hard-fought credibility of cannabis as medicine.

In a recent poll of 55 dispensary employees, a full 20% recommended inventory that they were trying to move, just like sweaters in a retail store. And 47% made recommendations based on the newest variety to hit the market.

Since cannabis dispensaries are legislated on a state-by-state basis, there are no current regulations or standards that need to be met at the critical point of filling the prescription.

One could argue that the prescribing physician should provide the patient education necessary such that the patient can make an educated decision independent of the dispensary staff.

And yet, we know that the education and experience of prescribers around cannabis is still limited, the extent of doctor-patient dialogue varies significantly across medical settings, and that patients don’t often absorb education in those settings, especially when they are confronted with a serious diagnosis, such as cancer, or are in significant pain.

Patients must be able to also rely on competent and compassionate patient liaisons at dispensaries. In order to meet the high demands of their patients, dispensary technicians need to be thoroughly trained.

A knowledgeable dispensary employee is…indispensable.

This is an area we are chasing, instead of leading. In an ideal world, before new medicinal options hit the market, reliable, long-term human studies have been conducted to determine benefits, side effects, contraindications, dosing recommendations, etc.

However, due to a long history of recreational and black market self-medication, historical and ongoing research restrictions, and propaganda efforts for (and against) legalization, medical professionals and the patients we serve are facing an uphill battle.

Research data is limited and has frequently been biased and unreliable. Patient knowledge runs from one extreme of problematic word-of-mouth recommendations from friends to minimal exposure to marijuana as it is portrayed in the media.

Misinformation is the norm, not the exception.

While further medical research and data is imperative to inform treatment protocols, more than 2 million patients are already receiving legally prescribed medical cannabis as of this year.

Ultimately, we all need to educate ourselves on this topic: the prescribing physicians, the dispensary technicians, and the patients.

A Minimum Standard of Care

Patients deserve more, and quite frankly so does the dispensary professional.

We can start with access to information.

We need to arm dispensary staff with the information they need to do right by their clientele. While the research in cannabis has often been paired with an agenda, there is no other drug that has been as heavily researched as cannabis.

These studies can be made available for anyone to read and review. Simply having access to these materials when a person walks through the door can help both patient and the dispensary staff to navigate individual needs.

Why not engage dispensary teams in developing and maintaining a physical library of research and reference materials, accessible to both staff and clients?

Materials can be catalogued for easy reference by patients, while supporting the patient liaisons who assist them. What kind of culture does this seed, setting the tone for staff-client interactions from the outset?

A new client prescribed cannabis for clinical depression could easily find and review the research summaries from studies completed in this focus area, learning which strains, doses and methods have proven most efficacious, which is much easier than training all staff members on all medical conditions and the relevant, evolving recommendations for each.

This type of resource is simple and low-cost, and yet communicates a high level of customer service, demonstrates a culture of education and patient care, and empowers patients far beyond their limited interaction with the budmaster.

Patient education is just as important as training our dispensary staff. Patients and consumers need to be able to make informed, empowered decisions.

We can help guide dispensary staff in asking better questions.

Across the board, not all strains are alike. Basic questions, in addition to a brief medical history can dramatically improve recommendations to best match patient needs.

  • Do you require a blend that is CBD-dominant?
  • Are you able to tolerate and prefer a blend that is THC-dominant?
  • Perhaps you’d be best served by a hybrid?
  • Do you need a delivery method that is faster, due to acute pain?
  • Do you need a slower release delivery method, to reduce the potential for anxiety throughout the day?

This, of course, relies on a basic level of patient education on the differences between THC (tetrahydrocannabinol) and CBD (cannabidiol), the two primary therapeutic cannabinoids found in Cannabis plants, and an informed dispensary professional who is prepared to both provide accurate information and ask the necessary questions.

We can lay a minimum foundation of understanding.

  • Cannabis 101: A baseline knowledge of cannabis plants and cannabinoids, including the varying effects of THC and CBD, and the body’s endocannabinoid system. While some dispensary owners may shy away from an orientation to the basic biological mechanisms operating behind the observable effects of these cannabinoids, we should both give dispensary staff credit for their ability to understand these mechanisms and recognize how this knowledge empowers a broader ability to educate patients and make better recommendations across complex situations.
  • Legality: A current and accurate knowledge of the federal and state laws associated with medical and recreational cannabis in that location. Laws around medical cannabis use are changing constantly and can impact patient access, the conditions that can be treated, legality of varying delivery methods, and much more. All staff should have a clear understanding of the current laws and regulations within their state and how to keep themselves and their clients safe from legal consequences.
  • Medical Benefits: An understanding of the medicinal benefits of THC and CBD and the primary symptoms and conditions where medical cannabis treatment is indicated. Cannabis plants are not a pharmaceutical drug developed to treat a single symptom. Medical research on just CBD has identified therapeutic potential for more than 50 conditions, and research continues to expand, focusing in on medical applications for THC, CBDA (cannabidiol in its raw acid form), THCV, CBG, and CBDV, for example. A thorough orientation to how medical cannabis can genuinely help patients, as well as it’s known limitations, is necessary to ask the right questions and make proper recommendations.
  • Contraindications: Knowledge of conditions that contraindicate the use of cannabis. For example, if a patient with schizophrenia were given a THC-dominant strain, according to research out of the Netherlands, this could make hallucinations worse. Similarly, THC has been shown to potentially worsen the symptoms of manic episodes among patients with bipolar disorder. While staff may not come straight out and ask a patient about psychiatric conditions, the dispensary technician can at least guide patients on which products are not advised for particular conditions, and allow them to show interest in the ones that seem right for them. Contraindications can also guide the selection of delivery methods. Patients with respiratory disorders exacerbated by smoking should obviously choose an alternative form of ingestion.
  • Potential Side Effects: Current knowledge of potential side effects across strains, doses, and delivery methods. An adverse side effect can be cause for alarm if a patient is not educated in advance of its potential, and whether to take any action should they experience a side effect. Additionally, some side effects can be effectively mitigated or better managed with a little guidance from a well-educated budmaster, supporting patients in obtaining positive, sustainable outcomes that don’t interfere with their life.
  • Drug Interactions: Understanding of the potential interaction between cannabis and and other medications. We can’t assume that the patient disclosed all of their current or occasional medications to their prescriber, or that the prescriber was well-informed on potential interactions. A basic orientation combined with a handy reference sheet can be invaluable for supporting staff and patients alike in recognizing any potential interactions ahead of time, helping the patient to prevent or at least recognize an interaction, such as the risk for experiencing hypomania when taking cannabis and Prozac simultaneously.
  • Product Knowledge: A thorough understanding of the different types of products available, and which are legally sold in that state. The latter may seem obvious, but a patient may ask about a product that is not available, to which the dispensary worker should be able to clarify whether the product is unavailable due to current laws, out of stock, or simply not part of their inventory, and offer information on comparable products based on the patient’s needs.
  • Delivery Systems and Equipment: Practical understanding and the ability to train patients on the features, proper use and necessary supplies associated with available delivery systems. Will the patient be cooking with edibles, smoking, using an oil, applying a lotion, using a tincture, vaping, or doing an infusion? The patient prescribed medical cannabis may be completely new to this world, so before the patient leaves, they need to understand how the product is to be used and obtain any necessary delivery equipment and supplies. The dispensary technician should be able to advise on how to use all equipment safely and effectively in order to maximize the patient’s treatment protocol and ultimately ensure they feel comfortable taking the next steps on their own when they return home with their prescription.
  • Safety: Recognition of the potential adverse outcomes associated with the use of cannabis, and how to avoid them. Safety is the responsibility of everyone, from the prescriber to the dispensary to the patient. It’s imperative that patients are educated in how to use cannabis safely. For example, we cannot assume that a new patient is aware that they should not drive or operate heavy equipment while impaired, or participate in activities that require a high level of focus and attention, such as childcare.
  • Customer Service: Practical understanding of how to interact with every client with a high degree of professionalism, compassion and respect for their privacy. As we identified earlier, it is especially important to recognize that the patients who walk through the dispensary door are potentially feeling vulnerable, embarrassed, or desperate to remove themselves from their current situation. What they find on the other side of the conversation should be patience, attention, knowledge, and individualized confidential guidance.

The better informed the dispensary worker is, the better they can direct, advise, and empower the patient to make an informed decision best aligned with their symptoms, co-occurring conditions, expectations and lifestyle, leading to improved patient outcomes and increased acceptance and support across the medical community and society.

The Good News

Many across our newborn industry recognize this need and better practices are emerging…toward the best practices that will guide the future of the dispensary-patient relationship.

Programs are being designed to fill this gap, piecing together a standard of care from the moment a patient walks through the dispensary door. It is encouraging to witness dispensaries taking the lead on creating these standards from within — even if they’re not being employed as quickly and consistently as patients need them to be.

Even in this messy middle ground, many patients are satisfied with the one-on-one help they receive when they walk into a dispensary.

65% of workers polled have even made follow-up calls to people they have helped, to see if the product is working as intended and answer questions. This, on it’s own, is in so many ways revolutionary within the medical industry.

The next stage will require the leaders within this growing industry to come together to ensure that 100% of dispensary staff members who will be in a position of making product recommendations to patients are required to receive a baseline orientation, with a commitment to ongoing continuing education, which will prove critical in the midst of the era of inevitable rapid change across prescribers, growers, and patient care that we now find ourselves in.

Regardless of your role, you can help support this necessary shift.

If you own a dispensary, you can start leading the way by implementing required, comprehensive orientation training for your staff members, curating a culture that encourages ongoing education and a commitment to patient outcomes over profits, and perhaps even catalyzing local conversations with business owners in this industry to support widespread adoption of minimum training and education expectations.

If you are a prescriber, like me, you can ensure that you yourself are well-educated and confident in helping guide patients, educating them before they ever get to the dispensary. And then you can take that a step further to visit and experience the local dispensaries your patients will turn to firsthand, so that you can guide patients to the dispensaries who are taking patient care seriously, while encouraging dispensaries behind the curve to step up.

If you are a patient, you are the lead of your healthcare team. Don’t be afraid to do your own research, to ask as many questions as you have, and to shop around to different dispensaries until you find a budmaster who is a fit for you.

Human need is at the heart of the grassroots movement of legalizing medical cannabis, but access is just the first step across a threshold on a historical march toward a common understanding of the legitimate role of cannabis as a healthcare ally. That history is being written with each prescription, and fulfilled at the dispensary counter.

If prescribers are the gatekeepers, then the budmasters are the mentors who empower patients to find the right relief from their suffering — relief that is desperately needed within our families, community and society.

We’ve stepped across the threshold, and now we must create the structures that maintain the integrity of this movement and empower those at the frontline of cannabis treatment to support positive outcomes — for each and every patient who walks through their doors, and for the state of healthcare in this country as a whole.

The bottom line: Patients aren’t shopping for the latest sweater. This is someone’s life. It’s not dispensable.

Mary Clifton, M.D.