Medical cannabis in Canada - the hazy road to cannabis legalization

BACKGROUND: In October 2018, Canada legalized recreational cannabis. The new regulations superseded previous medical cannabis regulations, leaving medical cannabis patients fighting for access rights that were won in 2001. At AIDS2004 in Thailand, we described the long road to the Marihuana Medical Access Regulations (2001). Access to medical cannabis was achieved on the basis that laws were unconstitutional, by violating the life, liberty, and security interests of persons under the Canadian Charter for Rights and Freedoms. The long-fought battles for access to medical cannabis also helped pave the road to the Cannabis Act, a legal and regulatory framework for recreational cannabis, and the introduction of government excise tax.
DESCRIPTION: (Table A) Cannabis in Canada Timeline outlines numerous times that medical cannabis patients and advocates intervened, challenged, and succeeded in maintaining a medical cannabis access program in Canada. With the new cannabis regulatory framework and the commercialization of recreational cannabis, clinical research on the risks and benefits of cannabis is critical in informing evidence-based cannabis health policy and ensuring the continuation of a medical cannabis access program.

Table A	Cannabis in Canada Timeline
2000	R. v. Parker (Ontario Court of Appeal) Landmark ruling that cannabis prohibition was unconstitutional because there was no exemption for medical use ' a violation of the right to life, liberty, and security of a person.
2001	Canada introduced the Marihuana Medical Access Regulations (MMAR) - Access to cannabis for medical purposes including people living with HIV/AIDS - Patients could grow their own or obtain from a government source. This made Canada the first country to legalize cannabis for medical use.
2004	Medical Marijuana - What a Trip! The Canadian Experience - Abstract at AIDS2004, Bangkok, Thailand
2003 - 2011	2003 - R. v. J.P. (Ontario Court of Appeal) MMAR did not create a constitutionally medical exemption that was acceptable. 2008 - Sfetkopoulos v. Canada (Federal Court of Appeal) Licenced producers allowed to grow for more than one person. 2011 - R. v. Mernagh (Ontario Superior Court) Sections 4 & 7 of the Controlled Substances Act were found constitutionally invalid and of no force and effect
2014	The Marihuana for Medical Purposes Regulations (MMPR) replaced the MMAR. Medical cannabis could be prescribed by a physician and a government license was no longer required.
2015 - 2016	2015 - R. v. Smith (Supreme Court of Canada) ruled restrictions of dried cannabis under the MMAR and MMPR was unconstitutional and expanded the definition to include any form of the drug. 2016 - R. v. Allard et al - Court injunction for those licensed under the MMAR. BC Superior Court ruled the MMPR was unconstitutional and gave the government 6 months to create a new framework.
2016	The Access to Cannabis for Medical Purposes Regulations (ACMPR) replaced the MMPR.
2017 - 2018	2017 - The Canadian Parliament introduced Bill C-45, the Cannabis Act, to legalize recreational cannabis by July 1, 2018. 2018 - The Senate passed the bill in June 2018 and the Cannabis Act and Regulations came into force on October 17, 2018.
2019 - 2022	Canadian AIDS Society (CAS) Cannabis Task Force, formed in 2019 2020 BMJ Open, Protocol - Canadian clinical practice guidelines for the use of plant-based cannabis and cannabinoid-based products in the management of chronic non-cancer pain and co-occurring conditions: protocol for a systematic literature review 2022 Canadian AIDS Society and the Task Force publishes the Canadian Clinical Practice Guidelines on the Use of Cannabis in the Management of Chronic Pain and Associated Symptoms CIHR CTN Cannabis Research Working Group, formed in 2020 CTN PT028: A pilot clinical trial to assess safety, tolerability and effect on inflammation in people living with HIV on antiretroviral therapy CTN PT037: Disentangling medicinal and non-medicinal cannabis use among people living with HIV: Feasibility of a smartphone-based assessment CTN PT043: Interplay between the expanded endocannabinoid (eCB) system and inflamm-aging: Implication between accelerated atherosclerosis in people living with HIV under ART Cannabis and mental health in racialized populations CAMH/CAS Cannabis and HIV Study Cannabis use and impacts among Ontarians living with HIV in the era of recreational legalization

LESSONS LEARNED: The Canadian AIDS Society Cannabis Taskforce (2019) and the CIHR CTN Cannabis Working Group (2020) were formed to conduct cannabis research and develop evidence-based clinical practice guidelines, to inform cannabis health policy that will enable patients to continue to access to medical cannabis, with a special focus on affordability including private and public insurance coverage.
CONCLUSIONS: The last 20+ years of medical cannabis in Canada have led towards the hazy road of legalization. Medical cannabis patients and advocates have temporarily succeeded in preserving a medical cannabis program in Canada alongside the legalization. Cannabis researchers and patient advocates now have five (5) years to provide clinical evidence on the risks and benefits of cannabis to inform health policies that will preserve a medical cannabis access program in Canada.

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