By Kate Masters

(VM) – While recreational marijuana is technically legal in Virginia, the path to purchasing it in stores is still a long way off.

In February, Republicans in the House of Delegates killed legislation that would have allowed limited retail sales later this year. The state’s recreational market is scheduled to begin in 2024, but with a long regulatory road ahead, there’s a strong likelihood that products won’t become available until months or even years later, according to JM Pedini, development director of the National Organization for the Reform Marijuana Laws, or NORML. 

With recreational sales stalled for the foreseeable future, Virginia’s medical cannabis program remains the only way for most residents to legally acquire marijuana short of growing it themselves. Currently, though, there are only 46,935 registered patients in Virginia, according to data from the Board of Pharmacy — a small number compared to the state’s overall population of more than 8.6 million. 

Pedini, who also serves as executive director of Virginia’s NORML chapter, said that’s largely due to barriers that still exist within the program, despite significant growth over the last three years. Unlike the early stages of the state’s gradual foray into medicinal marijuana, patients now have access to a broad array of products, from edibles to flower, rather than the low-THC oil originally offered through the program. And Virginia’s licensed processors are now able to open up to five additional retail dispensaries, gradually increasing availability.

“So, in some ways, this program is amazing,” Pedini said. In other ways, though, medical cannabis has struggled to gain greater traction in Virginia. Advocates say part of the problem has been the registration requirements for providers and particularly for patients, who frequently face a lengthy wait to legally purchase products. 

“Our process is so slow — in terms of the full process to get a card, historically — that it’s been difficult,” said Del. Dawn Adams, D-Richmond, a nurse practitioner who’s also registered with the state to certify patients for medical cannabis. “People can’t just access marijuana after an appointment the way you could for any other medical product in Virginia.”

Currently, cannabis patients face a three-step process. The first is obtaining a written certification from a registered practitioner — in Virginia, a doctor, a physician assistant or a nurse practitioner — attesting they would benefit from the drug. The second is registering with the state’s Board of Pharmacy and waiting for approval.

It’s that second step that leads to the largest delays, according to both Adams and Pedini. Practitioner enrollment in the program has traditionally been slow and many major hospital systems, including Bon Secours, Sentara and UVA Health, still outright forbid their providers from offering certifications or only allow cannabis in narrow circumstances, such as clinical trials or treatment-resistant seizures. Currently, there are 703 registered practitioners out of the roughly 41,544 eligible doctors, physician assistants and nurse practitioners across the state, according to the Board of Pharmacy.

Despite the small number, Virginia’s medical cannabis program allows telehealth appointments, and many existing practitioners don’t view provider availability as a problem. Athena Baldwin, an Alexandria-based physician assistant who started her own business offering certification appointments, said she’s seen 1,400 patients across the state since her company began in July 2020. They’ve included a large segment of people from Southwest Virginia, an area historically short of many providers.

“It’s fairly accessible for any practitioner who wants to do it,” she said. Patients, on the other hand, have to create profiles and register through the Department of Health Professions’ provider licensure portal, a non-user-friendly process that many struggle to navigate, according to Pedini. The process requires a $50 fee and multiple documents, including copies of the  patient’s written certification and driver’s license.

But the real problem is the wait time, experts say. The Board of Pharmacy is “working diligently to process all completed applications within 60 business days of receipt,” according to spokesperson Diane Powers, but recently reported a backlog of 8,000 applications. Adams said most of her patients wait months for full approval, only to submit the same documentation to dispensaries as legally required.

The lengthy process has been a barrier, Pedini said, but it could change by this summer. Earlier this year, Virginia lawmakers approved Board-requested legislation that removes the patient registration requirement, allowing medical cannabis users to purchase products from dispensaries as soon as they receive a written certification from a provider. The bill is still awaiting a signature from Gov. Glenn Youngkin, but advocates say it would be a step forward for patients.

“We keep trying to make it easier and better every year, and we have seen success,” Pedini added. “No other state has gone from allowing medical cannabis for a single condition” — in Virginia’s case, drug-resistant epilepsy — “to a program that dispenses every type of product, serves any patient, without a list of conditions or age limits.”

Despite the progress, many advocates and providers say there are still limitations that hinder patient participation. There’s the procedural component, including finding a licensed practitioner, getting a written certification and finding a dispensary, which can be another challenge. Currently, there are only 11 across the state, and one of Virginia’s health service areas — a large swath of that includes Winchester and Charlottesville — doesn’t have any licensed processors, the result of an ongoing legal battle. 

There’s also the price. Medical cannabis is almost never covered by insurance, and providers often charge between $100 and $150 for a written certification. Products in Virginia often cost double what they do in other markets, including Washington, D.C., which some processors have attributed to the state’s extensive regulations. A small tub of cannabis-infused salve from one Virginia processor, for example, is priced at $75 online.

More concerningly, to Adams, is the availability of products, especially in the formulations preferred by many of her patients. GLeaf Medical, for example, lists 20 different vape cartridges for sale at its location in Manchester but only a single tincture, which is often preferred by pain patients. At least currently, it’s not offering any nasal spray, a formulation that’s been used to treat patients with seizures.

“When you’re making vape cartridges that are 60, 70, 80, 90 percent THC, these are not medical products in my mind, at least for most people,” Adams said. “These are products that are for profit, and directed toward that sort of commercial market, which doesn’t exist yet.”

“We need tinctures, we need edibles, we need tablets, we need suppositories — we need products intended for medical delivery,” she added. “And we need product consistency.” Adams said one of her patients was affected when a processor changed the ratio of CBD to THC in one of the company’s tinctures, which made the treatment less effective for her.

The challenges faced by many patients underscore Virginia’s strange regulatory landscape as a state where marijuana is legalized but a recreational market still doesn’t exist. Ashley Allen, the vice president of government relations for Columbia Care — one of the state’s licensed processors — said the industry has been stymied in some ways by the lack of adult-use sales. 

“We’re seeing what’s typical in many states, which is that prices at the beginning are higher because demand is pretty low,” she said. With less than 47,000 potential customers, processors are dependent on Virginia’s medical cannabis patients to sustain profits. Allen also said that if there’s a more than 10 percent variation in the composition of an existing product — a change in the terpenes between different harvests of the same plant, for example — companies are required to register it as a new item with the Board of Pharmacy. 

“What you’ll see now is a lot of us have products just sitting and waiting for approval,” she said. Processors hope that consistency will improve over time, especially as production ramps up with the advent of recreational sales. 

When marijuana does become widely available in Virginia, Adams said she’d like to see Virginia’s medical program become even more patient- and practitioner-focused. Both she and Baldwin expressed concern that some practitioners viewed written certifications more as a business venture than a way to support patient care. 

Dr. Christopher Sendi, a psychiatrist and addiction treatment specialist in Northern Virginia, pointed out that most patients only see a doctor once a year to obtain a certification. And while some providers might recommend certain products, many patients are left on their own to decide what works best for them.

“The product itself — we’re not saying, ‘What’s the appropriate dose, what’s the end result?'” Sendi said. “We’re basically saying, ‘Go to the dispensary and get as much as you need to make yourself feel better.’ And it’s up to the patient to figure that out.”

Virginia does require pharmacists to oversee the production and sale of cannabis, and dispensaries are required to have them on site to discuss products with patients (another mandate that adds to high costs, some processors say). There have also been efforts to improve continuity of care among medical providers. The bill that removes registration requirements for patients also prohibits them from acquiring written certifications from more than one practitioner — an effort to crack down on what Adams described as “fly-by-night” clinics for medical cards. 

In the future, she’d like to see more training requirements for practitioners who offer medical cannabis certifications, as well as greater discussion on how to evaluate whether products are working for patients. But Adams said any new additions to the program should come after there’s better access to cannabis and more widespread availability. 

Pedini, too, said there’s wide frustration over the state’s inability to reach an agreement on recreational sales, leaving customers vulnerable to unregulated and untested products made largely with synthetic THC. 

“Once again, there was no peace in the valley on this issue in 2022,” Pedini said. “And ultimately, it’s Virginians who are left holding the bag, with no legal access outside of the medical program and a rampant illicit market that frankly preys on consumers.” Reprinted from Virginia Mercury: https://www.virginiamercury.com/2022/04/04/recreational-marijuana-still-isnt-legal-in-va-and-medical-cannabis-patients-face-access-challenges/