Cannabis should be treated like any other medicine, according to a new report that "represents a dive deep into the perceptions, concerns, and hopes of UK clinicians for medical cannabis". The report, Known unknowns of medical cannabis, set out to understand the limitations and innovations of medical cannabis prescribing in the UK since it was made legal for medical use in 2018.
Initially only for patients with "exceptional clinical need", the rules later changed so that patients can be prescribed cannabis if treatment is initiated via a specialist who deals in their particular problem, and for a set range of qualifying conditions such as chronic pain, intractable nausea and vomiting, spasticity, and severe treatment-resistant epilepsy.
Currently, medical cannabis is classed as an unlicensed special medicine and NHS guidance states it may only be used when other treatment options have been exhausted. Importing prescribed medicinal cannabis still requires a Home Office licence; however, since 2018 a number of private clinics have opened in the UK.
Still Relatively Few Prescriptions in UK
The report highlighted that medical cannabis "still sits on the fringes of the UK healthcare system, with prescribing remaining low". In the foreword, Dr Steve Hajioff, former chair of the British Medical Association's representative body and now chief medical officer at Sana Healthcare, the UK's first fully licensed cannabis specialist importer, wholesaler, and distributor, explained: "While there is a growing body of evidence that certain cannabinoids and products extracted from cannabis plants can be beneficial for some conditions, and despite the law now permitting the prescribing of cannabis-based prescription medicines (CBPMs) over and above those that have been licensed, relatively few patients have received cannabis products on prescription in the UK."
Written by Katya Kowalski, head of operations at London-based advocacy organisation Volteface, which aims to reduce the harm drugs pose to individuals and society, the report noted that "there are in excess of 40,000 specialist clinicians who are eligible to prescribe cannabis across the UK, yet only approximately 100 (0.25%) are actively doing so".
It pointed out: "If medical cannabis is to become mainstream, clinicians' confidence to prescribe must be addressed. Therefore, a clinician-centred model is required. Clinicians fundamentally have their patients' best interests at heart but are naturally conservative when presented with a botanical treatment, particularly one with unconventional delivery mechanisms, a history of patients' self-medicating usage and with links to the illicit drugs market."
For the report, Volteface interviewed 41 clinicians specialising in pain, psychiatry, gastroenterology, rheumatology, and neurology, in order to understand their perceptions towards medical cannabis. Three key themes that contributed to clinicians' hesitations emerged:
- Evidence – including a lack of randomised controlled trials and of real world evidence on the risks, side effects, interactions, and long-term impacts of prescribing CBPMs - a major barrier to clinicians' willingness to prescribe
- Governance – The vast majority of clinicians reported lacking support, guidance, and education on the practicalities of medical cannabis prescription. Many were unclear how legally to source the drug, or the requirements for prescribing it, with the bureaucracy and costs involved often dissuading clinicians from doing so
- The perceived uniqueness of medical cannabis – its complexity as a medicine, uncertainty about modes of administration, stigma surrounding illicit use, and the practicalities of prescribing requirements. Many clinicians did not want to develop a reputation as a cannabis prescriber in case it led to demand from patients requesting prescriptions without a legitimate need.
In the UK, the dominant industry narrative involves the cost of medical cannabis, the report said. "Although this is a legitimate concern for NHS trusts and patients at private cannabis clinics, the conversation should focus on the efficacy and safety of medicines, which would ordinarily play a more central role in a clinician's prescribing decision."
Clinicians Should be Empowered to Prescribe in Normal Clinical Settings
The report made a number of recommendations, including: empowering clinicians to prescribe cannabis in normal clinical settings, with a national campaign to increase this; addressing the lack of information and support for clinicians, and collecting data on specific products and indications; plus conducting more formal randomised controlled trials to supplement the knowledge base.
Medscape News UK interviewed Dr Mark Smith, now a cannabis prescriber in the UK who became interested in cannabis' medical potential during his time working in as a GP Australia. "We were allowed to prescribe it as if we were specialists; we didn’t have to ask for special permission," he said. This meant that patients didn’t have to go to "special and very expensive clinics".
"That worked. There now must be several thousand GPs who have prescribed [it] there at some stage," he said. When he left Australia, there were about 500 doctors classed as authorised prescribers. It’s "a completely different landscape" there, he opined. If patients want to try a cannabis-based medicine, or if their specialist suggests it, "it’s much easier to access it, and quite a bit cheaper; both the cost of seeing the doctor and the cost of the medicine, it’s about half the price of over here, so a lot easier for patients", he said.
The UK is the World's Largest Exporter of Medical Cannabis, but That It Can't be Prescribed Locally
Why is medical cannabis so expensive in the UK? "Mainly because it's got to be imported, and of a certain standard – although we do manufacture it here, and there is a fair bit of growing going on". In fact, the UK is the world's largest exporter of legal cannabis.
"It doesn’t make any sense," said Dr Smith. "We’ve got an industry here, yet we’re not allowed to use it. You can get CBD (cannabidiol) products over the counter... but anything that's got THC [tetrahydrocannabinol, the principal psychoactive constituent], with the potential of 'getting high' – although in my experience it doesn’t happen – you have to get on a prescription, but it will be an imported medicine, which is stupid beyond belief."
The cannabis plant has probably a thousand different constituents, Dr Smith explained, but the main two are cannabinoids: "THC, which gets you stoned," and "CBD, which can't get you stoned but is really important in its own right." Over-the-counter CBD is really quite weak, he said, "so it's not really medicinal".
"People conclude it's not worked, but that's because they've no had a proper dose – it's like taking a quarter of an aspirin for a headache – it ain't going to work".
And people in the UK "get put off because of the price", he added. That means they're less likely to take a full dose. "So, cannabis-based medical products can be just CBD, but usually will be a combination of the two."
He pointed out: "There’s still the belief amongst some people – general public, MPs, doctors – that THC is going to send everyone screwy – but that's comparing being prescribed a codeine for a migraine with going out and 'chasing the dragon' with opium". While they might be similar products, the effects are completely different – "it’s all dose-related".
A 'Rather Clever' Plant
Street 'skunk' cannabis from a strain of the plant that's really strong in THC isn't balanced out by enough CBD and can make people really 'high', so they might run into problems with it triggering psychosis, he explained. In contrast, medicinal cannabis doesn’t have enough 'affordable TCH' in it to abuse it - and you can't smoke it or get an immediate high.
"A product that's made as a medicine, that’s balanced between the two – because CBD helps to negate the 'high' effects of THC – then you’re getting all these endocannabinoid systems." We make endocannabinoids within the body, Dr Smith explained, and they represent "a really important homoeostatic mechanism, matched by these plant cannabinoids". The most common neuroreceptor in the brain is the CB1 receptor, he pointed out.
He emphasised that while this a newish area of medicine, these compounds have "a really important role" in tackling problems such as inflammation, anxiety, or sleep disturbances, "it’s all about trying to control things back to normal – anyone with pain, inflammation, [or] trauma might be helped by this rather clever plant".
The usual prescription is for an oil-based medicine that takes a couple of hours to start working then lasts for 8-10 hours, so requiring a twice daily dose to complement the endocannabinoid system 24/7. "It’s really difficult to abuse it," Dr Smith stressed – and doctors don’t generally get patients 'trying it on', because it [prescribed cannabis] "is just too bloody expensive compared with buying it behind the pub".
It's also pretty difficult under the current rules to get any cannabis prescription at all. The route in the UK at present is that, because the primary care health record is controlled by the GP, patients usually need to get a GP referral letter first. Then they have to go to a specialist, who may not be their normal specialist, because they have to be a cannabis specialist also. "This is weird, and slows down the journey for the patient," said Dr Smith.
Because it's so difficult to negotiate the system even to have a try with cannabis, Sana Healthcare, with whom Dr Smith is also affiliated, have introduced a free app called Script Assist that can be used by both clinicians and patients to help them navigate their way through all the rules and regulations. The app aims to make it easier for clinicians to be within the regulatory framework, to assist them with choosing medicine from those that have some evidence behind them, to assist patients to find a suitable clinician, and to help both parties find medicines that can be accessed by and are in stock at pharmacies.
"These are all hurdles to clinicians and patients at the moment," Dr Smith said. Speaking to us about his experiences in Australia, he explained that when the law was changed there to allow GPs to prescribe medical cannabis, "I didn’t have any intention or expectation that I’d be prescribing it". But patients came along asking him to get approval to prescribe it - and the feedback they gave was usually so positive, and nobody complained about side-effects.
The Most Rewarding Part of the Practice
"It just became the most rewarding part of our practice. People were saying 'well. this is the first time I’ve slept in 10 years', or 'the pain's a lot better now, I feel I can cope during the day' or 'my panic attacks aren’t so bad' or 'I managed to cut down my SSRIs, or my painkillers', or 'I’m coming off opiates'."
These are really important things that are real problems in the world at the moment, like people hooked on oxycodone, he said. "It was just really rewarding." In over 2 years, he ended up prescribing medical cannabis to just over 500 different people – "it became normal – something really good to do; so safe and simple".
In a retrospective audit he made of his prescribing in Australia 2 years after prescribing laws were relaxed there, he found that, of 131 patients initiated onto medical cannabis, 87 (66%) reported a benefit and wanted to continue their prescription.
Most had been prescribed the drug for "conditions that GPs have to manage every working day", such as anxiety, chronic pain, and insomnia, with "a rarity of reported side effects" compared with the rates attached to SSRIs or opiates.
"There is clear evidence of the effectiveness of cannabis products for a variety of conditions with reduction in reported symptoms, reduction in need for standard analgesia, benzodiazepine, and anti-depressants with increased productivity of those not losing days off work because of mental health or headaches," the report concluded.
Patients interested in medical cannabis in the UK are "still really puzzled" about where to go and how to get it, he said, but the Script Assist app will hopefully open that up, so they don't have to go to a dedicated cannabis clinic, they can speak to a normal specialist about it. "Unfortunately," the days of GPs prescribing it are probably several years off, he reckoned – though "it’s a really useful medicine" and side-effects are "very unusual".
He concluded that doctors "shouldn’t be scared of it, and it's not the same as street cannabis. It's as far away from street cannabis as smoking opium is from prescribing co-codamol – and that message hasn't quite got through."