14 Apr Medicinal cannabis is legal, so why aren’t doctors in the UK prescribing it?

The UK legalised medicinal cannabis products in November 2018. Scientists, researchers, and campaigners welcomed the change and hailed it as a landmark decision. Those who had been self-medicating through the black market or overseas channels for years expected their lives to finally become easier. People anticipated a rapid increase in the prescribing of these novel pharmaceuticals, both in the private sector and the NHS.

But during the entire following year, the NHS would provide only 18 prescriptions for cannabis-based medical products (CBMPs). This equalled less than 6.5% of the total number of CBMPs prescribed to UK patients in 2019. The private sector prescribed 259 such products, but the number of prescriptions was still lower than a hundred and cost about £1000 – £3000 a month.

These figures seem even more disappointing when you consider that at least 1.4 million people in the UK depend on medicinal cannabis for its therapeutic effect.

NHS patients have repeatedly complained about the difficulty of obtaining prescriptions for CBMPs. But the prescribing regime continues to be highly restrictive despite the legal status of medicinal cannabis. Reasons such as high risk or insufficient evidence of efficacy are often used to justify the stagnant state of affairs, with little regard to the lived experience and evidence of patients.

What is stopping doctors in the UK from prescribing medicinal cannabis despite its legal status?

The legalisation of medicinal cannabis in the UK came in the aftermath of a high-profile media campaign and backlash surrounding the cases of young Alfie Dingley and Billy Caldwell. Both children suffered from epilepsy and had frequent seizures, which could only be alleviated with cannabis oil. These patients still have access to specific CBMPs, but the majority of the 1.4 million medicinal cannabis users in the country have to face numerous impediments when seeking professional medical help.

The impediments aren’t necessarily due to the law, but they are almost always entrenched in organisational bureaucracy. For one, the interim guidelines for the legalisation of CBMPs were devised in a short period of time in the absence of adequate clinical data. Cannabis had been categorised as a Class A drug (under the Misuse of Drugs Scheduling Act of 2001) with no medical value until then, which made it doubly difficult for researchers to study its psychoactive properties.

The problem is compounded by the tendency of UK practitioners to only trust data collected within the country. But ignoring global data in a complicated field like medicinal cannabis, which as a product is much better regulated in other countries, is a serious handicap. As Alex Fraser, a specialist at Grow Biotech, explains to Wired :  “The main issue here is two-fold: that [specialists] don’t value or trust foreign data, and that traditional ways of studying medicines won’t necessarily work for cannabis.”

The law itself doesn’t differentiate between the types of CBMPs that can be prescribed, except for products that need to be smoked. But medical practitioners are the ones who claim they are unable to prescribe cannabis because they feel they aren’t informed enough on the subject. Doctors have been taught for ages that cannabis is a dangerous recreational drug. Most of them lack any experience with medicinal cannabis. Even after the law was changed, there has been no effort to raise awareness or understanding of medical cannabis among health professionals.

This leads to a huge but understandable reluctance on the part of doctors and pharmacies who don’t want to risk their licenses by facilitating patient access to CBMPs, most of which aren’t even licensed for distribution. In the case of such unlicensed products or ‘specials’, the responsibility for any harm that occurs from the use of the product lies with the prescriber, unless it is caused by a clear defect in the actual product.

How complicated is the process of prescribing medicinal cannabis products?

In practise, the use of medicinal cannabis in the UK is permissible only for a few conditions, such as severe forms of childhood epilepsy, nausea caused by chemotherapy, and muscle spasticity due to multiple sclerosis. CBMPs other than Sativex and Nabilone are ‘unlicensed specials’ and there is plenty of confusion in making sense of their regulatory framework.

Discouraging official statements, like the one by the National Institute for Health and Care Excellence (NICE) that warned against prescribing cannabis for a range of conditions like chronic pain, further complicate matters. Under these circumstances, the only way a prescription even happens in the NHS is when a patient is somehow able to convince a specialist doctor about medication that has previously worked for them.

This isn’t easy either, since treatment based on medicinal cannabis is primarily patient-driven. Many doctors feel that prescribing medicinal cannabis products based on a patient’s feedback and experience is akin to admitting that they may have better insights. Unfortunately, years of demands to allow greater patient involvement in treatment and decision-making has yielded little progress.

The challenges don’t end here. Patients can receive the treatment only if referred by a specialist GP or consultant doctor listed in the General Medical Council’s specialist register. Even when a specialist agrees to a CBMP line of treatment, the prescription has to be detailed to a specific level. It has to be written on a special pink pad for Schedule 2 drugs. The pharmacy that imports the CBMP and the company that ships and delivers it also need special licenses. The current prescription and delivery process can easily take over two months. Although the recommended dosages prescribed under the guidelines are roughly for a month, many CBMPs have expiry dates, which can be an additional constraint.

As it stands, the situation could become a self-perpetuating cycle of inadequate data leading to restrictive guidelines, which deters practitioners and results in fewer prescriptions, which limits patient use and fails to produce the formal data needed to support further research. Despite some efforts to ease the burden on patients – such as the new UK medical cannabis card to protect those using self-sourced medicinal cannabis – there are difficulties abound.

Until the UK medical community actively starts prescribing medicinal cannabis products where needed and pharmacies start importing products in bulk, it will be tough to improve patient access, bring down the costs, or bridge the gap between knowledge and experience.