About the CMC
The Centre for Medicinal Cannabis has a formidable in-house mix of medical expertise, political nous and analytical skills that our members can depend on to bring about positive reform.
Dr Daniel Couch, Medical Lead | The Centre for Medicinal Cannabis
Medical cannabis in the UK is not where we intended it to be. When the law was changed in 2018 to allow the prescribing of medical cannabis as a schedule 2 drug, many patients anticipated that they would be provided a new prescription to control their symptoms. Many expected that the transition from illegally possessed to legitimately prescribed cannabinoids would now be at least a partially open door.
A glance at the rates of prescription since show that this has not been the case. The Advisory Council on The Misuse of Drugs (ACMD) has found that in England between 2019 and 2020, 328 patients were prescribed a cannabis-based medicine in the NHS, with a further 537 prescriptions issued as a special since 2018.1 More recent data demonstrates that in 2021 at least 1,486 prescriptions were issued for a cannabis based medicine in England, although many of these may have been repeat prescriptions.2
But perhaps this should not be a surprise. It was clear from the outset that there are several immovable factors present in the medical and legislative landscape that prevent a novel medicine such as medical cannabis from being quickly adopted. These obstacles are slow and difficult to overcome.
Firstly, the high bar a medicine must pass prior to licensing is a challenge. The regulator – the MHRA – has a strong pedigree of licensing only medicines which have passed rigorous safety and efficacy testing. The hundreds of millions of pounds necessary to obtain this is often out of reach for the fledgling medical cannabis industry, and as such only a handful of licences have been granted. These make up all of the prescriptions issued by the NHS to date, the majority of them being Sativex and Epidyolex.
Without a licence and the necessary clinical evidence, NICE is unlikely to recommend a medical product for a given medical condition, and without this it is extremely unlikely that such a product would be prescribed within the NHS. Only Sativex, Epidyolex and Nabilone are licensed and recommended for spasticity in multiple sclerosis, two paediatric epilepsy syndromes and intractable nausea and vomiting. The majority of patients hopeful for an NHS prescription outside of these indications are very unlikely to receive an NHS prescription for such.
Patients however can be prescribed an unlicensed medical cannabis product as a “special” and when done so, this occurs largely in the private sector. However, this must be prescribed only by a GMC registered specialist, supported by a multi-disciplinary team. That clinician must take personal responsibility for the prescription and any adverse events arising from it. Not only are the financial barriers to a regular private prescription beyond the means of most patients, but there are also just not enough specialists in the UK able to write these prescriptions.
As of 2021 there are 62,000 specialists in the country, each with their own clinical workload from which medical cannabis competes for space. Of these specialists, only a fraction will be working in a specialty with patients that would potentially benefit from a potential treatment. It takes up to ten years to train a specialist doctor.3
A study by the CMC in 2020 estimated there are 1.4m people in the UK who would seek to be considered for a medical cannabis prescription. In the context that the recent BMJ rapid review suggested that medical cannabis could be used also to treat chronic pain, the UK simply does not hold the specialist faculty to assess this many patients within an appropriate clinical timeframe.4
We are at an impasse. We are not able to rapidly train more or reduce the workload of existing specialists. We are not able to reduce the demand, and unable to generate the clinical evidence required to obtain the sufficient licensing to allow wider prescribing within an acceptable clinical timeframe. Meanwhile patients suffer.
GPs frequently state that increasingly patients attend their practice to enquire about medical cannabis, but they are unable to help. Clinicians in primary care are not able to prescribe this medicine. Even if they could they currently may not have the prescribing frameworks necessary to safely do so and monitor their patients for adverse events.
We are at an impasse. We are not able to rapidly train more or reduce the workload of existing specialists. We are not able to reduce the demand, and unable to generate the clinical evidence required to obtain the sufficient licensing to allow wider prescribing within an acceptable clinical timeframe. Meanwhile patients suffer.
Paradoxically, despite being prohibited from prescribing by the 2018 regulations, primary care clinicians are in an excellent position to be at the helm of cannabis prescribing. For practicing specialists, whilst patients are admitted in hospital, they are reviewed daily. However once discharged from hospital specialists may see their patients less frequently and can go several months or maybe over a year before seeing them again. This is not conducive to the close clinical relationship required to satisfactorily dose a medical cannabis prescription in an unlicensed manner.
Contrast this with primary care. Family doctors and GPs, the first port of call for patients, see their patients much more often and are arguably more accessible. Furthermore, specialists have an in-depth knowledge of their specialism, but perhaps a limited understanding of wider medical issues. Primary care clinicians are trained across the breadth of medicine, and although may not have the detailed knowledge of the assessment and management of complex conditions, they are better able to appreciate how a new prescription may impact conditions in other areas of medicine.
Patients may travel many miles to see a specialist, whereas GPs are on hand within their local community. This allows them to develop the skills and tender the clinical resources appropriate to their population, the very reason for the creation of local Clinical Commissioning Groups (CCGs).
Since their creation, CCGs have been the focus of innovation in delivery of healthcare. They question how to deliver care in the most efficient and effective way. CCGs therefore may be the best placed groups to decide how to adopt medical cannabis for their patents. They are the financial key holders in the UK, and perhaps they are the right authority to decide economically and clinically how medical cannabis is delivered.
GPs, for these reasons, are best placed with the financial and innovative backing of CCGs to assess and prescribe these medicines. But this will not come about without legislative change. This is the crucial point. Like any other medicine, cannabis has been handled extremely conservatively with a sharp focus on efficacy and safety. To allow GPs to prescribe outside of a clinical study the law would have to change again.
The original change in scheduling came only through immense political pressure to intervene to help save a life. How best to bring about any further changes? How best to generate the adequate research when existing progress has been slowly gained? How best to overcome the frustration many patients feel when they discuss this with their doctor?
There is a vast capability for research in primary care in the NHS. Perhaps within primary care lies the answer to the enigma of medical cannabis in the UK. There is a clear and apparent need for a clinical pilot study in primary care to assess the effects of community prescribing in a supported format. This would allow us to assess the impact of medical cannabis on our patient’s quality of life, the economic effects of reduced referral to specialist care, and catalyse further studies and policy decisions.
If we want the landscape of medical cannabis in the UK to change to the benefit of our patients and prevent other jurisdictions from overtaking us we need to act now. Pilot schemes across Europe and beyond are leaving the UK behind in its understanding of how medical cannabis should be used. We have an opportunity to drive forward innovation and research, one of the pillars of the NHS, and drill down to the facts around medical cannabis.
There is a clear and apparent need for a clinical pilot study in primary care to assess the effects of community prescribing in a supported format.
The answer must lie with evidence and this evidence lies, it seems, in primary care. There is an immense capability for research in primary care that is not being used, and it is up to us to unleash it. Supporting the prescribing of medical cannabis within primary care is the obvious step forward the UK must take to widen access and improve the lives of our patients and communities.
1) Cannabis-based products for medicinal use (CBPMs) in humans. Advisory Council on the Misuse of Drugs. Nov 2020.
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/939090/OFFICIAL__Published_version_-_ACMD_CBPMs_report_27_November_2020_FINAL.pdf
2) Dronabinol/Cannabidiol prescribing by CCG in England. Openprescribing.net
https://openprescribing.net/chemical/1002020Y0/ Accessed 24/1/2022.
3) Medical staffing in England: a defining moment for doctors and patients. British Medical Association. July 2021
https://www.gov.uk/government/news/bold-new-life-sciences-vision-sets-path-for-uk-to-build-on-pandemic-response-and-deliver-life-changing-innovations-to-patients
4) Busse JW, Vankrunkelsven P, Zeng L, Heen AF, Merglen A, Campbell F, Granan LP, Aertgeerts B, Buchbinder R, Coen M, Juurlink D. Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline. bmj. 2021 Sep 9;374.
The Centre for Medicinal Cannabis has a formidable in-house mix of medical expertise, political nous and analytical skills that our members can depend on to bring about positive reform.