A new report gives an insight into the multitude of challenges preventing more UK clinicians from prescribing cannabis medicines.
Cannabis must be treated the same as any other medication if we want to see mainstream prescribing in the UK, say doctors in a landmark report out today.
Known Unknowns of Medical Cannabis, published by drug reform agency Volteface, brings together the perspectives of dozens of clinicians in order to identify the key issues preventing more widespread prescribing of cannabis.
It is the first time the views of specialist consultants have been highlighted in such a way since the law changed to allow them to prescribe cannabis for medicinal purposes in November 2018.
More than 40,000 specialist clinicians are eligible to prescribe cannabis across the UK, but according to the report, only around 100 (0.25%) are actively doing so.
As these doctors are the ‘gatekeepers’ to expanding access to cannabis-based medicines, supporting them to prescribe is crucial for more patients to be able to benefit from the treatment.
Volteface interviewed over 40 of those working in a range of specialisms, including pain, psychiatry, gastroenterology, rheumatology and neurology in order to better understand their perceptions of medical cannabis.
A number of issues including lack of governance, insufficient high quality evidence and doctors not being educated or supported in prescribing were identified.
Dr Steve Hajioff (left) Arjun Rajyagor (second right) and Dr Mark Smith (right) of Sana Healthcare and Katya Kowalski, Volteface launch the report in Parliament.
High quality evidence
Most of the doctors interviewed expressed an interest in prescribing, however, it is clear from the report that they want cannabis to be treated the same as any other new medication. This means meeting the required evidential and regulatory standards, such as undergoing randomised control trials (RCTs), which are widely regarded as the ‘gold standard’ of scientific evidence.
Some believe that calls for medical cannabis to be treated differently and bypass these regulatory frameworks ‘undermine its credibility’.
Dr Chris Derry, a neurologist who was interviewed for the report, said: “The first thing that is needed from my perspective is standard, medical grade evidence, so RCTs of a pharmaceutical grade drug. Once you’ve got those, you have something to work from.”
Most also felt that real world evidence on medical cannabis was ‘biased’ due to ‘prevailing preconceptions’ among those in the cannabis community that ‘amplify the perceived benefits of the medicine’ rather than ‘determining its true efficacy’.
As a result, the report says, many of those interviewed viewed the medical cannabis sector with ‘scepticism’.
“We talk a lot about evidence for cannabis, but it is about the type of evidence too,” said Dr Euan Lawson, a GP who is quoted in the report.
“Right now we’re seeing the sector trying to build evidence with biassed observational studies. The current model is giving cannabis to patients that want cannabis and want it to work.”
Perceptions among specialisms
Dr Richard Davenport, a neurologist, added: “You must understand the potential risks you run if you decide to treat it entirely differently from any other drug.
“It’s nothing to do with doctors wanting to see cannabis fail, or deny cannabis to their patients, which is how we’re sometimes portrayed. Some of the high-profile child epilepsy things, they’re portrayed in a particularly unsympathetic and difficult manner that is really evil doctors trying to deny drugs to patients, risking their lives, which is very easy to write in a newspaper but is nonsense.”
Despite epilepsy and MS being licensed indications for prescribing, the report found that neurologists were particularly conservative about cannabis. Gastroenterologists also felt there was little evidence to support its prescribing in their specialism, whereas pain specialists showed more interest and acknowledgement of its efficacy.
Psychiatrists appeared ‘open’ to their patients using CBD, but many had concerns around THC, particularly in relation to psychosis and treating people with complex mental health conditions. Several in this specialism thought cannabis would be a safer and potentially more effective treatment when prescribed in combination with psychotherapy.
Allowing GPs to initiate the prescribing of cannabis is thought to be one way of opening up access, as has been done elsewhere such as Australia, where GPs have been permitted to write prescriptions since 2019.
However, Dr Mark Smith, a UK-based GP who has just returned from Australia where he prescribed medical cannabis for three years, says the difference in the infrastructure of the healthcare system here and in Australia may present an issue.
“There are big differences that would need to be ironed out,” he told Cannabis Health.
“Here, GPs only have a 10 minute appointment and you’ve got to battle through the patients. Whereas in Australia, they’ve got twice as many GPs per head of population and you can set your appointment time, so it doesn’t matter if you have 45 minutes. We’re still some way off that flexibility that we had down under.”
Dr Smith added: “[Back here in the UK] all specialists and GPs I know are still completely clueless about medical cannabis, because it’s not on their remit to know anything about it. They’re not encouraged to look into it so they have no idea of the market at all. There’s just so much education yet to be had.”
Lack of knowledge, education and support
Doctors reported a general lack of knowledge and training in the field, such as how cannabis affects the endocannabinoid system, what formulations are available, the indications it can be prescribed for and the various benefits and side effects.
Some were also put off by the ‘bureaucracy’ currently involved in prescribing and the lack of infrastructure and support, and the report identified a fear of being reported to the GMC and causing damage to their reputation.
“Doctors just aren’t sure how it works and have little understanding of infrastructure and governance. Not knowing the practicalities is a massive barrier as we need to be certain around how it is prescribed and administered,” said Dr Euan Lawson.
“Having specific indications is essential, it can’t just be about pleasure seeking— without a specific indication it just gets too close to a recreational product.”
According to the report many doctors said stigma was not a ‘significant barrier’ to prescribing, however some of those quoted struggled to differentiate between medically prescribed and recreational consumption.
One neurologist who wished to remain anonymous said: “I think it is incredibly important to distinguish therapeutic from recreational use. I think an awful lot of therapeutic use is the folks who want to get high getting their foot in the door, it is a problem….I do not want to have a reputation that ‘this doctor prescribes medical cannabis’ because then you get all sorts of crazy people…who come along with a bogus diagnosis wanting some cannabis prescribed.”
Uncertainty around dosage and administration methods was common, particularly in relation to cannabis flower. Many said they would feel more comfortable prescribing medical cannabis in pill form.
“From my point of view, the medicalisation of it would require it to be made available, either injectable, tablet or syrup,” said Dr Justin Basquille, a psychiatrist.
“Vaping is too much like through a bong, and it also has implications for lung health. So I’d be worried about vaping, inhalation.”
Author of the report, Katya Kowalski
Cannabis clinics – a major barrier?
Another key finding of the report is a hesitancy among doctors to prescribe through a cannabis-specific clinic, with many indicating they would be more comfortable prescribing from their existing practices.
‘A clinic dedicated to a single product inherently creates a prescribing bias,’ the report states, ‘as opposed to encouraging an appropriate, balanced and ethical approach’.
An unnamed gastroenterologist commented: “Obviously if you go to that clinic, you’re going to attract people who want cannabis without any evidence. So, I am slightly concerned about these clinics and the bias and the motivations that are behind the people who run them.”
Author of the report and head of operations at Volteface, Katya Kowalski, said this was a ‘major barrier’ to emerge from her research.
“It is clear that medical cannabis does not fit neatly into the healthcare system. In order to see this change and become mainstream, we have got to see a broadening of choices for clinicians to prescribe outside of the cannabis clinic model,” she said.
“Nowhere else in medicine do we see single-drug clinics. From my research, this is a major barrier within the medical community, something we need to see addressed in the sector, to truly broaden confidence amongst clinicians to prescribe more widely, in turn expand patient access.”
Where do we go from here?
The report concludes by setting out some key recommendations to address the problems with the current model of prescribing. These include launching a clinician-centred campaign, carrying out more RCTs and developing innovative tools to encourage prescribing in mainstream practice.
Dr Steve Hajioff, a former chairman of the British Medical Association (BMA) and a member of the Quality Standards Advisory Committee for the National Institute of Health and Care Excellence (NICE) who wrote the foreword to the report, says it is time for the medicinal cannabis industry to ‘reflect’ and ‘adapt’ in order to address the concerns of clinicians on the frontline of prescribing.
“The enthusiasts who founded the cannabis industry and the families in desperate situations who convinced policymakers to change the law have done amazing work to get us where we are. Enthusiasts are at the forefront of innovation and initiate processes that can deliver radical change, but they are often different from most people at the coal face,” he told Cannabis Health.
“Most ordinary, working doctors want to see decent evidence that something is effective, who it is most effective for, and that it is safe. This is true for every medication, surgical procedure, psychological intervention. When doctors query why the cannabis industry is not being held to the same standard, they are not being ‘blockers’, they are being even-handed and acting in what they are certain is the best interests of their patients.
“Many other medicines have their origins in plants; vincristine, artemisinin, morphine, digoxin. All of these medications have had to demonstrate efficacy and safety, so it is not unreasonable for potential prescribers of cannabis-derived treatments to want the same.”
Dr Hajioff continued: “Rather than blaming others or claiming exceptionality, the industry needs to reflect and see how it can adapt to deliver the reassurance necessary for mainstream practice.
“[This means] proper controlled trials (or at least some evidence that a particular, consistent product is safe and effective in a given indication in the meanwhile), robust governance so the prescriber knows that they are not themselves engaging in unnecessary risk and mainstreaming prescribing into normal clinical practice.”
Dr Hajioff is now chief medical officer at Sana Healthcare, which has developed ScriptAssist, a new platform designed to streamline medical cannabis prescribing and support both private and NHS clinicians through the process.
“Having single medication clinics looks like an anomaly to the wider profession and there is a legitimate fear that the patient is not always receiving the treatment that is best for them at that time,” he added.
“Build the high quality evidence, build the governance, build formularies shaped around evidence of efficacy in a given condition, move towards delivery mechanisms that have been proven to be safe, consistent and effective. Build all that and the prescribers will come.”
You can read the full report here
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