Dr Nat Wright, clinical advisor to European cannabis company AltoVerde, discusses how cannabis can play an important role in treating substance misuse and in alleviating the over-prescription of opioids.
Medical cannabis became legal in the UK in 2018 and in the four years since, the number of patients has grown to upwards of 20,000.
On the NHS, medical cannabis is prescribed for only a handful of conditions including epilepsy, nausea caused by chemotherapy, and multiple sclerosis-related muscle spasms. But a number of private clinics in the UK now prescribe medical cannabis to treat a range of physical and mental ailments, with the majority of medical cannabis being prescribed for pain management and anxiety.
Dr Nat Wright is a GP who has worked extensively with patients dealing with substance abuse issues and who has more than 20 years of experience on several committees involved in raising the quality of healthcare provision to vulnerable groups. He believes that the role of cannabis in the inter-related world of substance misuse and pain management is an area that deserves more attention from medical professionals in the UK.
Given the over-prescription of opioid-based pain management across traditional medicine and the (arguably) related opioid epidemic that is devastating communities around the world, cannabis could provide an alternative to opioid-based pathways and be used as a treatment for those struggling with addiction and substance use disorders.
Dr Nat Wright, clinical advisor to AltoVerde
De-stigmatising treatment around drug addiction and substance abuse
“When I started in 1996, there were really no guidelines for GPs,” says Dr Wright.
“But I found myself in a job where I was required to prescribe for drug users. So I learned very quickly, and I learned a number of things.”
Back then, there was still little evidence supporting, for example, the use of methadone as a means to ease people off of narcotics such as heroin. Dr Wright became curious about how this could be done safely, effectively and in a way that adds to the quality of patient lives.
After becoming involved with the Royal College of GPs (RCGP) and their work in addiction and substance abuse, Dr Wright became a GP advisor to a special health authority under Tony Blair’s government in 2003.
“That’s where I really got interested in how this conservative establishment — the medical profession — could embrace this difficult area that many are reluctant to get involved in,” he says.
Even in 2003 GPs and other authoritative bodies were hesitant to prescribe methadone in cases of heroin addiction. On one occasion, Dr Wright was called to a local prison to help with heroin use and withdrawal. Authorities were against any sort of methadone treatment at the time, but he made the case that the alternatives — self harm, potential suicide — would be worse for patients, and could put the prison at legal risk.
He explains: “The chief executive says: can you stop us being sued? And I said, yes, but it will involve a methadone maintenance programme. This is now accepted as mainstream healthcare practice and has been for well over 15 years.”
These types of transitional treatments are now normalised, but stigma still surrounds people struggling with substance use and addiction issues. Combined with existing stigma against cannabis, this can act as a significant barrier in moving towards acceptance of cannabis-based alternatives for both addiction and pain management.
“Stigma is the one thing that’s always been there [especially] when working with drug users and prisoners” he says.
“But that said, there are a number of great groups — including the Council of Europe and World Medical Association — where people are challenging that stigma.”
He adds: “Do I intuitively think that we can challenge stigma and get a better quality of life [for patients] with medicinal cannabis products? Yes, I do.”
Listening to patients: cannabis as an alternative to opioid-based treatments
Dr Wright has seen first hand how treating alcohol addiction and drug dependency with controlled substances under safe conditions can offer effective relief for patients. But despite seeing the power that opioid-based addiction programs have had for drug users, as well as for communities devastated by illicit drug use, he understands there is an associated cost.
“There’s a price to all of this,” he admits.
“There are some side effects to opioids that have never sat comfortably with me. As a GP, I’m still very active in clinical work and am having difficult conversations with patients who are taking opioids for pain, and escalating doses on account of becoming addicted to prescribed opioids. We haven’t, as of this moment, got a plethora of options for their pain relief.”
With regards to pain treatment, opioid-based medicine is still the standard course of care, and opioids can arguably provide live-saving relief for patients. But opioid misuse and dependency is a debilitating problem, with opioid use disorder affecting more than 16 million people worldwide. In England, opioid prescriptions increased 128% since 1998, and opiates were involved in almost half (2,219) of drug-poisoning deaths in England and Wales during 2021.
“There are so many [patients dealing with substance abuse] that have said to me ‘cannabis helped me come off of opioids,’” shares Dr Wright.
“My feeling is that the side effect profile of cannabis is more acceptable to patients and to doctors than opioids. Opioids are Class A drugs, whereas cannabis is a lower Class B drug. Opioids are [also] much more habit-forming than cannabis. There are so many patient narratives on [how cannabis has helped] that there is a responsibility to harness that voice.”
To formalise cannabis as treatment for substance use and addiction, and potentially as an alternative to opioid-based pain management, a wider conversation needs to be carried out amongst senior clinical bodies in the UK and the Royal Colleges, he believes.
“We need to collect those patient narratives, because the patient voice is increasingly encouraged in the NHS, and it would be beneficial to work in proactive partnerships with the NHS,” he says.
Dr Wright has 20 years experience working with patients experiencing substance use issues.
Normalising cannabis treatments for substance abuse and pain
Of course, medical professionals are likely to be cautious when approaching cannabis as an alternative treatment to opioids.
“There is reticence in the healthcare profession for good reason,” explains Dr Wright.
“The regulation and the accountability frameworks for medics now are rightly stringent because of the potential for harm with a lot of the interventions we have. But this is not a reason not to do things.”
Dr Wright doesn’t think that GPs should suddenly be able to start prescribing cannabis as there is a need for more research, guidance and training in this area. However, a smart next step would be for certain GPs to take an extended role in, for example, substance misuse or pain who could then prescribe medical cannabis.
“The interface between primary care and pain management services is ripe for further development in this space,” he says.
The National Institute for Health and Care Excellence(NICE) guidelines on cannabis-based medical treatments provide comprehensive support for medical professionals interested in alternative treatments for a select number of conditions like intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.
“The NICE guidelines were a starting point for medics to have mature clinical conversations around a commonly agreed framework,” says Dr Wright.
The Alto Verde journey
It was a serendipitous storm of medical cannabis legalisation, the formation of the NICE guidelines, and a call from longtime friend and AltoVerde CEO Bryan Willis, that prompted Dr Wright to join the team. The company’s mission to bring high quality cannabis medicines to the market began in April 2019.
“What impressed me about the AltoVerde approach was the seriousness of the vision from the offset and the fact that they went about things in the correct and proper way,” says Dr Wright.
He was so impressed with the vision, he became one of the company’s founding executives.
“Dr Arpeat Kaviya and Paul Titus joined the team soon after and this was the beginning of our multi-disciplinary team,” he adds.
“From a team of five we now have 30 founding executives plus a vast advisory panel, a network of joint venture partners and strong industry allies.”
The European producer is currently in the process of obtaining licences for its five growing facilities across Europe, with its first cannabis-based products expected to be ready by late 2023.
Dr Wright is also a training lead in illicit substance misuse for the RCGP and Clinical Lead and the Primary Care Specialty Lead for Health Research Yorkshire and Humber Clinical Research Network.
So how does he think the medical community in the UK can better embrace cannabis as an effective treatment method, particularly for substance misuse and pain management?
“The standpoint I want to come from is: can cannabis provide a better quality of life for patients with less severe habit forming side effects, with side effects that we know are less extreme than opioids? That’s the position we want to cautiously move toward, given all the experience we have around clinical governance and accountability, and safety,” Dr Wright says.
“All of that has to be paramount, but it shouldn’t be a reason not to do something. It should be a reason to do it properly.”
AltoVerde has provided financial support into the production and distribution of this article. AltoVerde has also had editorial input into the content of the article and has reviewed it for medical accuracy.
The post Could medical cannabis play a role in treating substance misuse? appeared first on Cannabis Health News.
