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11 ways to enable more UK patients to benefit from medicinal cannabis

Medicinal cannabis was legalised in the UK in November 2018, yet there have been fewer than ten new prescriptions made through the NHS. Most of the prescriptions made have been private, and are financially out of reach for most patients, costing up to £2000 per month.

There are various barriers currently hindering physicians to prescribe medical cannabis. Current costs tend to be high due to import restrictions, and guidelines for prescribers are restrictive. NICE recommends the prescription of medicinal cannabis for only four main conditions (two of which are epilepsies): Dravet syndrome, Lennox-Gastaut syndrome, vomiting and nausea in chemotherapy, and spasticity in multiple sclerosis.

The guidelines don’t recommend the prescription of medical cannabis for pain. Yet patient-reported outcome studies and survey research has shown that pain is a common indication for which patients want to use and are benefitting from medicinal cannabis.

The Drug Science Medicinal Cannabis Working Group (MCWG) and Project TWENTY21 aim to further the availability of medicinal cannabis in the UK so that the medicine can reach patients in need.

The Medicinal Cannabis Working Group looked at six countries with better success stories for prescribing medicinal cannabis to patients: Germany, Netherlands, and Italy in the EU; Canada, Israel, and Australia globally. Based on this research, we have 11 recommendations for lessons to be learned in the UK.

1. Educate, train and support clinicians and HCPs

The prescription of medicinal cannabis in the UK has been hampered by a lack of training and education for physicians and other health care providers. There is an urgent need to develop and implement a registered accreditation and education platform.

This could allow current prescribers, and future prescribers in higher education, to become familiar with treatable symptoms, the therapeutic benefits of various compounds, and registered products. 

The Drug Science MCWG is currently developing a module on medicinal cannabis for use in UK universities.

2. Improve the evidence base

More real-world data is required to develop the scientific evidence, as the evidence base for many conditions is only just developing. Canada has a large-scale database for monitoring side-effects, but for many prescribing countries there are significant data gaps that need to be filled. 

In the UK, Drug Science has launched the biggest EU database on medicinal cannabis. Project TWENTY21 aims to register 20,000 patients by 2021 to provide an extensive evidence base regarding the effectiveness of medicinal cannabis.

3. Look to the Cancer Drug Fund as an example of a “Managed Access” program

The Cancer Drug Fund’s ‘managed access’ programme provides a way for patients to be prescribed drugs that are not otherwise available. Drugs deemed ‘promising’ by NICE but for which there is not enough evidence to justify routine NHS payment can be temporarily approved by NICE and paid for by the fund whilst more evidence is collected. 

This could provide a model for how medicinal cannabis products could be approved and funded whilst evidence is still being collected on their efficacy. 

4. Establish a medicinal cannabis office

Both the Netherlands and Israel provide examples of the benefits of an officially designated medicinal cannabis government office. Such an office enables the government to regulate and certify responsible cannabis production for medical and scientific purposes.

5. Require industry relationship transparency

Potential conflicts of interest need to be addressed when working with the medicinal cannabis industry. Transparency should be a basic requirement as it is in the tobacco and alcohol industries to establish trust among the public and physicians.

6. Effectively calculate demand

The UK is already the world’s largest producer and exporter of legal cannabis and needs to be able to ensure it can provide for its patients. It is important to accurately calculate the demand for medicinal cannabis and have a workable plan for how the market can meet this demand.

7. Clarify cost and insurance

The cost of medicinal cannabis should be met by the NHS so that it can be available to all patients who could benefit. Doctors may be reluctant to prescribe cannabis medicines because of the rigorous hurdles for approval by health insurance companies.

Given the potentially high costs, it would benefit patients the most if insurance companies can make positive recommendations. Universal criteria and assessment standards would enable more objective regulation and insurance.

8. Involve patients and address their concerns

As the end-users of medicinal cannabis, it is essential to involve and communicate with the public, especially to address their concerns. Setting reasonable expectations about the therapeutic outcomes of medicinal cannabis will take the pressure off doctors if expectations are not met. Risks, benefits, and alternative options need to be explored clearly with patients.

9. Cultivate communication between stakeholders

Controversy and uncertainty can be avoided through equal representation of all stakeholders, including patient groups, in the development of policy and regulation. Consistent and comprehensive stakeholder communication can foster relationships of trust between all interested parties.

10. Address stigma

There is a stigma around cannabis due to its recreational and black-market use. Increases in medical prescriptions will decrease stigma and increase the public conception of cannabis as a medicine. Pharmacies and official providers can lead the way in legitimising its medical use.

11. Address the role of the media

The media has a vital role to play in the dissemination of accurate information about medicinal cannabis. Sensationalist and false portrayals, whether positive or negative, can greatly damage the public perception. Given that information from the industry tends to be viewed suspiciously, journalists have a role to play in providing objective, accurate and neutral perspectives that account for any opposing views.

Project TWENTY21 and the way forward

As mentioned above, Drug Science has launched the biggest EU database on medicinal cannabis. Project Twenty21 aims to register up to 20,000 patients by the end of 2021 to provide an extensive real-world evidence base on the effectiveness of medicinal cannabis.

Drug Science believes that the benefit/risk profile of medical cannabis in certain disorders, and as a treatment for certain conditions, is favorable.  The risk of continued prohibitionist approach to medical cannabis increases harms by driving patients to the illicit market, with its attendant harms from cannabis of unknown strength and content as well as fuelling an illicit supply chain that will be difficult if not impossible to dismantle in the future.

We also aim to support prescribers to feel confident in prescribing medical cannabis to patients. We hope that by offering our support to prescribers through online forums, educational material, and the evidence that accumulate through Project TWENTY21, we will be able to make a case for the NHS to approve funding in the long term. 

Anne Katrin Schlag is Head of Research at Drug Science and Honorary Fellow at Imperial College London.

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