In June 2018, the then Health Minister, Jeremy Hunt, publicly supported the legalisation of medical cannabis in the UK, and announced that a review would be undertaken into its legal status.
Though much has changed for the industry since 2018, it has been frustratingly slow for many patients and advocates, with some significant challenges still unresolved. Today, the UK’s medical cannabis industry is at a crossroads.
2018 and 2019 saw a mixture of excitement and concern for the fledgling industry, with critics saying that ‘the floodgates were about to open’. There were predictions that tens of thousands of patients would soon be prescribed medical cannabis.
However, nearly two years since legalisation, the total number of patients are still in the hundreds. This is surprising given that over 1 million Britons already self-medicate with street cannabis.
So why after two years have so few prescriptions been written? What, if anything, has gone wrong?
‘The slow growth in prescriptions for medical cannabis so far isn’t unexpected, particularly when we look at what has happened in other countries where medical cannabis is used more commonly,’ said Dr Sam Murray, General Manager of Cannabis Access Clinics UK.
In Australia, very few prescriptions were written following legalisation in 2016. However, Its prescription numbers began increasing by 600% from 2018 to 2019.
‘Cautiously, I wrote my first prescription for medical cannabis at CA Clinics in Australia in late 2018, approximately 2 years after cannabis was legalised in Australia in 2016.’
With more doctors beginning to prescribe and product options increase, a similar trend may be expected with the UK’s medical cannabis market as it nears two years since legislation.
Lack of awareness remains an issue in the UK, and that has limited the number of prescriptions.
For advocates or those working in the medical cannabis industry everyday, it’s easy to forget that the majority of the general public have no idea that medical cannabis is legal even if it has been two years since legalisation. Many patients with chronic conditions and doctors remain unaware that medical cannabis is a legal option when other conventional licensed therapies have failed.
Following the review announced by Mr. Hunt, cannabis was legalised for medical use on November 1st 2018. The new law allowed for medical cannabis, officially known as CBMPs (Cannabis Based Medicinal Products), to be prescribed.
Importantly, the new legislation meant that medical cannabis couldn’t be prescribed by GPs, but only by GMC registered specialists, prescribing in their area of expertise. Before writing a prescription, specialists needed to be confident that there was enough evidence for the effectiveness of medical cannabis. They also needed to be sure that conventional treatments had been tried first.
This was a sensible safeguard to ensure that cannabis wasn’t a ‘first-line’ treatment, and that other treatments which have been more rigorously studied and tested, had been tried first. For example, it would be unreasonable for a patient with chronic back pain to jump straight from paracetamol to a prescription for medical cannabis, without having tried a number of treatments in between, like other licensed painkillers or non-pharmacological treatments like physiotherapy and pain management courses.
The downside of this legislation which does not allow GPs to prescribe medical cannabis, limits options and access for patients, and subsequently increases costs. Current estimates are that there are only 30-40 specialists in the UK that prescribe medical cannabis. Critics of the legislation argue that GPs manage chronic disease and chronic pain day in and day out, and would be well placed to prescribe medical cannabis after relevant education and training.
While medical cannabis has been legal in the UK for a while now, it takes time for doctors to be trained to prescribe, or even feel confident enough to refer on to a specialist doctor or clinic. It’s a big mental shift to move from being taught at medical school that cannabis is an illegal and dangerous drug, to something that potentially has real therapeutic value.
For the majority of doctors in the UK, they’re still yet to see first hand patients who have benefited from medical cannabis. Most aren’t ready yet ready to prescribe and many are still hesitant to support treatment via a referral.
This was also the case in Australia.
‘Prior to 2018, even after five years of medical school, and six years working as a doctor, I hadn’t even heard of the endocannabinoid system. I’m not ashamed to admit this because it simply wasn’t taught in medical school. Cannabis was only ever mentioned in passing as an illegal drug that had only negative effects ranging from ‘the munchies’ to psychosis. I had friends that occasionally used cannabis recreationally, and one friend that frequently used cannabis, who claimed to use it medicinally.
I am ashamed to admit that I had previously scoffed at this. I was a doctor with ten years of medical training, and thought I knew better!’
Dr Murray claims that two years after legalisation, many Australian doctors weren’t even aware that medical cannabis was legal, let alone know how to prescribe it.
‘I was skeptical, but intrigued. I furiously began researching medical cannabis. I learned about the endocannabinoid system, cannabinoids, terpenes, indica, sativa, THC, CBD, CB1 receptors, CB2 receptors, the entourage effect. It was an entirely new language. There was research into the role cannabis can have in treating epilepsy, nausea, anorexia, insomnia, chronic pain and tens of other conditions. There were patient stories of improved quality of life, patients coming off opioid painkillers, and finally getting a good night’s sleep. It seemed too good to be true.’
While there was a lot of excitement in this emerging medical field, there was also plenty of criticism.
‘Similar to the UK, in Australia there was plenty of criticism that more research was needed, complaints from patients and doctors regarding unaffordable prices, and supply issues meaning long waits for treatment. Patients and health professionals were still struggling to come to terms with the stigma attached to cannabis.’
However, after two years of medical cannabis being legal, Australian patient numbers began to increase as prescribers and referring GPs became more confident, and are now exponentially increasing. Similarly in the UK, as doctors become more confident, and GPs begin to see patients who have benefited from treatment, patient numbers are likely to increase.
‘GP referrals really picked up in Australia around the two year mark. A lot of these were for chronic pain patients, once GPs saw the value medical cannabis could have as an adjunct treatment to improve quality of life, and particularly in reducing the reliance on opioid painkillers. Reducing opioid prescriptions is a big challenge for GPs in Australia, and UK GPs are facing a similar problem’.
Perhaps the main factor that has kept patient numbers low is the cost of treatment. For the majority, medical cannabis is not available on the NHS, and so the only option is to access treatment privately. Medical cannabis can only be prescribed by GMC registered specialists, who tend to command a higher private rate than general practitioners. The cost of initial consultation at a private clinic with a specialist prescriber can cost anywhere from £150 to £500.
Dr Murray said, ‘At Cannabis Access Clinics, we’re aware that cost is a big issue for patients. The majority of patients have chronic conditions that may limit their ability to work full time. To help with this, we offer a free video consultation to assess eligibility for treatment, and if potentially suitable, we only refer on to specialists who agree to charge £149 for an initial consultation.’
Ongoing review consultations are also necessary as medical cannabis can only be prescribed one month’s supply at a time. Review consultations at private clinics typically cost anywhere from £50 to £150. Cannabis Access Clinics charge £110 for the first review, and then £49 for subsequent reviews.
The cost of the medication also remains an issue for patients, as the vast majority are private scripts, meaning patients need to cover the cost of treatment. However, prices have decreased significantly over recent months as supply chains have improved and the market has become more competitive. Cost of medication was sensationalised in the media during the first year after legalisation, while declining prices haven’t been widely reported. This has potentially scared many doctors and patients from considering medical cannabis as an option.
‘Medical cannabis remains very expensive for patients who are treated for epilepsy, as they typically require very high doses’ said Dr Murray. ‘However, for conditions other than epilepsy, most patients can typically expect to pay between £5-10 per day for treatment.’
Compared to the black market, medical cannabis was previously 200-300% more expensive, but recently this has reduced to 30-50%. Typically, cannabis costs £10 per gram on the black market, while medical cannabis now starts at around £13-15 per gram. In time, it can be expected that the cost of medication will become more affordable. However, It is unlikely that medical cannabis will ever be more so than its black market alternatives because of the standards it must comply with.
Inconsistent supply and long wait times have also limited the number of prescriptions that have been written. However wait times have improved for patients in 2020. Previously patients sometimes had to wait up to 3 to 4 months for their medication to arrive. Recently, this has reduced to an average of 1 to 2 weeks from initial contact with a private medical cannabis clinic, until commencement of treatment.
As the industry has developed, more suppliers have entered the market, with products being imported from mainland Europe, Canada and Australia, and recently some products are beginning to be produced in the UK.
While prescriptions for medical cannabis have been slow in the UK, the CBD (cannabidiol) supplement industry is booming.
‘Many people have heard of CBD, and seen it sold online or over the counter, and think that it’s the same thing as medical cannabis, which it is not,’ said Dr Murray.
Low dose CBD is freely available online, or the high street, and can now be found in oils, vapes, creams, lip balms and even drinks. However, it is important to note that CBD supplements cannot be sold or marketed as a medical treatment, contain significant amounts of other cannabinoids such as THC and do not have to comply with the same quality standards as medical grade cannabis. It’s interesting to note however, that despite this, CBD supplements remain expensive. Per milligram of CBD can sometimes even cost more than a private prescription for medical grade cannabidiol.
Almost two years later, since the legalisation of medical cannabis in the UK began to gain traction, there are significant challenges that remain. There is still a knowledge gap not only in the general public, but within the medical community too. However as awareness and acceptance increases and supply challenges and costs improve, it’s reasonable to expect that patient access will continue to grow.
If medical cannabis is indeed at a crossroads, the road so far has been a slow and rocky one, but the future one ahead is starting to look a little smoother.
If you would like to learn more about Cannabis Access Clinics visit CannabisAccessClinics.co.uk.