A Deep Dive into Drug Science’s Project Twenty21
On the 1st November 2018, cannabis was given the green light for use as a medicine in the UK. And yet 2020 rolls in and pro medical cannabis campaigners continue the tough battle to access the medication they, or their loved ones, need. This raises the question: if cannabis is now recognised as a medication, and doctors are legally able to prescribe it, why are so few able to access this medicine? Drug Science put together the medical cannabis working group to answer this question, and thus Project Twenty21, Europe’s largest medical cannabis registry, was born.
Barriers to access
Before delving into the Project Twenty21 concept, let’s outline the barriers between the patient and the medicine.
Firstly, this is a drug that has been demonised for decades. Creating a new and conflicting narrative, where cannabis is a medicine, will no doubt evoke a cognitive dissonance for many doctors; a highly anxiety-ridden mental state, possibly even one of anger. A shift in thinking is required within the medical profession, which is best achieved through increased access to education. The endocannabinoid system was not routinely taught in medical schools, to my generation or the one before, so it seems we are starting from scratch, with the added emotional obstacles mentioned above.
Cost has been another barrier to accessibility. With private prescriptions for medical cannabis costing in the thousands for a month’s supply, there has been no shortage of tragic stories depicting bankrupt families struggling to fund their child’s medicine. This issue is even more problematic than first observed; the very nature of the conditions expected to benefit from medical cannabis are traditionally over-represented in the lower socio-economical classes. It is no surprise that chronic pain and anxiety interfere with everyday functioning, thereby hampering earning potential. This gives rise to something of a Catch-22 situation; a patient needs the medication to work, but ironically needs to work to afford the medication.
So why is this vulnerable population unable to access medical cannabis through the NHS? At present, medical cannabis is only licenced in the UK for a handful of conditions which are eligible for NHS reimbursement. And even then, within these specific conditions one would have to find a doctor with the expertise to prescribe.
Another barrier is the lack of data. For the NHS to adopt this new medicine, there must be robust scientific evidence demonstrating efficacy and cost effectiveness. The department of health and social care have put out a call for more research focusing on medical cannabis, to shed some clarity on the therapeutics of this complex and stigmatised plant, in order to assess and approve – if shown to be safe and efficacious – on the NHS. It was in this climate that Project Twenty21 was conceived.
The T21 concept
Project Twenty was developed to address the challenge of controlling the cost of medication, supporting doctors, and building a database of health outcomes for those prescribed medical cannabis.
The registry system itself has been developed by a myriad of highest scientific expertise, ensuring that appropriate data points are collected during the clinical consultation to finally answer the primary questions about medical cannabis; where it is beneficial, and where it might cause harm. The project will ultimately provide robust scientific output for clinicians, patients, and regulatory bodies alike. The project has not been without challenges; private clinician time is a premium, so the balance between clinical time and data collection has required extensive consideration.
NHS access is currently limited to a handful of specific indications (severe treatment resistant epilepsy, MS related spasticity, and chemo-induced nausea and vomiting). But Project T21 recognises that cannabis Is used for a much broader range of conditions, and so must focus on the private sector, where medical cannabis can be prescribed off licence under specialist supervision. Up until now, for many, the cost of private medication has been an insurmountable barrier. To address the inevitable role of the emerging cannabis pharmaceutical industry in the UK, Project T21 has partnered with six licenced producers to provide a varied formulary of cannabis-based medicine at a significantly reduced cost of £150 a month. With hundreds of pounds taken off the previously monopolised market, the project can facilitate wider access to those in need.
Another challenge has been working with the regulations surrounding customs barriers and importing medical cannabis products into the country. Up until last month, THC products could not be stored in the country in any meaningful quantities to assist even moderate take-up of clinical applications. Importation could take up to six weeks, by which time patients often discovered their prescription was no longer valid. Good clinical practice requires vigilant doctors to be sensitive to symptom change and adjust medication regimes accordingly. With an undetermined wait of up to 6 weeks before patients start medication, a swift response to clinical presentation is a hefty ask. Since the launch of the project, regulations have changed to allow importation of up to three month’s supply of medication. This change, in part, contributes to a welcomed resolution.
The number of UK clinicians equipped with medical cannabis expertise continues to grow. With its colourful history of stigma and criminalisation, cannabis undoubtedly puts off many doctors. Five decades of narrative depicting the young first-time cannabis smoker, condemned to a resultant life-long schizophrenic illness, evokes in physicians’ images of lost medical licences. In recognition of medical colleagues’ apprehensions, educational resources have been provided, to not only promote safe prescribing, but to contain anxieties within the project’s research and development framework.
As a psychiatrist I recognise and anticipate the criticism that may follow regarding the use of medical cannabis to treat mental illness. My attention was recently drawn to a comment from a colleague, likening this new medicine to a glass of wine. As if to say, of course it will work on the surface, just like wine works to numb mental anguish, but what about the long-term dangers? Is it really a treatment, or just another stop-gap to supress and avoid the pain of the human condition?
The response to criticism such as this is to simply say – it is already happening. Mental illness occurs amidst a complex interplay of categorical disorders such as anxiety, PTSD, and chronic pain; all of which are so often underpinned by trauma, oppression, marginalisation, and social inequality. Such conditions may arguably be symptoms of a sick system, where societal distress has over time become localised in the individual. No wonder many turn to substances, to escape the pain and apathy of an unjust society.
Self-medication with cannabis has, sadly, for this population of people who find it effective as a medicine, become a focus of stigmatisation. Those who have failed to find relief in traditional medical interventions, and choose to use this substance in its illicit state, are often re-traumatised by societal shame, which further marginalises them and perpetuates both mental and physical pain. If the medical profession is able to evaluate and validate this management strategy, not only do we validate our patients suffering, but we break the cycle of shame and trauma, and provide a space to heal.
Contributed by Dr. Chloe Sakal, MBBS BSc MRCPsych, Clinical Director of Project Twenty21
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