Why GPs Should Be Able to Prescribe Cannabis in the UK
Since the re-classification of cannabis-based products for medical use in November 2018, there has been greater awareness and interest into their possible medical and wellness potential among the public, as well as healthcare practitioners.
Doctors, and particularly GPs, are noticing an increasing number of patients enquiring about medical cannabis for a wide range of conditions. The reality, however, is that medical cannabis generally remains poorly understood by doctors and largely unavailable for patients seeking it to help with a chronic medical condition, when other drugs have failed. The majority of patients currently seeking medical cannabis on the NHS are not able to obtain a prescription, for a number of reasons, including the lack of physician understanding and restrictive guidelines from professional medical bodies – including NICE – which largely prohibits the prescribing of medical cannabis on the NHS.
At a time when doctors should be working together to deepen our understanding of cannabis for medical use, the UK government has only allowed specialist doctors (consultants) to prescribe medical cannabis, excluding GPs and thus dramatically restricting the pool of potential prescribers, despite the level playing field of knowledge shared by both specialists and GPs. This current approach has already led to a 2-tiered system with the emergence of private medical cannabis clinics appearing throughout the UK, which serve those individuals and families who can afford to pay for their treatment.
In countries where medical cannabis is well-established in clinical practice, like the US and Canada, it is mainly GPs and family doctors who are prescribing medical cannabis, often undertaking additional training to help serve their patients and are becoming experts in this field. Other countries where GPs make up the bulk of prescribers include Denmark, Italy, Germany, Netherlands, Malta, Luxembourg, Switzerland, Australia and New Zealand (to name just a few).
Why GPs Should Prescribe Medical Cannabis
The reason for this trend is that GPs tend to be a first point of contact for patients and are often the main doctor involved with overseeing and coordinating medical treatments and managing day-to-day symptoms. GPs tend to have a deep understanding of complex overlapping chronic illnesses and the quality of life issues facing patients who have exhausted all conventional drug options. They may also have a more holistic approach to care, rather than focussing on one system or organ in isolation.
Cannabis-based medicines have been demonstrated to play an important role in relieving suffering and enhancing overall quality of life when more conventional medications and therapies have failed. Many GPs will manage several patients who are suffering with debilitating conditions, such as neurodegenerative disorders or cancer. These patients may not have responded well to conventional treatments and cannabis-based medicines – as an adjunct or add-on treatment under compassionate grounds – seems entirely reasonable in these circumstances.
Cannabis-based medicines require an individualised approach to dosing and monitoring; it can take weeks, and even months in some cases, to find the optimal type of cannabis medicine, including the perfect ratio of THC vs CBD. From a practical point of view, particularly within the NHS, this close, regular monitoring and subtle dose adjusting could be problematic for specialists who often have long waiting lists for follow-up reviews. Again, it is GPs who are probably best positioned to be reviewing patients on cannabis medicines, making dose adjustments and optimising treatment regimes.
One of the most commonly requested indications for medical cannabis is for symptoms of chronic pain; there is growing evidence that cannabis offers a safe and viable alternative to currently licenced medications for pain control. One of the most comprehensive reviews on this topic was produced by the National Academies of Sciences, Engineering and Medicine in the US which confirmed the efficacy of cannabis for chronic pain in adults.
Cannabis vs. Opioids
GPs are often the first point of contact for patients suffering with pain and commonly prescribe opiate-based medications. Although opioids for acute pain and in palliative care can be effective, there is now strong evidence demonstrating that opioids are not a safe and effective treatment for most types of chronic pain, despite an alarmingly high number of prescriptions. At high doses and if misused, opioids can be fatal. The current opioid crisis in the US claimed 72,000 deaths in 2017 alone (approximately 130 Americans dying every day) and it is feared that it could reach equivalent proportions in the UK, if the current overuse of opioid painkillers continues.
The difficulty for the prescribing (and often time pressured) GP is that chronic pain can be notoriously difficult to treat and when not managed properly can have devastating impact on quality of life – both mental and physical health. Patients who are referred to pain clinics by their GPs can wait up to 1 year to be seen in some areas of the UK; such patients will often make multiple visits to their GPs and may end up being prescribed higher doses opioids or alternative medications associated with adverse side effects and/or high dependency rates.
Unlike opioids, cannabis is safe in overdose with no reported deaths and carries a lower addiction risk. Cannabis also has opioid-sparing properties which may allow patients to safely reduce dosages of stronger opioid medications. Multiple studies have shown that, when given access to medical cannabis, individuals currently using opioids for chronic pain significantly decrease their use of opioid use and report the benefits and side effects of cannabis preferable to opioids.
Many patients are already aware of the pain-relieving qualities of cannabis and are accessing this illicitly through the black market. It is estimated that around 1 million people in the UK are using cannabis for medical purposes. In addition to the risks associated with breaking the law, illicit street cannabis is often high in THC, as well as a number of other impurities which can have a detrimental effect on health. Products containing CBD, which can be bought over the counter in health food stores, are also being increasingly utilised by the public for general well-being, as well as self-treatment of many chronic conditions where patients may feel let down by conventional Western medicine drug-based options.
Overseas data has also demonstrated a reduction of benzodiazepine prescriptions, as well as other prescribed medications, with the appropriate introduction of medical cannabis. This should resonate here in the UK where we have one of the fastest growing rates of opioid use in the world and an estimated 1 in 4 adults taking an addictive medication, such as: strong opioid, zopiclone, gabapentinoid or benzodiazepine. In addition, inappropriate polypharmacy (when one or more drugs are prescribed that are not or no longer needed) has become the norm rather than the exception and is associated with a wide range of negative health and economic outcomes.
The cost of medicines for the NHS grew from £13billion in 2010-11 to £18.2 billion in 2017-18, an average growth of around 5% per year. If the NHS is to remain cost-effective, we should be focussing on the benefits of alternative treatments, including medical cannabis, which could allow us to safely reduce down and stop unnecessary prescriptions. Data from the US has demonstrated that there can be a 25% reduction in opioid prescriptions after introduction of medical cannabis for pain. Similar savings occur with regard to anti-convulsant drugs and less hospital admissions for complications of epilepsy.
Moving Forward for GPs
GPs have been receiving mixed messages regarding when and how to discuss medical cannabis with their patients, and given the growing patient interest in this subject matter – and rapid advances in the medical and scientific literature into cannabis and its potential medical benefits – there is a clear and urgent need to provide support in education.
Recognising the need for high quality education and peer support, The Primary Care Cannabis Network has been set up by GPs and for GPs across the UK who are interested in learning more about cannabis-based medical treatments and how these can be better understood, to serve the needs of patients. GP members can be kept up to date with the latest academic research, key papers, clinical guidance and legislation to ensure they feel confident to discuss, oversee and monitor a range of medical cannabis treatments.
Contributed by Dr. Leon Barron, Primary Care Cannabis Network