Addressing the medical cannabis knowledge gap
The legalisation of medical cannabis in November 2018 was hailed as a landmark victory for the British medical industry, with scientists, researchers and patients alike all welcoming the change in law. However, whilst many took this as the beginning of a new progressive era in modern medicine, the reality is far removed.
Today regulations around the use and supply of medical cannabis remain vague and prescriptions are scarce. In fact, at the end of May 2019, Seema Kennedy, a public health minister, claimed that only six NHS prescriptions had been issued since the re-scheduling, with just ten private prescriptions issued between January and February 2019. This is despite there being over 80,000 UK doctors who are certified to prescribe medical cannabis.
For the handful of patients who have managed to obtain NHS prescriptions, many have had their access restricted by local clinical commissioning groups, on the basis that there is insufficient evidence for its efficacy, and many NHS trusts are refusing to honour prescriptions.
There is a clear gap between policy and implementation, and a noticeable need for cannabis education for healthcare professionals.
Unfortunately, not only does the cannabis knowledge gap mean health care professionals (HCPs) are holding patients back from potentially helpful options — such as medical cannabis — for treatment and pain management, but it also inhibits patients from getting the education they need to make informed decisions about their health.
Apprehensions remain from many of the health professionals who act as gatekeepers between the patient and medical cannabis. Increasingly, these apprehensions do not come from a wholesale rejection of cannabis as a medicine, but from a clear desire to better understand the intricacies of the drug before putting their signature to a prescription.
HCPs are currently relying on the interim guidelines issued by the Royal College of Physicians (RCP) and the British Paediatric Neurology Association (BPNA), which some have dubbed ‘unnecessarily restrictive’, ultra-cautious and open to interpretation, despite the health benefits claimed by users of medical cannabis
However, experts are used to having significant quantities of data from randomised control trials (RCTs) when they are drafting new guidelines.
To help combat this, in October 2019, the National Institute for Health and Care Excellence (NICE) will publish new guidelines, which may provide doctors with the information they need to confidently prescribe the drug.
Why is there a knowledge gap?
Little research has been done so far on the medicinal properties of cannabis given it was solely classified as a Class A drug until November 2018. This means there are currently no restrictions on the type of product that can be prescribed, apart from that it can’t be smoked.
HCPs are uncertain about the side effects and some of their perceptions stem from the drug’s legacy and negative cultural associations. Consequently, there is undeniably a lack of experience and training on the use and the evidence for Cannabis-Based Medicinal Products (CBMPs) within the medical community even at the specialist level.
Knowledge is disparate and often associated with a single condition or CBMP. Some of the largest gaps exist between current and desired knowledge of dosing and efficacy, the development of treatment plans, cannabis’ interaction with other medications, and the long-term impact of prolonged use on cognition and brain development.
Simply put, cannabis is not a “one size fits all” solution. There are a range of medical cannabis products available with varying cannabinoid profiles, with most currently focused on THC and CBD.
Building on this ambiguity, all cannabis-based products for medical use, except for Sativex, are unlicensed and can only be prescribed on a case-by-case basis by a physician once all other avenues have been exhausted.
Medicine of the last resort
There are two crucial issues at play here.
Firstly, that HCPs are being advised to only consider medicinal cannabis as a ‘last resort’ when in fact it may be the best treatment option available for a given condition. And secondly, as the drugs are un-licensed, doctors are not insured to issue prescriptions. Therefore, if a patient were to have a reaction, the doctor, or the trust the doctor works for, could be liable.
Unfortunately, because of this personal risk involved, many HCPs are reluctant to endorse medicinal cannabis until there is greater clarity surrounding the guidelines and evidence provided.
This is a travesty because there is vast anecdotal evidence that suggests medical cannabis has the potential to greatly improve and transform a number of patients lives. From treating seizures in childhood epilepsy and chemotherapy-induced nausea to alleviating symptoms in MS and easing chronic pain in adults, many patients have reported notable improvements upon switching their traditional treatment plans for medicinal cannabis.
Whilst multiple anecdotal stories can start to equate to a pattern of evidence, there are concerns regarding the quality of this evidence among HCPs. This is primarily regarding the potential of a direct link between cannabis use and psychosis.
Although there haven’t been any RCTs to warrant the argument that there is a causal relationship, guidelines from the Royal College of General Practitioners at the end of 2018 suggest that cannabis can trigger symptoms of psychosis in individuals who are schizophrenic or have a family history of psychosis.
However, whilst some studies claim that cannabis use can induce schizophrenia, the percentage of people diagnosed with the disorder has remained consistent. At a time when cannabis use is at an all-time high across the globe, these statistics don’t seem to add up. And whilst cannabis may cause temporary psychosis, so can caffeine, alcohol and nicotine. Whether it can directly trigger schizophrenic episodes is still up for debate.
A clearer understanding of the key elements of the cannabis flower is required, beginning with the key distinction between psychoactive and non-psychoactive compounds. THC is psychoactive, meaning it alters perception and thinking, while CBD is not. While THC is widely recognised for its recreational contribution, it also makes a significant medical contribution.
Cannabis is no magic bullet for everyone with one or more health issues. But for some people, it can be medicinally very beneficial.
The uncertainty and confusion amongst the medical community aptly demonstrates why there is a need for greater clinical and legislative knowledge surrounding medical cannabis backed by concrete science and studies.
In fact, The Commons Health and Social Care Committee has even suggested that ministers failed to clarify the practicalities of its medical cannabis legislation and this has left health care professionals at a loss.
Despite these acknowledgements, Matt Hancock, the health secretary, told MPs last month that medical cannabis will not need to be tested through RCTs in the UK in order to be licensed. Speaking at the Health and Social Care Select Committee, Hancock suggested that because the licensing process considers global evidence, localised trials will not be required. However, in spite of this the government funded National Institute for Health Research has already put in two calls for trial funding.
With confusion and mixed messages at every turn it is no surprise that medical practitioners are at a loss.
The National Institute for Health and Care Excellence (NICE) guidelines expected in October could be a real game changer in providing the right support system and information portal for HCPs.
Encouraging greater uptake among HCPs won’t happen overnight given the size and complexities of the NHS and knowledge transfer will be a gradual process.
Drawing on Canada’s experience many doctors do not, and even after a decade or more will not, prescribe CBMPs. However, a minority will, and the key to building a system of coverage that offers meaningful access is to connect those doctors to the larger pool of patients.
All medicine is, or should be, evidence based. As a natural product, medical cannabis does not entail the same approval process as synthetic drugs, but the industry depends and will continue to depend on research and evidence to support claims. This will enable HCPs to prescribe medical cannabis with confidence and a solid knowledge base.
At the end of the day, HCPs are regarded as trusted experts in society with access to portals of information, so they need education, evidence and the ability to share best practice based on their experiences
The transition of the growing acceptance of cannabis’ medical application and benefits provides an opportunity to develop and implement evidence-based education for HCPs. This should address the existing perceived knowledge gaps by collecting and disseminating information about the effectiveness of medical cannabis across qualifying conditions, evaluate the effectiveness of such strategies on clinical practice and, ultimately, on health outcomes.
About the author
Marc Davis is the president of Capital Markets Media (CMM) and co-founder of the Women, CBD and Medical Cannabis Conference. A former journalist and venture capitalist, he is regarded as a highly knowledgeable global cannabis expert and has worked with the biggest names in the cannabis industry, including Aurora Cannabis, Canopy Growth, Aphria, The Green Organic Dutchman, HEXO Corp. and iAnthus Capital.