Drug experts on the new guidance for medicinal cannabis
Opening up access to medicinal cannabis was welcomed by many as a bold policy move, but this hasn’t been matched by the reality for those trying to obtain these products. Only a few patients have been able to access medicinal cannabis on the NHS. Others have secured access though expensive private prescriptions – albeit still in small numbers.
Rescheduling cannabis-based products for medicinal use was a legal move which meant that doctors could prescribe, but not necessarily that they would prescribe. Indeed, doctors and their professional bodies have been cautious – waiting for The National Institute for Health and Care Excellence (NICE) to publish its clinical guidance on the topic. As with other guidance, it serves as advice rather than instruction, but doctors working in the NHS very rarely contradict NICE recommendations.
What the guidelines say
In short, NICE has concluded that more research is needed before it can recommend the use of cannabis-based products for medicinal use.
To reach this conclusion, NICE examined thousands of studies and found the majority of evidence on cannabis-based products for medicinal use was poor – and much weaker than is often popularly discussed. So despite high profile stories of individual patients benefiting from cannabis, NICE hasn’t recommended that such treatments should be provided on the NHS.
Not for the first time concerns about the misuse of these products were also raised. Some doctors are worried about mental health effects – with fears that patients could become dependent on the cannabis products prescribed, or that prescribed cannabis products will be sold on the black market. But given the ease with which cannabis can be obtained illicitly, it would be illogical for anyone to opt for the onerous route of obtaining a legal prescription for cannabis.
Research from the US suggests there is only a weak relationship between the introduction of medicinal cannabis products at state level and changes in adolescent use more generally. Illicit sales and distribution of prescribed cannabis in adults is usually a result of weak clinical and regulatory oversight and poor patient monitoring – something which would be of much less concern in the UK’s strongly regulated medicines system.
In the guidelines, NICE also highlights the importance of professional education, as current understanding of cannabis-based medicines in prescribers is low. The commercial sector is very active in promoting cannabis and is now beginning to provide professional education as well. But it’s important that education and training is developed and delivered by independent providers who are not influenced by commercial pressures – and that training is accredited and overseen by a certifying body so the potential benefits of cannabis are not overstated.
What this mean for patients and doctors
The hope was that patients and doctors would now have a list of recommended cannabis products and dosing regimes, matched with the conditions they can treat – as seen in some other countries. But this has not materialised. In some ways though, it may have been an unrealistic outcome. Naturally, excitement and interest in cannabis led to raised patient expectations and demand. But when cannabis was promoted as a medicine it also became subject to the same system of checks and balances as other medicines, and the same questions of evidence and affordability.
So while the new guidelines describe how the process of accessing and prescribing such products should be managed, it’s unlikely many NHS patients or their doctors will be navigating this system – at least for the time being. This will no doubt disappoint many patients and some doctors.
NICE will review these guidelines as new evidence emerges. But it’s worth keeping in mind that the original decision to change the law on cannabis was led more by political than clinical considerations. So it would be naive to think any change in the new guidance would be instigated purely by newly emerging evidence. Commercial and political interests will also play a part.
Some patients may receive cannabis medicines as part of these new clinical trials. But a lack of prescriptions may leave many other people with a difficult decision – should they break the law in the pursuit of something they think will improve their health? Only time will tell whether the police and courts will begin to take into account people’s claims they are buying and growing cannabis to self-treat a medical condition.
Harry Sumnall receives and has received funding from public grant awarding bodies for alcohol and other drugs research. He was an unpaid member of the Advisory Council on the Misuse of Drugs (ACMD) when the recommendation to reschedule cannabis was made and is currently an unpaid co-optee of the ACMD Working Group that is developing further recommendations on cannabis-based medicinal products and evaluating the impact of rescheduling. Please note that the contents and framing of this article are deliberately not based on any privileged information emerging from that work. Harry received travel expenses to contribute to a public health discussion panel at the 2018 Cannabis Europa conference in London. He has sat on previous NICE guideline development groups unrelated to medical cannabis. This article represents his personal views only.
Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.