The United Kingdom legalized medical marijuana in November 2018 but the program has been beset by access issues from the beginning. The vast majority of patients remain without access to legal medical cannabis, and the vast majority of those who do have prescriptions received them privately outside of the NHS.
An estimated 1.4 million Britons use illicitly sourced cannabis for medical purposes, despite non-medical cannabis being considered a Class B drug in the United Kingdom. Possession can be penalized by up to three months imprisonment and/or a fine.
Since November, 2020, however, patients who are self-medicating have the potential to avoid legal complications through an initiative known as “the Cancard.”
Medical authorities in the country have long stated that they have dragged their feet on expanding medical cannabis access due to a paucity of research into its safety and effectiveness.
While an estimated 1.4 million people in the UK use illicitly sourced cannabis for medical purposes, little more than a handful of Britons have received prescriptions through the NHS, according to a 2020 report by the Centre for Medical Cannabis. Another 2,500 patients in the UK received private prescriptions, a second report found.
An alternative to prescriptions: The Cancard
Since late 2020, the Cancard has allowed Britons without a medical cannabis permit to possibly avoid legal issues as long as they have been diagnosed with one of more than two dozen qualifying conditions.
Not quite a get out of jail free card, the Cancard is a credential that can be shown to a police officer to indicate that the person uses cannabis for medical reasons, helping the officer practice better discretion regarding whether or not to proceed with a possession charge. The Cancard is meant for Britons who do have a medical condition they are treating with cannabis, but who cannot afford the yearly registration fee or have been unable to gain approval.
In order to receive the card, a patient over the age of 18 must apply on the Cancard website using the following steps.
How to apply for a Cancard
- Receive a doctor’s diagnosis
Before applying for a card, the applicant must receive a diagnosis from their doctor that shows they have one or more of the qualifying medical conditions for medical cannabis in the UK. The diagnosis must also show that the patient has tried two other prescriptions or cannot do so because of side effects or dependence concerns. The physician does not need to recommend cannabis or be in favor of it as a medical treatment, they only need to state that the patient has the medical condition or conditions in question.
- Collect the required documents
- Passport or driver’s license
- Your NHS number
- General practitioner’s name, email address, and practice
- Summary care record — in particular, the page that shows your active conditions
- Upload your documents online
- Pay the administrative and annual fees
- The Cancard requires a one-time administrative fee of £10, as well as an annual fee of £20. People receiving public benefits can get the administrative fee waived by Cancard.
Medical cannabis in the UK — early days
A legal, nationwide medical cannabis program in the United Kingdom might have taken much longer to come to fruition if not for the high profile cases of two young boys, Billy Caldwell and Alfie Dingley, both with untreatable, severe types of epilepsy. Both children found relief from their seizures while traveling abroad where, under the care of specialist pediatric neurologists, they were given cannabis-based medicines.
Their cannabis-based medicines were confiscated upon re-entering the UK, however, because they contained higher levels of THC — the intoxicating compound in cannabis — than the law allows. Both faced dangerous deteriorations in their health without their medicines. A media storm ensued, until the government legalized the use of medical marijuana.
Then Home Secretary Sajid Javid stated at the time that, “having been moved by heartbreaking cases involving sick children, it was important to me that we took swift action to help those who can benefit from medicinal cannabis.”
Since the change took effect, specialist doctors have been able to prescribe cannabis-based medicines. Despite initial excitement from patients, however, stringent criteria and advice by governing bodies not to prescribe cannabis-based medicines has meant that prescriptions on the NHS are severely restricted.
What are cannabis-based medicines (CBPMs)?
According to NHS England, a cannabis-based medicinal product fulfills the following criteria:
- The product is or contains cannabis, cannabis resin, cannabinol or a cannabinol derivative
- It is produced for medicinal use in humans; and is a product that is regulated as a medicinal product or an ingredient of a medicinal product.
- CBD oils currently sold as nutritional supplements in the UK are not considered CBPMs
- Cannabis-based medicines may not be smoked as smoking weed makes it a Schedule 1 drug
All medical cannabis and medical cannabis products are considered unlicensed drugs, also known as specials. This is because they have not gone through the gold standard three-stage clinical trials necessary to prove the correct dosage, efficacy, and safety of the licensed medication. As a result, CBPMs can never be prescribed as a first-line drug, and are only considered after all existing licensed options and off label medication (licensed drugs approved for other conditions) have been exhausted.
This is very frustrating for patients who believe that a cannabis product will help their illness or indeed have already found relief by taking marijuana acquired illegally or abroad. However, this is standard protocol for doctors prescribing unlicensed drugs.
This is not the case for already approved cannabis-based drugs such as Sativex, although NICE has ruled that Sativex is not cost-effective and is therefore not available on the NHS as a treatment for pain and spasticity in multiple sclerosis.
What conditions qualify for a medical cannabis prescription?
The NHS states: “As with prescribing any other unlicensed medicine, it is a clinical decision to determine the most appropriate medication or course of treatment to prescribe for a patient, having taken into account the patient, the clinical condition, the clinical evidence of efficacy and safety and the suitability of licensed medicines.”
In effect, this means that if the prescribing specialist doctor believes there is sufficient proof of efficacy for cannabis as a treatment for a particular condition, they may prescribe medical marijuana.
However, most NHS doctors follow NICE guidelines when prescribing medication, particularly with something as unknown to them as cannabis-based medicine. NICE will only recommend treatments that are evidence-based and have been proven cost-effective.
Unfortunately, the recently released draft NICE guidance for prescribing cannabis-based medicines is even more restrictive than the initial NHS position. Citing a lack of sufficient evidence, they only recommend the prescription of Nabilone, a synthetic THC drug, for chemo-related nausea and vomiting, and explicitly say no cannabis product should be prescribed for chronic pain unless part of a clinical trial.
For the moment, NICE also does not recommend cannabis-based medicines, including pure CBD (Epidiolex), for severe, intractable epilepsy, based on lack of evidence and a higher than acceptable level of adverse events in clinical trials. That said, they do not recommend against CBPMs for epilepsy, stating “this would restrict further research in this area and would prevent people who are currently apparently benefiting from continuing with their treatment.”
Thankfully, NICE has recommended that further research be carried out examining the clinical and cost-effectiveness of CBPMs in fibromyalgia or persistent treatment-resistant neuropathic pain in adults, chronic pain in children and young people, CBD for severe treatment-resistant epilepsy, THC in combination with CBD for severe treatment-resistant epilepsy, CBPMs for spasticity, and intractable nausea and vomiting.
Prior to the release of the NICE guidelines, very ew patients had been prescribed CBPMs through the NHS. Many patients have been turning to the private health sector, which is not bound by the same financial restrictions as the NHS, although private specialists doctors and clinicians in medical marijuana clinics must still only prescribe where there is a clear, unmet clinical need. However, the list of conditions suitable for the prescription of CBPMs may be broader and include chronic pain, fibromyalgia, neurodegenerative diseases, migraines, PTSD, and anxiety.
Currently, NHS doctors have only been recommended to prescribe Nabilone in cases of intractable chemotherapy-induced vomiting and nausea.
Private consultants/specialist medical marijuana clinics may consider the following indications as appropriate for medical cannabis but only when there is a proven, unmet clinical need:
- Chronic pain
- Degenerative disc disease
- Nerve conditions
- Spinal cord injury/disease
- Post-operative surgery pain
- Nausea and vomiting through chemotherapy
- Cancer pain
- Alzheimer’s disease symptoms
- Chronic fatigue syndrome
- Motor neuron disease
- Multiple sclerosis
- Muscular dystrophy symptoms
- Parkinson’s symptoms
- Traumatic brain injury
- Eating disorders
- Obsessive-compulsive disorder
- Post-traumatic stress disorder
- Sleep disorder
Who can prescribe medical cannabis in the UK?
By law, medical marijuana cannot be prescribed by a general practitioner (GP). Prescriptions must only be issued by consultants listed on the Specialist Register of the General Medical Council specializing in the health condition for which you would like to receive medical cannabis. A GP may refer you to a consultant, but unfortunately, that doesn’t mean the specialist will agree to prescribe medical cannabis for the reasons outlined above.
One must also take into account the general lack of knowledge within the NHS regarding the use and efficacy of medical cannabis. For over 70 years doctors have been told that marijuana has no therapeutic benefit and is little more than a gateway drug. Doctors are also trained in practicing evidence-based medicine, only prescribing licensed medication which has been proven safe and effective, and where there is a recommended dose.
While anecdotal reports for the benefits of medical marijuana abound, clinical research is limited. Furthermore, there is no one-size-fits-all dosing regime for medical cannabis. Consequently, it’s unsurprising that doctors are resistant to changing their opinion on medical marijuana overnight.
Can you get a prescription for marijuana from a private health care facility?
Patients are turning to private health care providers where some specialists are showing greater willingness to prescribe cannabis-based medicines. A number of private medical cannabis clinics have opened around the UK, but again, unless your condition has not been helped by standard medications and there is clear evidence of efficacy, even private clinics are not able to prescribe CBPMs.
Of course, seeking medical cannabis privately will incur a cost, not only for the consultation and follow up treatment but for the CBPMs themselves, which can amount to over £1000 per month. Unfortunately, right now, none of this is covered by private health insurance.
Who can supply cannabis-based medicines in the UK?
By law, doctors can only prescribe a 30-day supply of medical marijuana which can technically be provided by any pharmacy. A prescription will state the type of marijuana medicine (oil, flower, capsules), how much THC or CBD is contained, the dose, and how often it should be taken.
Any CBPM supplied to patients in the UK must be approved and licensed by the Medical Healthcare Agency (MHRA) and Home Office, meeting strict criteria such as Good Manufacturing Practice (GMP).
The reality is that, as CBPMs are unlicensed, not all pharmacies will be able to supply the medicine, so you may need to approach various before finding success. According to the Centre of Medical Cannabis, ordering the medicine will take between two days to two weeks.
Again, like doctors, pharmacists are largely unfamiliar with CBPMs, so patience will be required.
If you are a patient in the UK hoping to get a prescription for medical marijuana, it would be easy to feel disheartened about the slow progress being made. Thankfully, groups such as the United Patients Alliance, End our Pain, and the Centre for Medical Cannabis are lobbying for a more open and sensible approach to prescribing CBPMs.
With the reclassification of cannabis and its derivatives to Schedule 2, we can expect more clinical trials proving medical cannabis as an effective treatment for a host of health conditions. All of which should mean that in the near future, getting a prescription for medical cannabis both through the NHS and in private clinics will be easier.
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