When medical cannabis became legal in the UK in July 2018, activists and patients around the country celebrated, imagining a future when they could finally access cannabis-based medicines. Unfortunately, a cautious initial response by both the Home Office and the National Health Service (NHS) means that in reality, very few people are considered suitable. This article outlines the criteria for getting a medical marijuana prescription through the NHS, what steps you need to take in order to request a prescription, and whether other options lie in the private sector.
Medical Marijuana in the UK — Early Days
The legal provision of cannabis-based medicines in the UK is in its infancy. Only two years ago it seemed an unthinkable dream that patients might be able to access medical cannabis without turning to the black market or traveling to countries like Holland or Canada where medical marijuana is legal.
Cannabis was classified as a Schedule 1 substance; denying its therapeutic benefit, and stifling any medical marijuana research. That all changed with the high profile cases of two young boys (Billy Caldwell and Alfie Dingley), both with untreatable, severe types of epilepsy. Both children had found relief from their seizures after traveling abroad where, under the care of specialist pediatric neurologists, they received prescriptions for cannabis-based medicines.
Because their medication contained over the legal limit of the psychoactive compound tetrahydrocannabinol (THC), on entering the UK, their medicines were confiscated, making a dangerous deterioration in their health likely. A media storm ensued, until finally the then Home Secretary, Sajid Javid, ruled that cannabis could no longer be classified as a Schedule 1 drug, and with it, legalized the use of medical marijuana.
Initially, patients had to apply to a specialist panel through their consultant for a prescription. However, since 1st November 2018 specialist doctors have been able to prescribe cannabis-based medicines. Despite initial excitement from patients, stringent criteria and overall advice by governing bodies not to prescribe cannabis-based medicines (CBPMs) has meant that CBPM 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 weed, cannabis resin, cannabinol or a cannabinol derivative
- It is produced for medicinal use in humans; and
- It 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 CBPMs 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 CBPM 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 the National Institute for Health and Care Excellence (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 CBPMs 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 CBPM 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 the NICE guidelines, only six patients had been prescribed CBPMs through the NHS. If the guidelines remain unchanged in the final document due to be released in October 2019, it is likely very few further patients will receive medical marijuana prescriptions on the NHS until their recommended clinical research is carried out.
As a result, 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 CBPMs. 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. Not only that, there is no one-size-fits-all dosing regime for CBPMs. Consequently, it’s unsurprising that doctors are resistant to changing their opinion on medical marijuana overnight.
As a result, patients are turning to the private health sector where some specialists are showing greater willingness to prescribe CBPMs. A number of private medical cannabis clinics have opened around the UK, but again, unless your health condition has not been helped by standard medication and there is clear evidence of efficacy, they will not be 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.