We have followed closely on this blog the legal journey of medicinal cannabis towards at least partial acceptance in the UK. In an article last month, we outlined the government’s proposal to place cannabis-derived medicinal products in schedule 2 of the Misuse of Drugs Regulations 2001 (MDR) with effect from 1 November 2018. On the face of it, this provides official recognition that they have a therapeutic value and therefore enables doctors to prescribe them.
However, with the further announcement that guidance was to be issued to the medical profession before 1 November 2018, we cautioned that the re-categorisation was not going to result in ‘open season’ for the prescribing of medicinal cannabis. How true that’s proved to be!
The promised guidance, “Cannabis-based products for medicinal use”, has now been issued to doctors by the Department of Health and Social Care. It contains no surprises.
Initially at least, prescriptions will be available only from specialists – not GPs, junior hospital doctors or others with prescribing powers – although they clearly anticipate this will create problems from a practical perspective, stating “we are exploring how this may work under shared care arrangements, however in the first instance we expect specialist prescribing only.”
As expected, although on the strict wording of the regulations medicinal cannabis can be prescribed for any condition, the guidance provides that initially it will only be available to people suffering:
- Nausea caused by chemotherapy
- Chronic pain
In respect of the longer-term position, the guidance goes on to state that:
“To support specialist clinicians’ prescribing decisions, the National Institute for Health and Care Excellence (NICE) has been asked by the Department of Health and Social Care to produce a clinical guideline on the prescribing of cannabis-based products for medicinal use in humans. This guidance is expected by October 2019 at the latest.”
The interim position
To cover the intervening period, following a request from the NHS, interim advice on prescribing medicinal cannabis was requested from:
- The British Paediatric Neurology Association (BPNA) in respect of patients with certain forms of severe epilepsy;
- The Royal College of Physicians (RCP) in respect of both intractable chemotherapy-induced nausea and vomiting and chronic pain.
However, the RCP recommendation in respect of the prescribing of medicinal cannabis for chronic (non-cancer) pain is stark:
“There is no robust evidence for the use of [medicinal cannabis] in chronic pain and their use is not recommended.”
Referencing, among others, the Cochrane Review on medicinal cannabis earlier this year, the RCP state further that:
“Patients living with chronic pain often have complex comorbidities and a multidisciplinary approach to management that includes physical and psychological therapy rather than reliance on medicines alone is more likely to be effective.”
In other words, there is little prospect for chronic pain sufferers of obtaining a prescription for medicinal cannabis any time soon.
The reaction of the medical profession
This strong message from the RCP is underlined by members of the medical profession who, in the last couple of weeks, have become vocal in their opposition to the MDR re-categorisation, certainly as far as it applies to chronic pain. In a letter to The Times, doctors say that the move could fuel an addiction crisis. In a subsequent interview, a lead signatory to that letter, Dr Rajesh Munglani, a consultant in pain medicine, said:
“The issue is that cannabis as a painkiller isn’t very good. The latest evidence suggests that you have to treat twenty-eight people before one person gets significant relief from cannabis. But on the way to finding that one person out of twenty-eight, four people will be significantly harmed [through] mental health issues and the onset of psychosis.”