Medical cannabis (prescription cannabis-based medication) has been legalised in a number of countries across the world, most notably Canada, many European countries, and the UK. But, even though there are provisions for medical cannabis in the UK (and have been since 2018), there have been surprisingly few prescriptions for the approved, cannabis-based medications Epidyolex, Nabilone and Sativex.
What is medical cannabis?
The term medical cannabis (often used interchangeably with medical marijuana), is any prescription-based medicine that contains cannabis. It’s different to CBD oil (derived from industrial hemp) as it’s use is strictly restricted and only available to a very small number of patients, while CBD oil is legal in the UK, and can be bought at almost any health store or purchased from a number of online shops.
Medical marijuana makes use of the more than 100 different cannabinoids in the plant to treat specific diseases and conditions. The two most well-known cannabinoids (and the two used in medicine) are THC, or Delta-9-tetrahydrocannabinol, which produces a psychoactive ‘high’ and CBD, cannabidiol, which is non-psychoactive.
The most common uses for medical marijuana include:
Based on numerous studies, there is strong evidence to support the regular, moderate use of cannabis. It can help to delay the onset as well as the progression of the disease. Medical cannabis is also being used to treat other neurodegenerative conditions.
The body of research is limited when it comes to cancer treatment in humans, with the notable exception of basal cell carcinoma. However, there is overwhelming evidence of anti-cancer properties in human cell lines (in vitro) and animal (in vivo studies).
In terms of the palliative (pain-relieving) value that medicinal cannabis offers, it has been shown to greatly benefit many cancer patients.
Ongoing, chronic pain affects millions of people across the UK, and medicinal cannabis has been proven to help. Evidence for this includes clinical trials (using placebos as controls), looking specifically at the efficacy and safety of medicinal cannabis in treating chronic pain.
Studies looking at Crohn’s and other forms of inflammatory bowel disease (including ulcerative colitis) show conclusively that cannabis can help resolve patients’ symptoms. In one study, over 50% of patients with Crohn’s disease achieved complete remission, and over 90% achieved substantial improvement.
Most of the studies look at the use of Epidyolex to treat sudden seizures. This is now considered a treatment for severe epilepsy in the UK when all other interventions have failed.
For people living with multiple sclerosis, studies investigating the use of cannabis as a palliative treatment show that it is a good option. There is also promising research underway that looks at the curative effects of cannabis in promoting myelin sheath repair.
Epidyolex, a full cannabis plant extract product but containing over 99% CBD, has been licenced in the USA for the treatment of Dravet and Lennox Gastaut syndromes.
What’s happening in other countries?
Medicinal cannabis is available for patients with a prescription in most European countries including Austria, Germany, the Netherlands, Italy, Portugal and Spain. It’s also available in Canada, Finland and the Czech Republic.
In the USA in 34 states, doctors can issue ‘recommendations’, an alternative to prescriptions. This gives an estimate of over 500 million people in developed countries who have legal access to medicinal cannabis.
In the US specifically, the FDA has approved the THC medications dronabinol and nabilone, marijuana-based medicine nabiximols (also available in the UK, Canada and many European countries), and CBD-based Epidolex.
These numbers make the slow uptake of medicinal cannabis in the UK even more noticeable, where as many as one million people would benefit from using cannabis for health reasons.
Why are doctors not prescribing medical marijuana in the UK?
Medicinal cannabis is legal in the UK, at least theoretically, as cannabis-based products were moved from Schedule 1 to Schedule 2 in 2018 under the Misuse of Drugs Regulation 2001. This was done in response to a successful publicity campaign around two children with severe epilepsy.
Unfortunately, to date, the number of prescriptions continues to be very low due to:
- The history and negative associations with cannabis
- The need for further research
- The knowledge and education of health professionals
- The potential health risks and adverse side effects
- The liability that doctors take on if they prescribe cannabis
Who can (theoretically) access medical cannabis in the UK?
Medical cannabis is only available by prescription and will only be given in a very select few cases. It can only be considered when other treatments are not suitable or have not been effective.
The three conditions are:
- Epilepsy, for children and adults suffering from rare, severe forms of epilepsy
- Vomiting or nausea, for adults (following chemotherapy treatment)
- Multiple sclerosis, for people with muscle stiffness and spasms caused by MS.
Epilepsy in children and adults: Epidyolex
Epidyolex is prescribed for people with rare forms of epilepsy including Lennox-Gastaut syndrome and Dravet syndrome. It contains CBD, a compound found in cannabis with a range of medical benefits. There is no THC in the products and it will therefore not get you high.
Chemotherapy patients: Nabilone
A common side effect of chemotherapy treatment is nausea or vomiting. In these situations Nabilone may be prescribed to relieve the symptoms, but only where other treatments have not been effective (or are not suitable). Developed to mimic the effects of THC (the psychoactive cannabinoid found in cannabis), it is available in capsule form and is often described as a “man-made form of cannabis”.
Multiple Sclerosis: Nabiximols (Sativex)
Nabiximols (Sativex) is licensed in the UK for people who have muscle spasticity related to multiple sclerosis. It can only be prescribed to those who have not responded well to other treatments. The medicine is cannabis-based and is sprayed directly into the mouth.
Why is access to medical cannabis so restricted even though it is legal?
There is not yet sufficient evidence that the use of cannabis products containing THC is low-risk enough to justify it’s widespread use. There are clinical trials underway, but until the results are available and peer-reviewed, it is not likely that the UK government will change their stance anytime soon.
Concerns about the risks of THC include:
- Dependency (or addiction), although the risk of cannabis addiction is very low when a specialist healthcare provider controls its use.
- Psychosis, regular cannabis use (sometimes even once-off) can trigger schizophrenia.
But that doesn’t cover Epidyolex which is a ‘pure’ CBD-only product (with no THC). For those suffering from rare forms of epilepsy there is some good news. New provisions made through the Misuse of Drugs Regulations came into force on June 24, 2020. According to the government’s circular that announced the change, “by placing Epidyolex in Schedule 5 to the 2001 Regulations, it is no longer subject to the prohibition on importation, exportation and possession under the 1971 Act.” The effect of this is to greatly reduce administrative processes for companies seeking to supply the medication to patients with severe epilepsy.
Epidyloex is made by London-based GW Pharmaceuticals, and their CEO, Chris Tovey, released a statement saying “”The decision to move Epidyolex to a low level of control is an important one for patients, their families, healthcare professionals, pharmacists and the (National Health Service) as a whole – reducing costs and ensuring the medicine can be dispensed more easily,”
The downsheduling of the medication means that there is a lower level of control, and the prescription validity has been extended so prescriptions can now go beyond the Department of Health and Social Care’s 30-day supply recommendation. This makes the medication more accessible, and reduces time and financial costs for patients and healthcare providers.
How does a person with a qualifying condition access medical cannabis?
With difficulty! Cannabis-based medication is not available from a GP, it can only be prescribed by a specialist doctor at a hospital. And a doctor will only consider prescribing medical cannabis if all other treatment options have been exhausted. The only exception to this is Epidyolex.
What is the future of medical cannabis in the UK?
Since November 2018, when the government changed the law to allow the legal prescription of cannabis-based medicinal products (CBMPs), there have only been around 400 private prescriptions and two NHS prescriptions. When you consider the number of people struggling with epilepsy, suppressed appetite (following cancer treatment), multiple sclerosis and long-term pain, the numbers are very low. The government’s response has been predictably slow and vague, and neglects to take into account the medical grounds for a cannabis prescription. However, it is likely that there will be an increase in prescriptions for Epidyolex following its downscheduling.
There is also hope that this may change going forward with this white paper that was recently put forward by a group of scientific experts. It details the accelerated integration of medical cannabis into the UK healthcare system.