Legislative Changes to Allow the Prescribing of Cannabinoids

This informal CPD article, ‘Legislative Changes to Allow the Prescribing of Cannabinoids’, was provided by Andrea Last, Director and Clinical Lead at Jenner Medical Consultancy, formed by three healthcare professionals looking for a new challenge, with combined experience in the NHS, private practice, pharmacy, hospital, travel clinics and Cannabis Clinics who want the name to not only be synonymous with training and embedding protocol but also as a go to for assistance and support.

Introduction

This article is an introduction into the changes surrounding the possession of cannabis. Much has changed in the last five years, changes a person not working in the field of medicine will be aware of. On the 26th July 2018, the Home secretary announced, following a recommendation from The Chief Medical Officer, and an ACMD review, that cannabis derived medicinal products would be rescheduled. Following this, in the autumn of the same year, the law changed to allow the prescribing of cannabis-based products.

Medical Cannabis and the Law

Due to a lack of knowledgeable staff in GP practices and wider NHS, patients prescribed cannabinoids often join an online forum where they can gain personal recommendations of strains proven to successfully treat a condition they may have, and read reviews of, sometimes costly vapes before purchasing. This is having both positive and negative consequences, positive is the patient feedback in an area of medicine that is still very much in its infancy, and a forum gives patients the room to be open without fear of prejudice or bigotry. The negative, unfortunately, is that clinic error, discrepancies in product quality and reactions of unknowledgeable individuals, including the police are shared and debated. A perusal of these forums will demonstrate the vastly different experiences these patients have when dealing with the police.

A Mayor of London Assembly document titled ‘Possession of Cannabis’ was last amended in January 2022 and gives no reference to cannabis possession via a prescription.¹ It states the action to be taken are:

• A warning to be given.
• A fixed penalty to be issued.
• Subject charged to proceed to court.

It goes on to state, “Once all paperwork and systems are updated the drugs will be disposed of through approved methods”.

While we can sympathise with patients’ frustrations, we also must acknowledge the police are doing what they have been trained to carry out. An update is very overdue.

Cannabis users can be split into two groups:

• Recreational users
• Medicinal users

There are, of course, further elements, an example being people that are using cannabis medicinally now who have had prior experience of it recreationally. In amongst this cluster will be people with “previous” (people already known to local police for being found to be in possession at some stage in the past), some of these may initially come across as antagonistic as they recall past experiences.

There are a small number of patients who are completely new to cannabis, finding themselves at a more mature age with a debilitating condition for which previous prescribed medication has not proved successful. These people will need a sensitive approach. In my experience, patients that are cannabis naive will venture slowly, starting with CBD oil, then maybe moving onto THC, possibly a cartridge to begin with. It would be some time before they would be confident enough to handle flower, having found a form of treatment that works, they may be battling with years of conditioning regarding the illicit use of cannabis. At this point, a negative encounter with the law would have a very detrimental effect and may result in them sacrificing their health and wellbeing.

Medical cannabis Clinics

Currently patients are unable to obtain cannabis-based medication from their primary care provider.  It can only be prescribed privately by a consultant on the specialist register through a CQC registered clinic. There are, at the time of writing 31 clinics in the UK including The Channel Islands.

Globally the route to administer cannabis has many iterations:

• Smoking (In a roll up {spliff, joint} with or without accompanying tobacco)
• Smoking (In a pipe or bong) NB It is illegal to smoke cannabis that is prescribed medicinally in the UK.
• Vaping

These methods will see cannabis enter the blood stream via the lungs.The lungs are lined with millions of tiny air sacs called alveoli. Since alveoli has a large surface area, it’s easy for THC and the other compounds to enter the body.

• Oil (taken sublingually – the area under the tongue has many tiny capillaries, or small blood vessels which allow medication to be absorbed directly into the bloodstream.)
• Edibles 

This method see cannabis enter the bloodstream via the liver, called the First Pass Effect. THC is converted into 11-OH-THC and into a water-soluble form so the body can utilise it and then excrete it effectively.

• Cream and balm applied topically.

At present prescriptions in the UK will be for oil, both CBD and THC, flower to vape and prefilled vape cartridges, individuals should be able to demonstrate a working vape. With research and development ongoing we expect to see much more varied choice in the future, including administering better pain control in end-of-life care.

The patient demographic is incredibly diverse, in my experience of working with clinics I have dealt with the housebound disabled, people at the height of their career managing debilitating arthritis, those suffering with PTSD following a life changing traumatic event and, sadly, those at the end of life. Most of them will approach a clinic personally, with a few being referred by their GP or consultant.

Conditions treated vary very little between the clinics and a full list can be found on the website of any of the UK clinics, patients may, however, need to research the specialist consultants with that clinic to ensure there is one with them that meets their needs.

Patients will, at the onset be asked to complete a health questionnaire, at this time they will give consent for their primary care provider to be approached so the clinic may view a summary care record. Patient must meet conditions which includes a confirmed diagnosis and a history of previously tried medication (there must be at least two medications that have not been successful at treating the condition or have been stopped due to adverse side effects). Careful consideration is given to a patient’s mental health, a diagnosis of psychosis whether current or historical will exclude them. There are also certain medical conditions which necessitate stringent follow ups and monitoring, an example is the medication Warfarin, THC and CBD are metabolised by CYP3A4 and CYP2C9, Warfarin is metabolised by CYP2C9, if it is unable to work on both Warfarin and medical Cannabis INR may go up risking a bleed.

They will also be asked about lifestyle with particular focus on whether they drive or work with machinery, if they work in an environment where drug testing takes place we encourage them to discuss their new medication with their HR department.

Patients will have access to an online portal where they can find copies of their prescriptions, they can also request travel letters to enable them to take their medication on holiday, we always recommend communication with the relevant embassy as the legality varies from country to country. I have also worked with clinicians to produce a statement to support patients facing legal proceedings, not just for in possession, but also for tribunal and family law.

The relationship between cannabis clinic and primary care provider is important but not without its difficulties. The medical profession has, for a long time, labelled cannabis as a ‘gateway drug’, wrongly assuming that in the hands of anybody it would lead to experimentation with other substances. Some GP’s are curious but the majority of them will admit to knowing very little about cannabinoids, one in particular was horrified at the prospect he may be called upon to prescribe at some time in the future! While the clinic will always share details of the consultation with the primary care provider two-way communication must be encouraged, after the initial registration and receipt of medical summary clinics will rely on the patients GP to notify them of changes.

Communication would always be welcome from the police, whether that be to check on a patient’s registration with the service or to inform us of concerns – whether they be mental health or safeguarding. Clinics and pharmacies are also at risk from unwelcome attention including attempts at illegal entry and stalking of staff members, a good relationship with local police stations is always important.

In terms of advancement in medicine the position we find ourselves in at this time is nothing short of historic, we have come a long way since the dangerous drugs act of 1965, the 2019 general elections saw parties pledging “more clinical trials for cannabis in medicinal use”. The future is looking at more changes taking place, the US now has 24 states where recreation use of cannabis is legalised and a short walk-through New York will demonstrate the extent of availability, this suggests a future move away from private clinics which would in turn make medical cannabis an option for more patients who at this time cannot afford clinic fees.

We hope this article was helpful. For more information from Jenner Medical Consultancy, please visit their CPD Member Directory page. Alternatively, you can go to the CPD Industry Hubs for more articles, courses and events relevant to your Continuing Professional Development requirements.

References:

1. https://www.london.gov.uk/who-we-are/what-london-assembly-does/questions-mayor/find-an-answer/possession-cannabis