17 Nov Medical Cannabis: The View From Primary Care
GPs are the first point of contact for most patients and have noticed a substantial increase in the number of expectant patients requesting medicinal cannabis.
The rescheduling of cannabis for medical purposes in 2018 was seen as landmark moment for patients and indicated a shift in medical policy and attitude within the UK. Heightened media attention has brought medical cannabis as a legitimate therapy firmly into the mainstream and into the public consciousness. Two years on from legislation change however, medical cannabis remains a subject that is generally poorly understood by most doctors and is largely inaccessible for patients through the NHS.
GPs are the first point of contact for most patients and have noticed a significant increase in the number of expectant patients requesting medicinal cannabis. Research carried out in 2019 surveyed over 2,000 GPs and found that 61% of GP partners reported an increase in medicinal cannabis queries. In a more recent preliminary poll undertaken by the Centre for Medicinal Cannabis, (CMC) GPs were asked how often they encounter patients using cannabis to relieve symptoms or those enquiring about a medical cannabis prescription, with the majority responding either on a weekly or monthly basis.
The mismatch between patient’s expectations and what is actually available to them continues to be a major problem and this can be a challenging subject for GPs to navigate within a clinical setting.
I have encountered patients who have reported how they have been made to feel uneasy and uncomfortable when bringing up the subject of cannabis use for medical purposes with their own GPs and have even been on the receiving end of negative or dismissive comments. These types of experiences for patients can have a long lasting and damaging impact on doctor-patient relationships. In contrast, I have also met patients who have a described a feeling of the weight of the world lifting off their shoulders when they have felt supported by their GPs after disclosing the use of cannabis for medical intent or when asking their GPs about the possibilities of medical cannabis treatments.
It is worth considering why GPs may struggle with this subject matter. Firstly, in the UK, most GPs have very little knowledge of the endocannabinoid system and cannabis-based medicines, having had no teaching throughout medical school or post graduate training. The UK continues to lack any formal education programme for medical professionals and individual doctors wishing to learn more about cannabis and the endocannabinoid system often have to source their own learning online. When it comes to referral and treatment options, many GPs simply do not know where to turn to or which options are available for patients.
The stigma around the cannabis plant is hard to overcome and is not going to simply disappear overnight.
Since prohibition in the 20th century and through various political agendas and stereotyping, the negative impacts of cannabis misuse and the association with psychosis are deeply set within the minds of GPs. Many of these views have been re-enforced throughout medical school, post graduate training and through personal clinical experiences. Most GPs for example have spent time working in psychiatry posts where they have witnessed first-hand the detrimental impacts of high THC street cannabis (skunk) or synthetic cannabis use (spice) on mental health. It is reasonable therefore that GPs will naturally be hesitant and cautious in their general views and feelings on cannabis as a medicine. I have personally experienced the stigma of cannabis amongst my peers. “Snake oil” and “legal drug peddling” are just two of the comments that have stuck with me after sharing with colleagues my interest and enthusiasm for cannabis-based medicines as legitimate therapies. When I have challenged these attitudes, it has quickly become clear that understanding of the endocannabinoid system and the pharmacology of cannabis are both largely non-existent. We should be reminded that doctors should never come from a place of ignorance when expressing a strong opinion on a medical treatment and keeping up-to-date with advances in medicine and science (which includes cannabis-based medicines) is not only a professional duty but also forms part of the GMC Good Medical Practice Guidelines.
GPs like guidelines and will regularly turn to these for the most up to date evidence-based treatments and referral pathways which inform day to day practice. The Royal College of General Practitioners desktop guidance on cannabis based medicines (designed specifically for GPs for use in consultations) takes a rather tentative view on medical cannabis stating “there is limited clinical evidence on the use of cannabis based products for medical purposes and cannabis based medicines including long term use and efficacy” and that “if a patient has an appropriate condition, such as a person with intractable epilepsy or multiple sclerosis, a referral needs to be made to a relevant specialist.” The GP needs to help manage the patient and carer’s expectations as this is a new and complicated process and is unlikely to be fast.” NICE (National Institute of Clinical Excellence) remain conservative in their approach with the conclusion that there is not enough evidence for the use of cannabis-based medicines for the treatment of chronic pain or for conditions such as anxiety and PTSD.
Under current regulations, after the initial prescription, subsequent prescriptions of cannabis-based medicinal products may be issued by GPs as part of a shared care agreement under the direction of the initiating specialist prescriber. However, the reality is that this is just not happening in practice. Unlicensed medical cannabis products prescribed in private clinics cannot be re-issued by NHS GPs as any attempts will be blocked by Area Prescribing Committees. There will be some very rare cases of NHS GPs re-prescribing cannabis-based medicines under the direction of NHS hospital specialists but these will be few and far between and very much on a case by case basis. There are anecdotal reports that some GPs have been reluctant to engage with private medical cannabis clinics on various grounds. One could also argue that the exclusion of GPs as primary prescribers of medical cannabis treatments has led to a general lack of interest and disengagement on the part of GP. I have encountered patients who have reported that their GPs have told them that this is something to discuss with their specialists as there is no role for them in prescribing this medication.
So where from here?
Recognising the urgent need for GP education, The Primary Care Cannabis Network (PCCN) has been set up specifically for those GPs who are interested in learning about cannabis based medical treatments and how these may serve the needs of patients. Bringing together GPs from across the UK, the PCCN is building up a community and providing an independent platform to share ideas, open dialogue and debate. The PCCN provides balanced opinion and clarity to GPs amid growing patient interest in this subject matter. By reaching out to “cannabis friendly” GPs across the UK and building a network of GPs nationwide, the hope is that the one day they will be trained in prescribing and will be able to have the skills and knowledge to serve the needs of their local communities. Currently working in partnership with the CMC, the PCCN is gathering larger scale data on GP attitudes and knowledge of cannabis-based medicines. When complete this will be of central importance in informing policy within the UK.
The main focus now must be to engage with and gain the trust and confidence of wider professional medical communities to accept cannabis as a safe and legitimate treatment.
Education programmes for medical practitioners on topics related to the endocannabinoid system must now be a top priority if doctors are to understand and prescribe medical cannabis safely and effectively. Clearly, we cannot ignore the need for more evidence and there are now large studies underway and patient registries in the UK and beyond which are generating valuable observational data on real world clinical practice and outcomes.
If this pandemic has taught us anything it is that we are all truly connected and that healthcare and scientific knowledge should have no boundaries. We are fortunate in the UK in that there are many other countries ahead of the curve when it comes to medical cannabis and we should be looking to work in collaboration and learn from our overseas colleagues.
The UK is perfectly placed to become a world leader in cannabis research if it grabs the opportunity. To date progressive UK policy and research tends to largely be focussed on tertiary care. But as the majority of clinical medical cannabis interactions occur between the patient and GPs, perhaps the focus should now shift on how to best moderate the primary care environment to the benefit of patients and wider public interest.