22 Jul Prescribing (lots of) Cannabis in Australia
My name is Mark, I’m a 58 year old UK GP who left for Australia in 2015 with my GP wife after finding running our own separate practices less than rewarding. Here’s my experience of learning how to prescribe Medicinal Cannabis.
Every country has approached the legalisation of cannabis and medicinal cannabis in different ways. Here, in February 2016 the country legalised the growth of Medical Cannabis for the first time, and by 2017 specialists were allowed to prescribe. Then, state by state (they all have different governments and laws for many things), non-specialists, us GPs, were allowed to prescribe too. Here in Perth, Western Australia it wasn’t allowed until late 2019. This covers CBD and CBD/THC containing products without a specialist needing to be involved.
Although I knew the rules had been relaxed the process looked intimidating. How do I apply? What do I prescribe and what doses are needed for all the different conditions? Some of us might have had our interest piqued but it was still daunting. But it wasn’t long before a patient came to ask. I’d never met him before but with cerebro-spinal degeneration he was suffering with fear, anxiety, dreadful insomnia and was quite nihilistic. I promised to look into the process. I didn’t realise then how time consuming the application for one prescription would be.
Prescribing in Australia is quite different in general. The equivalent of the NHS is Medicare and Medicare doesn’t cover everything, just like the NHS. If medicines are covered by the system (PBS) the maximum prescription charge for a month’s supply is around 22 quid until you reach an annual cost cap. However, if PBS doesn’t cover the medicine, such as cannabis, or any pill other than Microgynon, BPH medicines, Viagra etc, then the patient pays the whole cost. But the big difference is that GPs can still prescribe it without fear of being reported for prescribing privately to their own patients. There isn’t a registered GP system anyway, patients can rock up to any surgery, even multiple times a day and get seen.
So as a GP here we can sort of prescribe what we like and depending on the medicine the government/tax payer may not have to pick up the bill. Although they do have to pay towards the cost of every GP visit thus the inefficiency and duplication of services is eye opening.
The process for prescribing ‘unapproved’ medicines like Cannabis is cumbersome though. A document justifying the prescription with a description of the condition and what medicines have been trialed and failed has to be uploaded to the Special Access Scheme application website and the application will be assessed in the capital Canberra over several days. Sometimes it will get refused but mostly allowed as long as patient isn’t under 18 and wanting THC. This approval then gets sent to the State authority as well in Western Australia for another level of bureaucracy.
Starting out I got great support from Little Green Pharma who are based here in Perth. Another company I contacted didn’t even respond, so funnily enough most of my prescribing is of Little Green Pharma products. Your first look at the market is like a minefield, so many different companies, combinations, products. Yet at the end of the day its actually fairly simple by deciding doses in milligrams of CBD or THC or both.
There is a simple and easy to understand decision making process to decide on the choice of pure CBD or mixed THC/CBD 1:20, 10:10 or 20:5 formulas, and what doses to use. You ‘start low and go slow’. Here in Australia we make sure it’s a quality company with Good Manufacturing Practice (GMP) accreditation. Little Green Pharma make excellent quality, reliable and effective products. Having visited the growing facility, I can see why.
After several months experience, they then helped me through the ‘Approved Prescriber’ process that now allows me to prescribe on the spot without needing to apply through SAS. All within a 30 to 45 minute appointment, a patient can be assessed, fully briefed on how to take it and leave with a prescription for immediate dispensing from the pharmacy downstairs. A vastly streamlined and efficient process compared with the UK. I am already up to over 250 individual patients and there
is no slowdown in demand. Especially so since a research study called QUEST started in early 2021. It has similarities to Project21 in the UK and also subsidises the cost of products.
There are now over 200 Authorised Prescriber GPs in Australia, many others prescribe too but we are still in the minority (Australians can be pretty conservative). The cost of seeing that GP can vary a lot. One of the private clinics here in Perth charge the equivalent of £382 for an initial assessment but far less for follow ups. My approach has been to charge £163 for the 45 minute appointment and the patient gets £60 back from the Government from seeing an approved GP. £50 (and £20 back from Medicare) for the follow up appointment which will then generate a repeat prescription for up to 6 months’ supply.
CBD only products will be available over the counter by 2022, so in that respect Australia lags behind the situation in the UK. But they will have to be fully approved from GMP companies only so something the UK has yet to stratify. And it is CBD only oils that have become 80% of my prescribing. Initially I had a lot of chronic pain sufferers, but as word has got about, many more anxious and insomniac patients have come forward. Great results for migraineurs, chronic headache and dermatitis too.
THC has its place for pain but there is an Australian legal drawback as the law still bans anyone from having any THC in their system whilst driving and with random alcohol breath and saliva drug stops a common sight here (there is even a TV show about them called RBT) anyone using THC oil in a morning dose are likely to test positive within 6 hours of ingestion. So many people opt for CBD only so they don’t risk their licence.
My original patient? He did very well from the off. He reported sleep before being 5/10 but was now 8/10, depression/mood before 1/10 had become 10/10 and appetite before 5/10 was now 9/10. He had suggested from forum research that a balanced formula would be best. Little Green Pharma Classic 10:10 was prescribed
Dr Mark Smith – Australian based GP and PCCN Advisory team member