Information for Clinicians
Evidence, Confidence and Practicalities
Is it legal? Is it evidence based? Its not in the BNF?! Is it off license? Are we allowed to talk to our patients about it? What are the risks? But it's... Cannabis!
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I get asked the above questions regularly by my healthcare colleagues - and I'm glad - it's right that we should seek the evidence, efficacy, risks and practicalities of any treatment we recommend or discuss with our patients.
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So, below I have discussed some of these questions to help healthcare professionals explore and build confidence in discussing this as an option with their patients.
Clinician
attitudes towards medical cannabis...
In 2021 the Primary Care Cannabis Network carried out a survey of the attitudes of UK GP's around Medical Cannabis. 1005 GP's were interviewed. 51% of respondents supported cannabis based medicinal products (CBPM's) as an alternative treatment for patients who had exhausted licensed medications or interventions. Yet, 72% of respondents were concerned that these medications were off license and 68% were concerned about the evidence base for use of CBPM's.
As clinicians we are open to new and effective ways to treat our patients - that's what we do, but naturally we want to know that it is safe for our patients to take, and safe for us to recommend.
But Why?
Hands up who feels we are managing chronic pain or mental health caseloads effectively? How many times do we get to the top of our analgaesics ladder and run out of options? How many times do we start another opioid or another anti-depressant when we know that we would rather have a different option?
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Let's take chronic pain as an example...
There is variance in the reported prevalence of chronic pain in the UK, depending on the definition and measure of pain.
One systematic review found that between one third and one half of the UK population are affected by chronic pain. A 2021 Lancet update on chronic pain states that 30% of the world's population is living with chronic pain. I know that when I am working on a typical 'on call' day in general practice, I will consult with many patients whose pain is not adequately controlled.
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Not only are we aware of the burden this is on the quality of life of our patients, but also on the services that we run. Chronic pain behaves like a chronic disease, but in primary care it is not funded like a chronic disease. In addition to that we have the ongoing need to reduce opioid use.
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In 2016 Professor Mike Barnes presented an in depth report for the All Parliamentary Group for Drug Policy Reform on the evidence base for medical cannabis. The report rightly recognises that the ever growing body of evidence is difficult to summarise, given that studies use different formulations and dosing and different definitions of pain. Almost all of these studies however show improvement of pain symptoms. The report concludes that there is good evidence, with particular reference to several class 1 studies.
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Evidence can be conflicting. A 2017 systematic review of the efficacy, tolerability and safety of medical cannabis across different types of pain concluded that there was insufficient evidence at that time. Part of this challenge is that pain is subjective and measured on patient reporting and has such variability. Observational studies like this one (2020) show statistically significant improvement in patient reported symptoms as well as a significant reduction in oral opioid requirements in a study of over 700 patients.
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We see similar findings across other chronic conditions such as anxiety, spasticity and nausea/vomiting.
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Perhaps some of the best evidence is found with the number of patients who self medicate with recreational cannabis. How often do we ask our patients if they are already using cannabis to improve their symptoms? In my experience, it is safer for patients to access medical cannabis on prescription under the guidance of a clinician with regulated medicines.
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Medical Cannabis is an off license medication. It is also a controlled drug. It was legalised in the UK as a medicine in 2018. Like other unlicensed medications that we prescribe, as clinicians we must provide a sound clinical judgement that this is in the best interest of the patient and based on the best available evidence at the time.
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Here are the current NICE Guidelines regarding cannabis based medicinal products. This helps to provide further evidence and guidance.
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How do I talk to my patients about Medical Cannabis?
Many patients are already using or have tried using cannabis to manage their symptoms. It can feel strange having a conversation about cannabis with our patients in our usual consultation structure, but most patients are open to discussing new approaches to managing their symptoms, especially if they are not achieving sufficient relief from other treatments they have tried. Medical Cannabis should be discussed in the same manner as any other prescribed medications, discussing how it works alongside risks and benefits. In addition patients need to understand that they will need to pay for their medical cannabis and associated consultations and they will need to know where to access these things.
It can help to give the patient the above patient leaflet so that they can get more information and self refer if they choose. You can also refer or discuss a patient by sending an email to referrals@kernowcann.com.