Why UK Doctors are not Prescribing Cannabis.

Known Unknowns of Medical Cannabis, conducted by drug reform agency Volteface, gives the viewpoints of dozens of clinicians to pinpoint the key issues preventing more widespread cannabis prescribing in the UK. 

More than 40,000 specialist clinicians in the UK are eligible to prescribe cannabis. Still, according to the report, only 100 (0.25%) actively do so. 

Over 40 doctors in various specialisms, including pain, psychiatry, gastroenterology, rheumatology and neurology, were interviewed to understand their perceptions of medical cannabis better. Issues identified include a lack of governance, insufficient high-quality evidence and doctors not being educated or supported in prescribing.

Evidence 

Most of the doctors interviewed voiced an interest in prescribing. However, the report shows they want cannabis to be treated like other new medications and be subject to the required regulatory standards, such as randomised control trials (RCTs), widely regarded as the 'gold standard" regarding scientific evidence. 

Most also felt that objective world evidence on medical cannabis was 'biased' due to enduring preconceptions among the cannabis community that talk up the perceived benefits of cannabis rather than looking at its true efficacy. 

As a result, the report says, many interviewed viewed the medical cannabis sector with 'scepticism'. Currently, the sector is attempting toconstruct proof via biased observational studies. The current model is seen as simply giving cannabis to patients that want it and want it to work. It's not that doctors want cannabis to fail or don't want their patients to have it, which is often how it is portrayed in the media.

The report showed that despite epilepsy and MS being licensed conditions for prescribing, neurologists were particularly hesitant about cannabis. Gastroenterologists also saw little evidence to support prescribing it for conditions under their specialism. Pain specialists, however, showed more interest and acknowledged the efficacy of cannabis. 

Psychiatrists appeared more accepting of their patients using CBD. Several believed that cannabis might be safer and possibly more effective when prescribed in combination with psychotherapy. Although many still held concerns about THC. In particular, the subject of treating people with complex mental health conditions and psychosis.

It was acknowledged in the report that many doctors know very little about medical cannabis. They're not encouraged to look into it and have no idea or knowledge of the market. There's not enough education or training on the subject.

Lack of Knowledge.

Doctors reported a general lack of knowledge about subjects such as the effects of cannabis on the endocannabinoid system, the formulations available, the symptoms it can be prescribed for and the different advantages and side effects.

Some were put off by the 'bureaucracy' surrounding prescribing and a lack of infrastructure and support. There was a fear of being reported to the GMC and damaging professional reputations.

Many doctors commented that stigma did not play a 'significant barrier to prescribing. There were concerns, however, that some doctors struggled to distinguish between medically prescribed and recreational use.

There also exists much uncertainty on the topic of dosage and administration methods, particularly in the case of cannabis flower. Many doctors said they would prefer to prescribe medical cannabis in pill form. 

Are Cannabis Clinics a Barrier?

Another essential finding of the report is the reluctance among doctors to prescribe via a cannabis-specific clinic. This is due to the belief that clinics dedicated to a single product intrinsically create a prescribing bias instead of encouraging an appropriate, balanced and ethical approach.

The Future

The conclusion is a series of crucial recommendations that hope to address the issue with the current model of prescribing. This includes;

•  Launching a medical professional-centred campaign
• carrying out more RCTs on medicinal cannabis
• The development of resourceful tools that will encourage prescribing in mainstream medical practice. 

Dr Steve Hajioff, is the former chairman of the British Medical Association (BMA) and a member of the Quality Standards Advisory Committee at the National Institute of Health and Care Excellence (NICE). He says that it is time for the industry to 'reflect on and 'adapt to the concerns of the clinicians on the frontline of prescribing.

"Build the evidence, build the governance, build formularies shaped around evidence of efficacy in a given condition, move towards delivery mechanisms that have been proven to be safe, consistent and effective. Build all that and the prescribers will come."