Therapeutic cannabis industry labelled ‘Wild West of medicine’

A recent study by Monash University has described cannabis prescribing in Australia as the ‘Wild West of medicine’.
 
It reports the dangers posed by vertically integrated clinics ‘dedicated’ to medicinal cannabis and highlights a glaring conflict of interest when these clinics are owned by suppliers of the cannabis products.
 
The 2023 Cannabis in Australia report by the Penington Institute also acknowledges the conflict of interest, stating that some clinics sell their own brand of cannabis medicines or otherwise direct patients to specific pharmacies with commercial agreements with the prescribing clinic.
 
To reach their findings, Monash University academics conducted in-depth interviews with 17 Australian doctors, many of whom expressed concerns over cannabis being prescribed in these clinics without taking an adequate medical history and risk assessment.
 
‘I think the industry has a serious conflict of interest problem with clinics being owned by suppliers, which is rampant, and zero transparency about that,’ one doctor who has issued more than 1000 cannabis prescriptions said.
 
‘Similarly, there are numerous dodgy deals in relation to pharmacies, so patients being forced to use a particular pharmacy …
 
‘There [are] all sorts of weird stuff going on because it’s the “Wild West of medicine” at the moment in some regards.’
 
As well as potential harm to the patient, the doctors said unethical prescribing also reinforces the stigma associated with cannabis prescribers. These doctors experienced indiscriminate criticism from colleagues following a lack of differentiation between ‘good’ and ‘bad’ prescribers in the community.
 
‘I’m a bit quiet about it,’ another doctor who has also issued more than 1000 prescriptions said.
 
‘People look at me like I’ve got about three or four heads, and go, “you don’t prescribe that, do you?”, “Oh, really. Well, there’s no scientific evidence for that”.’
 
With more than 800 different medicinal cannabis products available, it can be challenging for doctors to know which products are in stock and which pharmacies will dispense them, which has been associated with a rise in dedicated cannabis clinics.
 
In fact, the study highlights that almost 10 years since the legalisation of medical cannabis in Australia, a widespread lack of knowledge among doctors is still the main barrier to cannabis prescribing.
 
Other obstacles include a time-intensive prescribing process, divided opinions on the net usefulness of cannabis and negative attitudes towards prescribers from their peers.
 
But even though the average GP may feel uncomfortable or reluctant to proceed when a patient brings up medicinal cannabis, our important role cannot be ignored.
 
Statistics from the Australian Institute of Health and Welfare show that in 2022–23, 3% of Australians (around 700,000 people), had used cannabis for medical purposes. This was most commonly, according to the National Drug Strategy Household Survey, for chronic non-cancer related pain, as well as anxiety and cancer-related pain and nausea.
 
While the majority (70%) still acquire their medicinal cannabis without a prescription, prescriptions for cannabis have recently increased 10-fold.
 
In 2019, only 1.8% of people on medical cannabis obtained it through prescriptions. In 2022–23, this number has risen to 22%.
 
With medical cannabis prescriptions on the rise, it seems logical that all GPs have a basic understanding of its potential use and harms. Yet the study suggests there is an overwhelming lack of training in the pharmacology, available products, dosing and adverse reactions among the medical community.
 
Subjects admitted this was an area not at all covered during medical school and that most knowledge was gained through self-study using online resources. However, most found it hard to find resources that were unbiased and credible.
 
Concerns over adverse reactions and resultant medico-legal liability, as cannabis has not yet been approved by the Therapeutic Goods Administration (TGA), were also quoted as barriers by the participants.
 
Melbourne-based GP Associate Professor Vicki Kotsirilos is an experienced authorised prescriber of medical cannabis. She says GPs are ideally poised to manage the nuanced prescribing required for medicinal cannabis treatment and cautions against referring patients to specialist cannabis clinics.
 
‘We know that the evidence behind medical cannabis is not that strong, but it may play a role in non-cancer related pain not responsive to other treatments,’ she told newsGP.
 
‘Nonetheless, medicinal cannabis is an unapproved medication and should only be used as a last resort treatment when all other evidence-based treatments have been exhausted.’
 
She believes the long-term ongoing relationship GPs have with patients means they are ‘always in the best position’ to manage treatment.
 
‘We know what their risks are, such as previous psychosis, planning for pregnancy or being under 18, and what they’ve tried,’ Associate Professor Kotsirilos said.
 
‘GPs are holistic. We are able to look at all of the contributors to a problem including lifestyle and behaviour factors, for example, how stress or trouble at home might be impacting chronic pain.
 
‘We can then facilitate evidence-based non-medication treatments such as cognitive behavioural therapy too.’
 
Associate Professor Kotsirilos encourages all GPs to develop a basic understanding of the potential roles and risks of medicinal cannabis so they can have informed and non-judgemental conversations with their patients.
 
She also strongly believes in patients undergoing a thorough risk assessment and continuous monitoring by their own GP, and considers some ‘dedicated’ cannabis clinics unethical.
 
‘It is important for both the patient and the doctor to feel comfortable having a conversation about medicinal cannabis,’ she said.
 
‘If the patients feels dismissed, they may pursue other channels to get cannabis. This may include approaching “dedicated” telehealth clinics with an obvious conflict of interest or even obtaining illicit THC, which can be very dangerous.
 
‘At the end of the day, we want to consolidate a model where the patient goes back to their regular GP, because GPs know their patients well.’
 
More information on cannabis prescribing, including the cannabis prescribing safety checklist and consent form, is available on the RACGP website.
 
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