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GPs go forth

Cannabis debate leaves GPs facing a prescribing conundrum

Dr Ellie Cannon

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Not long ago, I was interviewed on the radio about the use of cannabis and whether or not this would be something I would be prescribing. I explained, as I often do when talking about new treatments, that it was unlikely until we had the solid evidence base that it works as we do with other drugs, old or new.

The presenter, normally pretty sensible, was horrified at my stance and proceeded to shout me down, exclaiming that we know it works from the huge number of recreational users, and that he has the first hand evidence to prove it from a relative whose pain was cured.

He seemed so incensed by my need for clinical caution and desire for an evidence-base for treatments that he pretty much put the phone down live on air, before I had the chance to deliver my favourite line in these circumstances: the plural of anecdote is not data.

After the Government’s review of cannabis for medicinal purposes, rather than wait for sensible and clear-cut guidance, it is these types of conversations that I am afraid will set the agenda. Cannabis for medicinal purposes has become a hugely messy web, where the lines are blurred between recreational drug use, wellness and the cannabis industry, alongside age-old tropes such as ‘bad pharma’ and ‘bad cop’ doctors withholding treatment from good people.

With the headlines that have ensued, it won’t be long before patients are asking us for medicinal cannabis 

And it will be us GPs at the coal face who get caught in the middle, with patients wanting to be prescribed what they believe the home secretary has told them they can have, when in fact he said nothing of the sort.

I certainly feel unskilled and uneducated when it comes to medicinal cannabis. Because the debate has mostly centred on cannabis as a recreational drug, even the notion of cannabis as a pharmaceutical has come as news in the past few years to many GPs, who are not necessarily au fait even with the terms ‘THC’ or ‘CBD’ and the differences between them. When Billy Caldwell’s case hit the news, I was amazed to hear it was prescribed by colleagues at a hospital in the UK after a temporary lifting of the ban. What was the regime and who supplied it? I don’t believe the average GP would be comfortable with prescribing it, even if they have used cannabis themselves recreationally.

The GP in Northern Ireland, Dr Brendan O’Hare, who initially issued a one-off prescription for Billy Caldwell, states he prescribed on the basis of a specialist opinion, as we do with other medications, but admitted himself to having limited knowledge. I’m still curious to know what he wrote on the FP10.

What is abundantly clear to me is that GPs will have to play catch-up, for our own sakes and that of our patients’. To me, this very much mimics what has happened in the past three years with vaping. A groundswell of lobbying and opinions from the public and of course (we must be cynical after all) commercial ventures, fuelled the exponential rise in e-cigarette use long before any medical bodies had a chance to give an opinion on safety, efficacy or benefits. I felt relieved when Public Health England published their 2017 review, so we actually had concrete information and advice to give patients. There really is an urgent need for the same for medicinal cannabis.

We desperately need due process to counterbalance the campaigns, online petitions and cases that make the news. The two-part review by the Chief Medical Officer concluded there does appear to be evidence for the treatment of certain conditions

But with the headlines that ensued, it won’t be long before patients are asking for medicinal cannabis in a consultation. Essentially as the media debate continues, all doctors, but particularly GPs, need guidance so we can genuinely be part of an informed debate that is clearly very important to many of our patients.

The Multiple Sclerosis society has recently suggested that cannabis could benefit as many as one in ten MS patients for spasticity and pain. And given how common chronic pain consultations are, the time will no doubt soon come when we are all asked about prescribing it, being referred for it or being referred to a specialist who can. Personally, I wouldn’t know where to start – would it get through referral management? I would really like some answers before my next radio interview.

Dr Ellie Cannon is a portfolio NHS GP in London and broadcast media doctor


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Readers' comments (24)

  • It may be anecdotes again, but I daily see lives wrecked by the toxic effects of cannabis. No way would I prescribe any of the currently available preparations:- it needs the psychotoxic and carcinogenic components removed to make any medicinal compound I would prescribe.
    Who these days prescribes smoked poppy or even Omnopom?

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  • AlanAlmond

    Try telling a chronic cannabis user they should think about stopping. These consultations have have a similar (although admittedly less desperate and anxious ) vibe to discussion with people hooked on benzodiazepines. They just ‘know’ it’s good stuff just don’t. There’s often little space for an open discussion - unless you have an hour and a half to waste in an angry evidence thin debate.

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  • Marijuana will be fully legalised in Canada this year after being available as 'medical marijuana' for a number of years. it is an entirley political decision unrelated to factual, data based evidence for efficacy in any but a very small cohort of medical disorders, e.g. reduction of seizures in Dravet's syndrome.

    It's political philosophy/stance is to 'protect our youth and to get the criminals off the streets', verbatim from the Provinical and Federal Ministers responsible.
    This is rhetoric and nonsense, if only because of the same intention relating to the succes of keeping alcohol and cigarettes out of the hands of the underaged. What a joke. Current study estimates that around 43% of 15-19yr old use, or have used, marujuana, and this while has been illegal.

    There are currently 111 licensed commercial growers in Canada and the estimate of their combined production is over 400 tons annually of dried marijuanaamte. The 'average' joint is stated to contain about 0.5 grams. You work it out
    Additionally, every household will be legally entitled to grow 4 plants for their 'own' use.
    This is sheer madness and a long term social distaster in the making.
    Canada will become the new Panama-Columbia. The largest Canadian grower, Canopy Growth, which has 1,000,000 sq ft of greenhouse space, already exports to Germany.
    The only benefit for physicans will be that the 'needy' requests for 'medical' marijuana will be more easily refused.
    Regarding prescribing marijuana, it is akin to precribing a bunch of foxgloves t.i.d. for heart failure.

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  • David Banner

    Oh it will start for the genuine MS patients, but soon all those dodgy skinny 28 yr old blokes and obese depressed 52yr old women already on pregabalin and fentanyl patches for their horrendous sciatica will undoubtedly be queuing up to demand that medical marijuana be added to the list, aided and abetted by Pain Clinic if you are daft enough to refer them.

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  • Cannabis is a good drug for specific disorders like
    pain and muscle spasms or cramps associated with multiple sclerosis or spinal cord damage;
    chronic neuropathic pain (mainly pain associated with the nervous system, e.g. caused by a damaged nerve, phantom pain, facial neuralgia or chronic pain which remains after the recovery from shingles);
    nausea, loss of appetite, weight loss and debilitation due to cancer or AIDS;
    nausea and vomiting associated with chemotherapy or radiotherapy used in the treatment of cancer, hepatitis C or HIV infection and AIDS;
    Gilles de la Tourette syndrome;
    therapy-resistant glaucoma.

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  • It is safer than opioids and is of extreme value to tackle the opiate crisis being experienced in US/Canada. I have patients on medical marijuana and all of them have been able to cut down or stop morphine/benzodiazepines that they had been on chronically. I understand the fear to prescribe this because marijuana has been stigmatized by the legal system and politicians for years. What we should clamour for evidenced based, clear prescribing guidelines from NICE and good post- prescribing data and side effect monitoring.

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  • I agree with GMC survivor. Have seen them used to great effect in chronic pain, allowing withdrawal of opiates. Not for everyone but better than poppy products.

    Always got the pain team to do it though.

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  • AlanAlmond

    GMC survivor/ Motdoc
    What/who are you ? Paid employees of the medical marijuana industry?. It’s not legally prescribable in the U.K. yet here we have two Drs (GPs no less??) one after the other both with extensive experience of its benefits in clinical practice. I smell a very smelly rat ...this kind of crap is what we have too look forward to in the UK with ever increasing tentacles of business and greedy money makers ..covert advertising by people looking to make money . I don’t believe you are who you pretend to be

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  • AlanAlmond

    This comment has been moderated

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  • @Alan- I have no payments from any pharmacy company, I don’t own any shares in any cannabis company, I have not received any payments regarding cannabis prescription or use, I have no financial incentives to give the response that I have written previously . We are physicians and we can be civil. I just shared from my personal experience. In a matter of few weeks to months- doctors would be allowed to prescribe after requesting a licence in the UK. UK has been behind regarding this aspect of care. Countries in Europe and also Canada have allows medical Cannabis and even US which is very restrictive has allowed it for certain seizures in children. NICE will come up with guidelines for cannabis. No doctor will be forced to prescribe it. Physicians are only allowed to prescribe within what they a comfortable with.

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