Cannabis debate leaves GPs facing a prescribing conundrum
Dr Ellie Cannon
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