Could medical cannabis be a treatment option for chronic pain patients living in the UK?

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I have suffered with chronic pain all my adult life. I am a fibromyalgia patient who has exhausted all conventional routes for treating my condition. I have been prescribed a multitude of different pain medications over the years, and they have all either been ineffective for my pain, or the side effects have been too severe for my body to tolerate. I currently take CBD (Cannabidiol) oil, which has been somewhat effective for treating my pain, but I still suffer severe pain when my symptoms ‘flare’. I have extensively researched cannabis as a source of pain relief and I see it as a viable option. If CBD is partially effective, it makes practical sense that a full spectrum cannabis product including THC (Tetrahydrocannabinol), would be an even more effective solution. But is medical cannabis even a legal option for me at the moment, as a chronic pain patient living in the UK?

How effective is cannabis for chronic pain conditions?

In a comprehensive, Harvard-led systematic review of 28 studies examining the efficacy of exo-cannabinoids (e.g. synthetic formulations or cannabinoids from the plant) to treat various pain and medical issues, the author concluded, “Use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high quality evidence.”

Of the studies reviewed, six out of six general chronic pain studies and five out of five neuropathic pain studies found a significant improvement in symptoms among patients.

The truth is, there is still a lot of research that needs to be done to determine the effectiveness of cannabis based medication for treating chronic pain, and the results from clinical trials are very limited. But cannabis is fast becoming a promising solution for the treatment of chronic pain, offering sufferers pain relief without the side effects associated with opioid use.

Recent developments in the UK.

If you have be keeping up-to-date with the recent news with regards to medical cannabis laws in the UK, you will know that the government has recently shifted it’s thinking towards the potential medical benefits of cannabis. The government’s stance was always that cannabis had no medicinal properties and this was the reasoning behind it’s schedule 1 classification.

Following a couple of high profile cases the government ordered a review on medical cannabis and set up a temporary panel to assess applications for licences on a case-by-case basis. The government also ordered a review into current evidence of the medicinal benefits of cannabis based products and the appropriateness of their place within Schedule 1 of the Misuse of Drugs Regulations 2001.

The Cannabis Scheduling Review carried out by Dame Sally Davies (CMO) stated:

“Schedule 1 drugs by definition have little or no therapeutic potential. As summarised in this review, there is now conclusive evidence of medicinal benefit of cannabis based products for certain medical conditions, and reasonable evidence of benefit for indications that they may be useful under restricted circumstances.

My recommendation is that cannabis based medicinal products are moved out of Schedule 1 of the Misuse of Drugs Regulations 2001. It may be pragmatic for them all to be moved to Schedule 2 pending a fuller review by ACMD that can differentiate different products into the appropriate different Schedules.”

This was further backed by the recent recommendations put forward by Advisory Council on the Misuse of Drugs (ACMD) to the Home Office about the scheduling of cannabis-derived medicinal products.

“The ACMD agrees with the Chief Medical Officer for England (CMO) that there is now evidence of medicinal benefit for some Cannabis-derived products in certain medical conditions for some patients.

The ACMD advises that clinicians in the UK should have the option to prescribe Cannabis-derived medicinal products that meet the requirements for medicinal standards to patients with certain medical conditions. It is therefore appropriate for these medications to not be subjected to the requirements of Schedule 1 of the Misuse of Drugs Regulations 2001, as amended (MDR)”

Therefore, we can conclude that cannabis is likely to be rescheduled to Schedule 2 from Schedule 1, allowing it to be prescribed where a GP or other health professional deems it applicable, however, the fact remains that there are still few studies into medicinal access and most medical professionals are still not educated enough to prescribe it.

So what does this mean for chronic pain patients who think they may benefit from cannabis based medication? In the future GPs may be in the position to prescribe cannabis but as things stand at the moment, the only option would be to submit an application through the temporary panel that has been set up. What is the likelihood that an application for a medical cannabis licence would be successful for these conditions?

To answer these questions we must first establish the criteria behind the application process, and the potential barriers that have been put in place for patients wanting to access medical cannabis.

Application process and requirements for eligibility.

Who is eligible to apply?

Anyone who feels that they will benefit from taking medical cannabis, has backing from their clinician and has exhausted all conventional medication, in principle, can apply for a medical cannabis licence; no medical conditions have been excluded from this process. But in reality, the conditions of eligibility place significant barriers that make the application process very daunting, and unrealistic for most patients.

The following conditions apply to all licence applications to the panel:

1. You cannot apply yourself.

Patients cannot apply themselves, their clinician must do this. This means that, not only must your clinician have knowledge about cannabis based medication, but they must also be willing to take the time, and risk, to back your application. This is a huge barrier considering the majority of UK doctors are ignorant with regards to cannabis-based medication, not through fault of their own – cannabis science and the endocannabinoid system are not taught in medical schools. You could carry out your own research and try to educate your doctor, but it is unlikely that any doctor would be willing to take on the responsibility of prescribing a substance they have not been trained to prescribe. The lack of evidence about the effectiveness and safety of cannabis based medication is also a barrier.

Sir Mike Penning (MP) stated that “the implication that any prescribing clinician will be taking on personal liabilities” would deter many doctors from agreeing.

2. Doctors will have to prove there is an “exceptional clinical need”.

Patients must have exhausted all other treatment options before receiving access to medical cannabis, which could delay receiving the medication that works for many months. Doctors will have to prove there is an “exceptional clinical need” and no other medicine would be suitable for their patient. If given approval, doctors will then be able to write a prescription.

3. Evidence must be provided.
There is also a requirement that if the medicine has not been tried (by travelling abroad) then it must have been through a clinical trial – which being illegal, most cannabis medicines have not been subjected to clinical trials.

Realistically, travelling abroad, is not possible for the majority of patients, therefore it is hoped evidence from clinical trials and experience from other patients with similar conditions will be sufficient. This highlights another barrier as there are very few, if any, double blind trial results to use as evidence.

4. Cost

The current cost is £3,665 per licence application. It isn’t 100% clear who would be liable to cover this cost but in England it’s likely to be your local CCG (Clinical Commissioning Group), and there is no guarantee that this fee will be authorised. This cost is likely to prohibit many patients from gaining access to medicinal cannabis, although this cost is under review.

What advice is available if you decide to apply?

If you do decide to put in an application, the advice given by Hannah Deacon, who has already gone through the process to access medical cannabis for her son Alfie Dingley is; Educate yourself. Research what options are available. Full spectrum cannabis products are very different to CBD products which are currently legally available in the UK. Don’t assume your doctor will know anything about cannabis – be prepared to educate them. Collect as much evidence as you can and contact the organisation ‘End our pain’, they are in the process of compiling a guide into the application process.

What is the likelihood an application would be successful?

The truth is; no one knows. This process is new to everyone involved so the outcome cannot be predicted. If you can meet the criteria stated, and you have the backing of your clinician, then it’s possible; no medical conditions have been excluded from this process. However, there are a lot of barriers that have been put in place which will prohibit the majority of patients from gaining access to medicinal cannabis. The biggest barrier being; the fact that there are still few studies into medicinal cannabis and the medical professionals are still not educated enough to prescribe it.

The licences granted so far have been for patients with epilepsy. Sativex (nabiximols) has been available to a limited number of MS patients for a while now, but to date no licences have been granted for chronic pain conditions like fibromyalgia. But this doesn’t mean it’s not possible, and it doesn’t mean you shouldn’t try.

The current application process is a temporary one and permanent definitive process will eventually be implemented. But no one knows whether ‘temporary’ means weeks, months or even a year.  Is it worth waiting until a permanent definitive process has been implemented? Is it worth waiting for the cost to be reviewed? Possibly, but we don’t yet know what medical conditions will be eligible once this permanent process has been implemented; will there be a strict limited set of conditions eligible or will anyone who’s doctor thinks they will benefit from medical cannabis be allowed to apply?

Personally, I’m going to have to wait and see what the next step is. I don’t have the backing of either my GP or Rheumatologist. Hopefully, once a permanent application process has been implemented, my options will look more promising. Until then, I will continue to treat my pain with CBD oil and and follow developments closely.

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