OPINION: The highs and lows of prescribing medical cannabis down under

Dr Mark Smith, is a UK-trained GP and member of the Medical Cannabis Clinicians Society (MCCS), who has been practicing in Western Australia since 2015. Here, he shares his experience prescribing medical cannabis to more than 200 patients. 

First, a bit of history. In February 2016 Australia legalised the growing of cannabis for the first time as long as it was for medical use and research purposes, and by 2017 specialists were allowed to prescribe. 

Dr Mark Smith has been practicing in Australia since 2015

Then, state-by-state, non-specialists (GPs like myself) were allowed to prescribe too (as in the US, each state has different laws for everything). Here in Western Australia it wasn’t allowed until late 2019.

Although I knew the rules had been relaxed, the process looked intimidating. How do I apply? What do I prescribe and what doses are needed for all the different conditions? Some of us might have had our interest piqued but it was still daunting. 

But it wasn’t long before a patient came to ask about it. 

I’d never met him before, but with cerebro-spinal degeneration he was suffering from fear, anxiety and dreadful insomnia. I promised to look into the process. I didn’t realise then how time consuming the application for one prescription would be.

Prescribing in general in Australia is quite different from the UK. The equivalent of the NHS is Medicare, but this system doesn’t cover everything either. 

If medicines are covered by the Pharmaceutical Benefits Scheme (PBS) the maximum prescription charge for a month’s supply is around £22 until you reach an annual cost cap. 

However if PBS doesn’t cover the medicine, as with cannabis products, then the patient must pay the whole cost. 

The big difference is that GPs can still prescribe it safely, but the process for prescribing ‘unapproved’ medicines like cannabis is still cumbersome. 

A document justifying the prescription with a description of the condition and what medicines have been tried and failed has to be uploaded to the Special Access Scheme application website and the application will be assessed in the capital Canberra over several days. 

Sometimes it will get refused, but most are allowed as long as the patient isn’t under the age of 18 and wanting access to THC. 

This approval then gets sent to the state authorities in Western Australia for another level of bureaucracy.

Starting out I got great support from Little Green Pharma (LGP) who are based here in Perth.

After several months experience, the company helped me through the ‘Approved Prescriber’ process which allows me to prescribe on the spot without needing to apply through SAS. 

All within a 45 minute appointment, a patient can be assessed, fully briefed on how to take it and leave with a prescription for immediate dispensing from the pharmacy downstairs. 

It’s a vastly streamlined and efficient process compared with the UK. I am already up to over 200 individual patients and there is no sign of demand slowing, especially since the QUEST research study launched in early 2021.

Not dissimilar to Project Twenty21 in the UK, QUEST is run by the University of Sydney in partnership with LGP and allows patients discounted access to cannabis medicines in return for their participation in a study monitoring their progress.

For monthly emailed questionnaires a 50ml bottle (2500mg) is discounted to $165/£90 including postage, whether it’s the CBD 50 (usual price $225/£122) or the THC products that are usually $175/£95 (it’s worth noting that all products dropped in retail price this year anyway).

There are now over 200 Authorised Prescriber GPs in Australia, and many others prescribe too but we are still in the minority (Australians can be pretty conservative).

In 2020, 60 percent of prescriptions were for THC containing products but this year it’s been quite different. 

Many more anxious patients have been presenting, resulting in 80 percent of prescriptions being written for CBD only.

My impression is that early seekers of cannabis medicines were pain sufferers, hence the greater demand for THC containing oils. But it is clear to me that CBD is a tremendous breakthrough for anxiety patients. Most people will also report better sleep. 

THC has its place for pain, but the local drawback is that the law still bans anyone from driving with THC in their system.

With random alcohol breath and saliva drug stops a common sight here (they even have their own TV show) anyone using THC oil in the morning is likely to test positive within six hours of ingestion.

The law is also very strict regarding manufacturing (GMP) and only reliable products can get approved for prescription. There has to be a guarantee of no detectable THC. LGP estimates 40 percent of the cost of the product is growing and manufacturing – 60 percent is testing and compliance.

Many people will still get success for chronic pain, headache and migraines from CBD only, but the dose has to be right. 

Everyone is different but it will usually need to be at least a 25mg dose twice daily. 

A few months ago CBD was finally legalised for pharmacy sales in Australia, with the Government allowing a daily dose of 150mg of over the counter CBD. 

I suspect sales will take off, but it will be imperative for patients to know how much to take, in milligrams. Take too little to try and save money and it is not going to work.

My original patient? He did very well from the off, reporting significant improvements in his sleep, depression and mood and appetite.

Here’s a few other success stories taken from my notes:

Female, 20, CBD only for anxiety reporting a vast improvement in anxiety and sleep

Male, 62, CBD only for chronic headache reported reduced headaches, spells with no pain and improved sleep 

Female, 64, CBD, brilliant response to 0.5ml, best ever sleep and pain doesn’t need paracetamol any more

Female, 41, CBD only reported a vast improvement in endometriosis pain. No longer needing time off work. Migraines eased too, easier to cope all round. Halved analgesic use. 

Male, 72, was prescribed 10:10 balanced CBD:THC for chemotherapy symptoms. Appetite great, rested after sleep and done away with Norspan opiate patch with no detriment. Very pleased. 

You’ll note that the majority of patients are treated with CBD only, due to the random roadside drug testing laws and 80 percent of this years consults have finished with a CBD prescription. What this could suggest, is that medicinal quality, full-spectrum CBD has a lot of value – so much so that THC isn’t always needed.

Dr Mark Smith hopes to return to the UK early next year where he plans to use his prescribing experience to help improve access for patients. 

Find out more about joining the MCCS here