The barriers to regular GPs prescribing make the rise of dedicated clinics and ‘cannabis specialists’ inevitable.
“Wild west” may be a slightly clichéd way to describe a medical field lacking regulation – but that’s never stopped us.
Most recently your Back Page scribe and TMR editor applied this news trope to medical cannabis, where, as Steve Jones reported, commerce appears to be a nose ahead of medical ethics and the normal separation between prescribing and dispensing has dissolved.
The same imagery has been used by one of the practitioners interviewed in this qualitative study from Monash University titled ‘The wild west of medicine’: A qualitative investigation of the factors influencing Australian health-care practitioners’ delivery of medicinal cannabis.
Psychology student Olivia Dobson interviewed 17 subjects, not all prescribers: four GPs, four “cannabis specialists” – i.e. working for dedicated cannabis clinics – three psychiatrists, three non-GP specialists, two nurse practitioners and one junior medical officer, most of them male and most in private practice.
She identified four themes from their interviews.
Clinical capabilities required for prescribing
Participants said that the basic clinical knowledge needed to prescribe, “including pharmacology, evidence, available products, dosing, adverse reactions and contra-indications”, was generally lacking, thanks to cannabis being “outside the mainstream” and therefore absent from tertiary and further medical education and from on-the-job learning.
Would-be prescribers were therefore on their own: all knowledge was self-taught out of hours, and while online resources were plentiful, identifying credible and unbiased sources was hard.
Prescribing unapproved therapeutic goods
Three barriers repeatedly mentioned were the time-consuming bureaucratic process to become a prescriber, high product costs compared to PBS-subsidised pharmaceuticals and fear of legal liability, especially around driving.
Negative attitudes towards prescribers in the medical community
Stigma, while decreasing, was still present.
One participant 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’,” while two others said they had been verbally abused by other treating clinicians.
As suggested in our recent feature, many worried that the cavalier attitude to prescribing taken by dedicated clinics was bringing cannabis into (further) disrepute.
“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,” said one. “Similarly, there are numerous dodgy deals in relation to pharmacies, so patients being forced to use a particular pharmacy … There’s all sorts of weird stuff going on because it’s the wild west of medicine at the moment in some regards.”
Divergent beliefs about clinical utility
A handful of participants were dubious about the therapeutic benefit, citing absence of strong scientific evidence, and were therefore unmotivated to undertake the education or bureaucratic process, but were happy to refer on.
Those in favour of its clinical utility saw it not as curative but as providing symptomatic relief and improving quality of life for people with chronic conditions, especially as a safer alternative to benzodiazepines and other medications.
In the Back Page’s view, the absence of “strong scientific evidence” is undeniable, but is also exactly what you’d expect of a substance that is not only illegal and hard to run experiments with, but still sitting under a cloud of politically motivated propaganda. Its other great disadvantage is an association with mental illness whose causal direction has never been established, but which makes clinical study ethically harder to do.
What is never brought up as a counterweight is its long history of use in various communities and its safety, there being no lethal dose.
Boring conversations, paranoid thinking and “couch lock” are the main adverse effects from overdose, in the Back Page’s couldn’t-really-call-it-medicinal experience.
Mind you, is the medicinal/recreational distinction even real?
With the difficulties facing “regular” GPs who want to prescribe, and patients in finding them and then pharmacies that will supply, it’s no wonder that dedicated businesses have sprung up to fill the demand, and that according to this paper a new “specialisation” of medicinal cannabis prescribers has emerged.
The downsides of this include “the fragmentation of care for patients with potentially complex clinical conditions and costly consultation and monitoring fees not reimbursed through usual channels such as the public health care system”.
Participants reported the industry in Australia “was rampant with ‘bad actors’, including practitioners who held conflicts of interest due to financial interests in medicinal cannabis products or were perceived to not adhere to minimum standards for patient care … This was also viewed as potentially perpetuating stigma towards medicinal cannabis and negative attitudes towards those who prescribe it, which may entrench polarised professional identities and discourage prescribing among practitioners outside this niche.”
The takeaways for the Back Page are that if you don’t like the cannabis script mills and you don’t want your patients seeking therapeutic help from men in tracksuits: decriminalise and demystify cannabis so regular GPs can get their heads around it, remove the legal barriers to studying it at scale, believe patients who say it helps them, and stop looking at prescribers like they’ve got “three or four heads”.
Send robustly evidenced story tips to penny@medicalrepublic.com.au.
