Exclusive data obtained by Prohibition Partners from the NHS Business Services Authority details how the amount of medical cannabis being accessed by patients in England is growing rapidly. This topic is also explored in Prohibition Partners’ recent European Cannabis Report: 7th Edition.
Opening up of medical cannabis patient access
The UK is home to one of the largest patient populations using cannabis in Europe, and regulators are increasingly supportive of patients obtaining products via legal prescriptions.
Of course, major regulatory hurdles remain before all of the estimated 1.4 million patients are granted legal access to medical cannabis. For the past two years, no official data has been available on the amount of legal medical cannabis being prescribed in England or the UK, since a Freedom of Information (FOI) request by Alfredo Pascal in 2019.
The NHS Business Services Authority recently released data in response to a request from Prohibition Partners detailing the number of privately prescribed, unlicensed medical cannabis items dispensed each year in England covering the period January 2019 until August 2021. Private prescriptions refer here to those prescriptions not covered by the NHS. One item here refers to a single product on a prescription, e.g. if a patient is prescribed three packages of Tilray 25:1 oil and one of Noidecs 20:1, these would register as just two items. The data shows a massive increase each year since 2019, albeit from a low base.
Based on Prohibition Partners’ calculations, which conservatively assume all quarters in 2021 are equal, the annual number of products for last year amounted to 23,466 – a 425% increase on 2020. Things are moving more quickly elsewhere in the UK. On the island of Jersey, with a population of just over 100,000 inhabitants, more than 2,000 prescriptions were filled from January 2019 up to late 2021.
Dr Mike Barnes, Chair of the Cannabis Industry Council, and a Director of Maple Tree Consultants, who is a leading figure on cannabis in Europe, spoke to Prohibition Partners about the progress being made in the UK, saying: ‘We estimate there are now about 15,000 patients in the UK prescribed full-spectrum products (about 55% flower and 45% oils) privately and still only three on the NHS. These figures are gradually increasing as more clinics come on stream (now 19 active) and more doctors (now about 100) prescribing. Also, patients now have a better choice of product (over 120) from 18 different importers. We’re getting there as an industry but are still hampered by intransigence and ignorance amongst many doctors. We hope the lobbying efforts by Maple Tree and supported by the Cannabis Industry Council will make a difference in the coming months.’
An important factor in opening up patient access in the UK is the establishment of medical cannabis clinics, such as those run by the Medical Cannabis Clinics, Sapphire Clinics and more recently by German-based Cantourage. These clinics guide patients through the process of obtaining a prescription, starting with initial consultations and referrals to specialists. These clinics are associated with extra costs which can be problematic for some patients. One solution for patients to lower costs is accessing medical cannabis via Project 2021, which subsidises treatments (see below).
Barriers to access
The situation for medical cannabis patients in the UK is improving each year. However, many barriers still remain for thousands of patients still locked out of the legal market by high prices, lack of willing prescribers and no small amount of bureaucracy. Prohibition Partners recently spoke to Dr Anne Katrin Schlag (Head of Research at Drug Science UK) in our recent European Cannabis Report: 7th Edition about these issues:
‘There are a range of issues that present barriers to patient access. The costs of private prescriptions are still very high, and there is limited – if at all – reimbursement through health insurances as in other countries, such as Germany.
‘Understandably, prescribers tend to adhere to the National Institute for Health and Care Excellence (NICE) and the British Paediatric Neurological Association (BPNA) guidelines, which, at present, are still very restrictive. For example, in these guidelines, medical cannabis is not recommended for chronic pain – even though this is the condition for which patients most often look to medical cannabis, in the UK, as well as globally. Most doctors have not been trained in prescribing cannabis; add to this that cannabis is still a rather stigmatised substance, and it is easy to see why there is such caution, which, unfortunately, contributes to the limited patient access.
‘Also, prescriptions cannot be written by GPs initially, which is a shame, as many of the conditions are actually conditions patients come to see a GP for, rather than a specialist.
Only doctors on the specialist register can initiate a prescription, but under a shared care agreement, any doctor or prescribing pharmacist can actually continue such a prescription, under the supervision of the specialist – a fact that is often not known!’
Medical cannabis prices in the UK vary widely. A search performed by Prohibition Partners showed a range of €6-16.5 per gram of flower, averaging at €11.18 for products in stock as of April 2022. For oil, the price ranged from €2.35-€30.1 per ml averaging €6.42 per ml or €0.02-€0.54 per mg of CBD and THC combined, averaging €0.18. Costs of clinic consultations also vary, and vary in the time taken between each visit. On average, the initial consultations costs from 7 UK clinic franchises is €165 euro, €90 for follow up visits which are often every three months, and an average of €60 euro for a repeat prescription, though in at least three clinic chains this is free. As of March 2022, products accessed under Project 2021 have a price of cap of €8.42 per gram of flower or ml of oil, lowering the costs for several different products.
Evidence key for further progress
In the UK, NICE has indicated that there is a lack of convincing evidence for recommending the prescription of medical cannabis to patients. To address this, several projects are gathering real-world data and, now, clinical-trials data with hopes of convincing the medical establishment of the therapeutic potential of medical cannabis.
Project Twenty21 aims to assist patients in accessing medical cannabis in the UK at a capped price and to have their treatment tracked by Drug Science UK. Drug Science will use the data from Project Twenty21 to provide evidence for NHS funding of medical cannabis treatment. This project is now the largest and most transparent source of real-world data on medical cannabis usage in the UK, providing key metrics such as patient success rates and product choices for the 2,342 participating patients as of March 2022. This register has now been followed by the creation of another private registry by Sapphire Clinics and one by the NHS themselves.
New clinical trial
The Health Research Authority (HRA) of the UK recently approved the first clinical trial for the use of medical cannabis flower against chronic pain in the country. The trial has been given preliminary approval for a feasibility study with 175 patients before a full study of 5,000 patients is conducted and the results compared against 5,000 control cases. Note that this is not a fully fledged, double-blind randomised controlled trial, and the patients will still have to pay for the medicines rather than being given them as in normal trials. The company in charge, LVL Health, hopes that the project will still go some way to convincing NICE, or at least some domestic doctors of the medical utility of cannabis flowers in non-cancer pain conditions.
The UK is notable for having one of Europe’s oldest pharmaceutical cannabis production sites, under GW Pharmaceuticals, though not a single fully operational, commercial unlicensed medical cannabis production site. GW Pharmaceuticals remained as the lone licensed commercial cultivator and producer of medicinal cannabis in the UK from around 1998 up until 2021. Since then, new medical cannabis production facilities have been approved in the UK, including a 2.5-hectare greenhouse for Glass Pharms in southern England. Both Celadon and Ananda Developments have been approved to produce test batches of cannabis, allowing for the development of stable genetic strains. In January 2021, Northern Leaf secured the first cultivation licence on Jersey for a 75,000 sq. ft facility. The first licence for cultivation was issued to 4C Labs on Guernsey in September 2021. No unlicensed medical cannabis produced in the British Isles has reached the market.
Prohibition Partners spoke to Greg Dobbin, CEO of 4C labs on the benefits of local production:
“Domestic cultivation of craft medical cannabis in the British Isles brings West Coast medical cannabis within the sphere of the UK and the Channel Islands. Apart from the supply chain benefits, (such as freshness of product, stability of supply, environmental impact etc) the opportunity to cultivate allows people from the region to become involved in the process, develop expertise and take ownership of the industry. There is no reason why all of the medical cannabis destined for UK medical patients can’t be grown locally.”
Products being used
The majority of unlicensed medical cannabis products being used in the UK are flower products. Data from Project Twenty21 shows that just under 80% of products there are flower, as opposed to oil products. This data may be somewhat skewed by the population currently accessing medicines via Project 2021, as the estimates of Mike Barnes place the market share of flower products at about 55% based on private data. The majority of flower products being used are high-THC, such as are commonly used to treat pain, the most common condition for which medical cannabis is used.
While full medical cannabis access schemes are developing, e.g. in the UK and in Germany, many countries are currently operating pilot schemes to assess the feasibility of more permanent access schemes. These trials are emblematic of Europe’s more gradual and cautious approach to medical cannabis legalisation compared with the rapid liberalisation seen in North America.
France started its pilot trials in 2021, which aim to treat 3,000 patients by 2023 before assessment and potential permanent establishment. As of February 2022, 1,218 patients had received their initial treatment. Ireland treated its first patient under a pilot trial in early 2022, with assessment of the trial expected in five years’ time. Denmark’s pilot scheme, which began in 2018, has been extended by the Danish parliament until at least 2025, and the laws allowing for medical cannabis cultivation in the country have been made permanent. In Germany, an official Government assessment of medical cannabis access is expected in 2022.
On the subject of medical cannabis product formats, Dr Schlag said the following:
‘As CBMPs become more widely used in medicine, there is likely to be a move away from flower (not entirely, but its “market share” will reduce). Currently the majority of medical cannabis users in the UK are not “naive” but often already have a history of treating illness/es with cannabis – and they have used cannabis sourced from the illicit market (from necessity). When seeking legal cannabis, they are perhaps more familiar or more comfortable with flower (which dominates the illicit market to a greater extent than its current domination in the medical market) and therefore seek flower prescriptions. When CBMPs become more mainstream – and the patient population includes an increasing number of cannabis-naive patients – we might expect that these patients are more likely to be prescribed other products such as oil.
‘In the future, other changes may include the introduction of alternative routes of administration – such as “patches” that different companies are developing, which may be helpful for certain conditions.’