Cannabis prescribing

Overview

The following advice has been provided by the BNSSG Medicines Optimisation Team regarding medical cannabis:

Purpose

To highlight the changes in legislation and clarify the prescribing responsibility of cannabis-based products for medicinal use issued from NHS England to all prescribers.

Recommendation

1. GPs are not permitted to prescribe cannabis-based products for medicinal use.
2. Only those clinicians listed on the Specialist Register of the General Medical Council may prescribe cannabis-based products for medicinal use. Specialist doctors should only make the decision to prescribe within their own area of practice and training (e.g. physicians for adults should not be prescribing for children) and the decision to prescribe should be agreed by the multidisciplinary team.
3. Cannabidiol (CBD) products such as CBD oil, food supplements, drinks, cosmetics and liquids for vaping are available to purchase legally online or on the high street and are sold for their potential to produce 'well-being' benefits. These consumer CBD products are not licensed medicinal products, which have not met strict safety and quality standards and the proportions of cannabinoid compounds may vary from batch to batch.

Background

Background

From 1st November 2018, certain cannabis-based products for medicinal use (CBPMs) have been rescheduled to Schedule 2 Controlled Drugs which means they can be prescribed medicinally where there is an unmet clinical need.

Due to the limited evidence base and their unlicensed nature, the Government has chosen to restrict the decision to prescribe cannabis-based products for medicinal use to only those clinicians listed on the Specialist Register of the General Medical Council. The decision to prescribe within their own area of practice and training (e.g. physicians for adults should not be prescribing for children) should be agreed by the multidisciplinary team.

Any decision to prescribe must take into account the relevant GMC guidance and the relevant NHS Trust governance procedures for unlicensed medicines in the normal way. As a minimum, NHS England expect that approval for use is granted on a named patient basis by the Drug and Therapeutics Committee Chair, or Trust Medical Director. It is also good practice to discuss use of cannabis- based products for medicinal use with a peer clinician in the same Specialist Register of the General Medical Council.  Any such discussions should be appropriately documented.

Clinical guidance is based on the best available clinical evidence.

Adults

• NICE guideline [NG144] on Cannabis-based medicinal products

Spasticity

Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) (Sativex®) oromucosal spray is on the BNSSG Adults Formulary as TLS Red, restricted to use for moderate to severe spasticity in patients with multiple sclerosis in accordance with NICE guideline NG144 and for prescribing by a specialist with expertise in treating spasticity due to multiple sclerosis.

Severe treatment-resistant epilepsy

Cannabidiol (Epidyolex®) is included on the BNSSG Joint Formulary as TLS Red for use in three conditions in which epilepsy is a severe problem in line with NICE technology appraisals:

NICE TA614 in combination with clobazam for treating seizures associated with Dravet Syndrome

NICE TA615 in combination with clobazam for treating seizures associated with Lennox-Gastaut Syndrome

NICE TA873 Cannabidiol for treating seizures caused by tuberous sclerosis complex

• Royal College of Physicians (RCP) guidance around prescribing of cannabis-based products for medicinal use  in chemotherapy induced nausea and vomiting, chronic pain and pain in palliative care patients.

Paediatrics

• British Paediatric Neurology Association (BPNA) on the use of cannabis-based products for medicinal use in children and young people with epilepsy.

The BPNA supports the use of one cannabis-based medicinal product called Epidyolex® within its licensed indications.

• Cannabidiol (Epidyolex®) is included on the BNSSG Joint Formulary as TLS Red for use in three conditions in which epilepsy is a severe problem in line with NICE technology appraisals: NICE TA614 in combination with clobazam for treating seizures associated with Dravet Syndrome
• NICE TA615 in combination with clobazam for treating seizures associated with Lennox-Gastaut Syndrome
• NICE TA873 Cannabidiol for treating seizures caused by tuberous sclerosis complex

Referral

Referral to secondary care

Patients should not be referred to any specialty for a specific medication, including cannabis-based products. These can only be considered by a Specialist when a patient has an unmet special clinical need that cannot be met by licensed products. Local treatment guidelines and referral pathways should be followed.

Medical cannabis and pain

Please note that at present local pain clinicians have advised that they will not prescribe medical cannabis in their clinics.

A Cochrane review for neuropathic pain states that ‘there is a lack of good evidence that any cannabis-derived product works for any chronic neuropathic pain’. 

There are no licensed cannabis-based products, for medicinal use, available for use in pain.

References

Guidance to clinicians: The process for prescribing Cannabis-based products for medicinal use: Department of Health and Social Care. NHS England. December 2019

Cannabis-based medicinal products: NICE guideline [NG144] Published: 11 November 2019 Last updated: 22 March 2021

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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