Is the current commercial model of medicinal cannabis in the best interest of patients?

To the Editor: Medicinal cannabis has been legal in Australia since November 2016; however, the rate of special access scheme approvals increased substantially in 2019 and appears to have stabilised at about 4000 new approved applications a month.1 The most frequent indications for prescription are anxiety disorders and insomnia, despite there being conflicting evidence for the effectiveness of cannabis in treating those conditions, especially the latter.1,2,3 The use of medicinal cannabis for psychiatric disorders is concerning, as there is evidence indicating that δ‐9‐tetrahydrocannabinol (THC) increases positive, negative, general, and total symptoms on the positive and negative syndrome scale even in people without psychiatric histories.4 Although there is hope for cannabidiol (CBD) as an anxiolytic and in the treatment of cannabis use disorder, there is currently conflicting evidence for its use.4,5

Given this, the surge in medicinal cannabis prescriptions appears perplexing from a clinical standpoint. However, from a commercial angle, it may make sense with consultations often being brief and expensive. Some companies promote “100% risk‐free” consultations, where payment is waived if the patient is not eligible for a cannabis prescription (evidence available at request). This introduces a financial incentive to conclude that a cannabis product is indicated for a particular patient, and a punishment (reduced earnings) if a decision is made against recommending a cannabis product. Although this issue may only be a theoretical concern, it is essential that the government identifies and mitigates any financial incentive when designing regulatory frameworks within which appropriate medicinal cannabis prescribing can occur. Moreover, the widespread promotion of clinics prescribing a specific medication may be akin to direct‐to‐consumer advertising, contravening regulations in Australia.

Currently, it seems that medicinal cannabis, an addictive substance with known harms, is being prescribed and advertised with little regulation, sometimes for indications with limited evidence of effectiveness, by prescribers who may feel incentivised to prescribe it.

Medicinal cannabis might have a role in clinical practice, but current evidence is not conclusive for all its advertised indications. The current model of cannabis prescribing could erode trust in the profession and may lead to poor clinical outcomes and unintended social consequences. Change is needed, whether that be increased governance of prescribing or increased regulation of marketing of cannabis prescribing services.