Cannabis as a Schedule 2 drug: how does this impact GPs?
In November 2018, cannabis was reclassified in the UK as a Schedule Two substance, from its prior Schedule One status.
Schedule One substances include hallucinogenic drugs like LSD, raw opium and ecstasy-type substances, which are illegal to possess, with a Home Office licence generally being required for their supply, production or possession. As defined by this category, these drugs have no recognised therapeutic value and have a high potential for abuse, potentially leading to severe physical or psychological harm in many cases.
Schedule Two substances include opiates, major stimulants and cannabis products for medicinal use. These substances can be legally prescribed by doctors and pharmacists when other medication has failed, provided that the full Controlled Drug requirements are followed by such professionals. As Cannabis now falls into this classification, it is recognised that cannabis has a medicinal benefit in certain circumstances.
Currently only General Medical Council (GMC) specialists can prescribe cannabis-based medicinal products, but the regulation changes means that GPs are uniquely positioned to discuss cannabis-based medicinal products with their patients, making them a crucial first point of contact before possible referral to specialists.
If regulations changes again in the future to allow GPs to prescribe CBMPs directly, GP training in cannabis-based medicine will likely be much like the training of a GMC specialist, but with knowledge covering a wider range of conditions rather than focusing on one, specialist area in depth.
In this event, a thorough understanding of the medical cannabis will be necessary, particularly as patients are likely to become increasingly aware of the benefits of medicinal cannabis when compared to some traditional first line options. Even if such changes do not take place for some time, keeping up to date with medical and scientific advances is considered a professional duty of those involved in medical fields, with this diligence forming part of GMC Good Medical Practice guidelines.
What indications should GPs be most aware of?
Mainly, GPs should be aware of when to refer individuals with poor responses to conventional medications to GMC specialists with training in cannabis-based medicine. Conditions that would be appropriate for such referral, once all traditional treatment methods have been exhausted, include:
- Chronic pain
- Spasticity and severe treatment-resistant epilepsy
- Multiple sclerosis
- Anxiety disorders
- Tourette’s symptom management
- Treatment-resistant insomnia
- Intractable nausea and vomiting
Medical cannabis referral should also be considered by GPs when such medicines may holistically improve a patient’s overall quality of life, for instance when an individual has a disabling chronic condition or if they are approaching the end of their life.
Some important considerations to make in this case would include:
- Whether the patient in question has been using cannabis recreationally or to self-medicate. It is essential that GPs discuss recreational drug and alcohol use with their patients in a supportive and non-judgmental manner to establish the most effective plan of care possible.
- Whether it’s important to clarify the patient’s drug and drinking habits further, in which case GPs can use CAGE or DSM IV alcohol dependence questionnaires for this purpose.
- Whether a psychological assessment is necessary for patients looking to explore medicinal cannabis use further. For instance, patients with a history of psychosis or schizophrenia may need to be cautioned against high THC products.
GPs are also more generally encouraged to discuss with their patients that:
- Any information discussed with them is confidential. Only in very rare circumstances will their confidentiality be breached, for instance if there is a serious risk of harm to themselves or others, or if there’s a risk of serious crime.
- Cannabis purchased on the street remains illegal so an individual in possession of cannabis can receive a heavy fine or be sentenced to up to five years in prison. The side effects of increasingly potent street cannabis can also increase the risk of adverse side effects like anxiety, paranoia and psychosis so the sourcing and use of such products should be vehemently cautioned against.
- CBD products now commonly available on the high street, frequently sold as ‘wellness supplements’, are often marketed as unapproved treatments for a range of medical conditions from epilepsy to cancer and HIV. Patients who choose to investigate such products further should be cautioned about the lack of regulation of these products, which could detrimentally affect their safety.
Overall, it is clear that the transition of cannabis based medicinal products (CBMPs) from a schedule one substance to a schedule two substance provides promise for many sufferers who hope to one day be prescribed medicinal cannabis quickly and easily by their GPs. Despite current regulations on medicinal cannabis prescription meaning GPs cannot currently prescribe CBMPs personally, The Academy recognises that nonetheless doctors will be increasingly called upon by patients to advise them on their medicinal cannabis treatment options.
As this is certainly going to be the case for the foreseeable future, we see it as necessary for doctors to keep up to date with changes and developments in the medicinal cannabis field so that their patients can be best advised and counselled.
Further investigation and research into cannabis use (both recreational and medical) is thoroughly encouraged by The Academy, particularly through the use of our own online courses and evidence base. Specific information on how cannabis rescheduling affects GPs can be found in our free introductory course.