2.1
The committee heard that the first hurdle in a patient's journey to access medicinal cannabis is to find a medical practitioner who is knowledgeable about medicinal cannabis, understands how to prescribe it, and who has an understanding of the range of products available.
2.2
As pointed out by the Medical Cannabis Knowledge Network, the role of health practitioners is fundamental and unavoidable:
… unless Parliament can be persuaded that a formal doctor’s prescription should not be the avenue through which cannabis products are made available … then regardless of what arrangement is employed to facilitate access administratively speaking, the decision-making of doctors remains the sole route by which such products may legally be obtained.
2.3
The committee received considerable evidence in relation to health practitioners refusing to prescribe medicinal cannabis to patients. The reasons for refusing to prescribe medicinal cannabis are explored throughout this chapter and broadly reflect a lack of education about medicinal cannabis and a lack of knowledge about the process to prescribe it.
2.4
The chapter first examines the issues related to health practitioners' limited knowledge of medicinal cannabis. It then discusses the adequacy of the training available to health professionals in relation to medicinal cannabis.
2.5
The second part of the chapter discusses the appropriateness of the information made available to patients and health professionals in relation to the process to prescribe medicinal cannabis, the range of products available, and likely costs to patients.
Education about medicinal cannabis
2.6
Submitters were of the view that most health practitioners lack knowledge in relation to medicinal cannabis.
2.7
At a public hearing in Melbourne, Professor Iain McGregor, Academic Director at the Lambert Initiative for Cannabinoid Therapeutics (Lambert Initiative), gave an account of the findings of a survey of general practitioners (GPs) conducted by the organisation in 2018:
A clear majority were in favour of having medicinal cannabis as an option that they could prescribe, but they did not feel comfortable talking to their patients about it, because they didn't feel well educated … they want to have it in their doctor's bag, if you will, but they feel uneducated.
2.8
In addition to a general lack of knowledge about medicinal cannabis, doubts about the efficacy and safety of medicinal cannabis, the view that medicinal cannabis should be only prescribed as a last-line therapy, and the ongoing stigma attached to cannabis make it difficult for patients and medical practitioners to discuss the use of medicinal cannabis as part of a treatment plan. This this often results in patients leaving their doctors' surgery without a prescription.
Medical cannabis efficacy
2.9
The contentious issue of the efficacy of medicinal cannabis was mentioned on numerous occasions as a reason for health practitioners to be reluctant or refuse to prescribe medicinal cannabis to their patients.
2.10
The Australian Pain Management Association reported that some patients advised them that their GPs had refused to prescribe them medicinal cannabis because there was 'no evidence of its efficacy'.
2.11
A patient who participated in the inquiry also mentioned that he had dealt with GPs and specialists who did not want to prescribe cannabis because there was not enough evidence.
2.12
Dr Harry Nespolon, President of the Royal Australian College of General Practitioners (RACGP) explained that some GPs are unwilling to prescribe because of their concerns about the lack of evidence for the use of medicinal cannabis:
There are a lot of GPs who don't want to prescribe, because they don't believe that medicinal cannabis does have enough evidence behind it for them to be prescribing it for their patients.
2.13
In their submission, Professors Wayne Hall and Michael Farrell, cited a research paper published in the Medical Journal of Australia in 2018, which identified 'the absence of good evidence of safety and efficacy as a major reason why many medical practitioners are reluctant to prescribe cannabis-based medicines'.
2.14
Pain Australia acknowledged that the lack of evidence about suitable doses of individual cannabis products 'makes it difficult for practitioners to prescribe, despite community expectations that these products will be made available to treat chronic pain'.
2.15
The Australian Medical Association (AMA) is of the view that 'for medicinal cannabis to be taken up by more medical practitioners, we must have a clinical, evidence base'.
2.16
While this report will not attempt to provide the definitive compilation of evidence for the efficacy of medicinal cannabis as a treatment for many conditions, there is substantial evidence available from around the world to that effect, which should be made available for prescribing doctors to consider.
Treatment of last resort
2.17
The view that medicinal cannabis should be used as a treatment of last resort was mentioned as an additional barrier to health practitioners considering prescribing medicinal cannabis.
2.18
As further discussed in Chapter 3 of this report, this view stems from the interpretation of the guidance for accessing unregistered medicines through the Special Access Scheme (SAS), which states that health practitioners 'will have considered all appropriate treatment options before considering accessing an unapproved medicine under the SAS for their patients'.
2.19
For example, a patient with chronic pain reported that 'doctors are told that cannabis should only be prescribed once all other avenues have been exhausted, that it should be a last ditch attempt for people living with chronic pain, cancer and other disability'.
2.20
Mrs Joylene Donovan, the mother of a child born with Dravet Syndrome, is of the view that 'the attitude of our medical profession is that you will only be considered for cannabis once you have failed all other options' and added:
I believe our daughter has the right to all treatments on offer, as we choose, and that cannabis should not be a last option treatment but one of the treatments available to try.
Stigma
2.21
Mr Justin Sinclair, Research Fellow at the National Institute of Complementary Medicine Health Research Institute, and other submitters identified the stigma and prejudice associated with cannabis as a key barrier to patient access.
2.22
In their submission, Associate Professor Kate Seear and Springvale Monash Legal Service noted 'with disappointment' reports of 'persistent stigmatising attitudes held by some doctors'.
2.23
A patient with chronic conditions reported his experience with his GP when he tried to discuss the suitability of medicinal cannabis:
He is dismissive, uneducated and displays the well-entrenched perspective promulgated that cannabis is addictive and usually results in the emergence of psychological conditions and poor mental health. Thus, in the case of my GP, and his peers at the clinic I attend, medical practitioners in the Ballarat region dispense prejudice as opposed to informed advice.
Impacts on patients
2.24
The Alcohol and Drug Foundation pointed out that stigma about medicinal cannabis and its relationship to illicit drug use may impact on patients who are legitimately prescribed cannabis, and added:
The impact of stigma and discrimination towards people cannot be understated. While it is illegal to promote the use of any Schedule 4 or 8 medication, appropriate information given to patients to share with others may be of use to help reduce this stigma.
Need for targeted campaigns to reduce stigma
2.25
The Queensland Nurses and Midwives' Union is of the view that education and public awareness campaigns will assist in reducing the stigma around medicinal cannabis and demonstrating that medicinal cannabis products are not illegal and may be suitable as part of a treatment plan.
2.26
A patient shared a similar view and believes that the development of a Department of Health public campaign would remove the stigma and encourage GPs to start prescribing medicinal cannabis.
2.27
Epilepsy Action Australia also recommended that funding education materials for healthcare consumers and professionals would 'demystify' medicinal cannabis for Australians.
Training
2.28
Inquiry participants identified a critical need to train health professionals. As Mr Justin Sinclair from the National Institute of Complementary Medicine Health Research Institute pointed out, a lot of doctors have not had any training in the endocannabinoid system during their studies:
I gave a talk at a hospital in Queensland late last year where I asked everyone in attendance—some 130 nurses, doctors, et cetera—whether they had had any training in the endocannabinoid system during their undergraduate training, and not one hand was raised.
Training available
2.29
According to United in Compassion, there are only three RACGP accredited training courses about medicinal cannabis for healthcare professionals.
2.30
Professor Kylie O'Brien, Member of the Australasian College of Nutritional and Environmental Medicine (ACNEM), told the committee that ACNEM was running a two-day course about medicinal cannabis but could only offer it twice a year because of funding constraints:
Twice a year at the moment, and that's really just because we're all not-for-profit organisations, so we don't have any government backing on this, so we actually rely on sponsorship from some of the medicinal cannabis companies, and nutritional medicine companies as well, to be able to run these things.
2.31
Professor O'Brien added that other options available include 'fairly clunky' online courses from the US, which is why ACNEM is currently developing some online modules about medicinal cannabis and its applications.
2.32
Epilepsy Action Australia contended that 'in the absence of a government lead [sic] medical education program, smaller entities have attempted to fill this gap with seminars and conferences of variable quality'.
Training needs
2.33
Submitters advocated for the development and delivery of training and education on medicinal cannabis to enable health practitioners to relay informed advice to their patients regarding the use, applications, side effects and costs of medicinal cannabis.
2.34
Dr Christina Xinos, Medical Director at Canopy Growth Australia, is of the view that more training options should be developed, including a peer-to-peer mentorship program and added:
And we can also learn from other countries. The New Zealand Ministry of Health has budgeted to facilitate education for GPs, and we think that Australia should follow suit.
2.35
Entoura submitted that the availability of high-quality education via Continuing Professional Development conducted by independent not-for-profit organisations such as ACNEM should be expanded and supported through government funding.
Universities and colleges
2.36
The Medical Cannabis Council and other submitters recommended that modules on the endocannabinoid system and medicinal cannabis be included in medical, nursing and pharmacy courses at colleges and universities.
2.37
The Lambert Initiative pointed out that the training of doctors should not be left to the medicinal cannabis industry:
We need to better weave medicinal cannabis education into the syllabus of current medical degrees, and not simply leave the medicinal cannabis industry, with its inherent conflict of interest, to educate our doctors.
Information about accessing medicinal cannabis
2.38
Both patients and health practitioners mentioned the lack of information on the process to access medicinal cannabis as a significant barrier for medical practitioners to prescribe medicinal cannabis.
2.39
At present, it appears that the main source of information on how to access medicinal cannabis is the TGA website.
2.40
In an effort to assist GPs and their patients, the RACGP advised the committee that it has developed a 'prescribing medicinal cannabis products' checklist to assist with the TGA and state and territory governments' approval processes.
Patients' perspectives
2.41
A submitter who was interested in cannabis oil to treat his chronic pain told the committee:
I was overwhelmed by the lack of information available for people interested in seeking out alternative medical treatments. I went around in circles for days and did not find anything that got me any closer to the process.
2.42
Due to the lack of information on how to access medicinal cannabis, Mr Mark Thomas, a young veteran residing in the Northern Territory, sought out a clinical education session delivered by the Northern Territory Chief Health Officer to understand the process:
The session … began with [the doctor] joking he had illegal cannabis in a pouch on stage. This set the tone for the presentation and trivialised the clinical benefits of medicinal cannabis and did not provide clinical pathways or [the] ability to find prescribers in the NT.
2.43
A patient reported that his doctors, whilst being supportive of trying medicinal cannabis, did not want to prescribe it as they were not familiar with the TGA application process and felt it was too complicated.
2.44
Another patient pointed out that some doctors are confused about the process and eligibility criteria for access to medicinal cannabis:
I was told by my doctor that legal medicinal cannabis can only be prescribed to cancer sufferers, where I think that is not correct.
Health practitioners' perspectives
2.45
Health professionals mentioned their lack of adequate knowledge of the access pathways to prescribe cannabis as a key barrier to discussing medicinal cannabis with patients and prescribing it.
2.46
The Australian and New Zealand Society of Palliative Medicine suggested that there were issues around the quality, availability and suitability of the TGA guidance documents, and many doctors have had limited interface with the TGA pathways in their day-to-day work.
2.47
The RACGP and other submitters also noted particular concerns about the difficulty for practitioners in understanding the variations in prescribing requirements in each state and territory.
Development of resources
2.48
The RACGP is of the view that there is a need for the ongoing development of resources on the legislative and clinical aspects of prescribing cannabis products, as well as guidance on clear governance processes on prescribing medicinal cannabis products.
2.49
The Royal Australian and New Zealand College of Psychiatrists submitted that education and training activities about the regulation of medicinal cannabis could be facilitated and delivered by the TGA:
The TGA could provide holistic training, which addresses the relevant regulatory, medical, therapeutic and legal considerations involved in the regulation of medicinal cannabis.
Medicinal cannabis products
2.50
The lack of information on medicinal cannabis products that are available for prescribing is another barrier for both patients and health practitioners.
2.51
The AMA reported that 'some doctors expressed frustration that they are not sufficiently informed about what cannabis products are available and for what conditions'.
2.52
For example, a patient reported that he had spoken to three GPs who were willing to write a script, but the issue was that each GP did not know what product should be prescribed and said that the process was all 'too hard'.
2.53
Mr Ray Hill, a patient who has been prescribed medicinal cannabis, reported that he was unable to source any information about the likely costs of his medicine by phoning companies that supply medicinal cannabis in Australia, and concluded:
I would have liked to contact all 13 suppliers to get the best price for the medicine supplied by them but this is not possible in this country … it is not fair to the patient seeking to lessen the burden of the costs of their legally prescribed medicine as in all other products.
Committee view
2.54
The committee heard on many occasions during the inquiry that patients had negative experiences with their GPs or specialists when they tried to discuss using medicinal cannabis as part of their treatment plan. At best, patients are not being prescribed medicinal cannabis because their clinician acknowledges their lack of knowledge about medicinal cannabis, and may refer them to a colleague or another health practice. At worst, the committee was told that patients were simply rebuffed and felt ostracised by the negative or dismissive attitude of the clinician they consulted.
2.55
Alarmingly, the stigma attached to medicinal cannabis remains a live issue throughout the health profession. This needs to change. Trust is one of the central features of the patient–clinician relationship and is the cornerstone of good medical practice. Patients should feel comfortable discussing medicinal cannabis and treatment options with their clinicians. Patients should not feel ostracised for seeking potential medical cannabis treatments.
2.56
The committee recommends that the Department of Health, in collaboration with the Australian Medical Association, the Royal Australian College of General Practitioners and other specialist colleges and health professional bodies, develop targeted education and public awareness campaigns to reduce the stigma around medicinal cannabis within the community.
2.57
As noted by submitters, access to any form of medicinal cannabis in Australia is currently not possible without a script from a medical practitioner. Therefore educating medical practitioners about the endocannabinoid system and medicinal cannabis is fundamental to ensure patients can have access to medicinal cannabis treatment options.
2.58
The committee noted the paucity of training options available for existing health professionals. Given that GPs and other clinicians are time-poor, the committee is of the view that a range of courses, including online, should be developed to ensure medical practitioners are equipped to discuss medicinal cannabis with their patients and prescribe it when deemed appropriate.
2.59
The committee recommends that the Department of Health allocate funds to relevant medical colleges and peak bodies to support the development and delivery of accredited face-to-face and online training programs on medicinal cannabis for medical practitioners.
2.60
The committee believes that including modules on medicinal cannabis in the curriculum of medical degrees would ensure that doctors are equipped to discuss and respond to patients' queries and requests about medicinal cannabis. It would also contribute to eliminating the stigma around medicinal cannabis.
2.61
The committee recommends that the Australian Medical Council, as part of its role in the accreditation of Australian medical education providers, make mandatory the inclusion of modules on the endocannabinoid system and medicinal cannabis in curriculums delivered by primary medical programs (medical schools).
2.62
In addition to a lack of education about medicinal cannabis and its medicinal properties, it is clear that the lack of information about the process to get a prescription and the types of products available is significantly impeding patient access. There is evidence that many patients and doctors are ignorant, confused or misinformed about the process and regulatory framework supporting access to medicinal cannabis in Australia.
2.63
There is an urgent need to develop information resources for both patients and health professionals. In the absence of such resources being quickly developed, patients will continue to miss out on potentially beneficial treatment options, and, worryingly, may continue to turn to the black market in a bid to access medicinal cannabis products. The issues related to the reliance on the unregulated market (black market) are discussed in Chapter 5.
2.64
The committee recommends that the Department of Health commission the development of a suite of printed and online resources for patients, aimed at explaining the regulatory framework and process to access medicinal cannabis.
2.65
The committee is aware that information aimed at medical practitioners about the process to prescribe medicinal cannabis is available on the TGA website. Based on the evidence received by the committee, this information is insufficient as many health professionals appear to remain unaware of these resources or do not use them. The impact of this is discussed in Chapter 3.
2.66
The committee noted that both patients and medical practitioners also felt that there was not enough information about medicinal cannabis products. The issues related to the manufacture, supply and dispensing of medicinal cannabis products are explored in Chapter 4.