In this article Dean Billington, Chief Operating Officer at Brains Bioceutical, discusses how medical cannabis can help the UK’s chronic pain problem.
Chronic pain is one of the most troubling and expensive issues for the NHS and patients. In fact, a recent study by The British Pain Society suggests that chronic pain affects more than 40% of the UK population, meaning that more than 26 million people in the UK are living with pain that has lasted three months or longer. The BMJ has suggested that this could rise to as high as 60% among those over the age of 75.
For many patients battling this silent epidemic, it is a hopeless exercise of jumping from one prescription drug to another and at a huge cost. For example, the associated treatment for these patients is estimated to account for 4.6m GP appointments each year at a staggering cost of £69m.
Unfortunately, treatment pathways often direct patients to opioid painkillers. A recent review published by Public Health England revealed that the UK now has the fastest-growing rate of opioid use across the world, with prescriptions rising by 22% over the past decade to 40 million prescriptions a year. This is despite the fact that NHS guidelines recommend that opioids should not be taken for more than a few weeks at a time as patients can become addicted to them. In addition to this, health experts have warned that opioid painkillers are not effective for 90% of people with chronic pain.
With the NHS now looking to move away from prescribing these addictive opioids or non-steroidal anti-inflammatory drugs (NSAIDs) – following updated draft guidance issued by NICE last month – there is an undeniable need for alternative medicines that are effective and affordable.
Just last month, Dr Steve Hajioff, a former chair of the British Medical Association, said that cannabis should be made available legally using prescriptions to prevent patients turning to the black market for pain relief.
As international medical cannabis markets continue to develop at their own pace, the UK has been slower to adopt wider change and embrace medical cannabis fully as a medicine. So, what is needed to progress the medical application of cannabis and how can the industry help sow the seeds for change?
The medical cannabis sector in the UK
In November 2018, UK law was amended to allow specialist doctors to prescribe a range of cannabis based medicines to patients who might benefit from them. This amendment to the Misuse of Drugs Regulations 2001 (MDR 2001) was considered a landmark decision at the time.
However, while there has been some support in the healthcare industry, very few prescriptions have been issued on the NHS. This is partly due to the lack of education around cannabis based medicines available to doctors, but also due to the responsibility placed on doctors who elect to pursue this form of treatment. With the exception of Sativex, which is a fully licensed drug, all other cannabis based medicinal products (CBMPs) are unlicensed which means that doctors are not insured to prescribe them. Qualifying for medical cannabis treatment is also complicated. Patients must get a referral from their GP to a specialist clinician listed on the Specialist Register of the General Medical Council.
A YouGov poll (commissioned from the Centre for Medicinal Cannabis in November 2019) suggests that around 1.4 million people in the UK regularly use cannabis illegally for medical reasons. The UK’s failure to prescribe cannabis to patients is driving people to purchase cannabis outside of the law as a means of treating chronic health conditions.
Cannabis as an alternative to opioids
Amid the UK’s chronic pain problem, already an estimated 540,000 Britons are addicted to opioids. With prescription opioid painkillers rising drastically from common-use pills to a massive public health crisis, there is a need for more potent analgesics that are non-addictive and non-toxic. Evidence from clinical trials showed therapeutic benefits of cannabis, especially THC (delta-9-tetrahydrocannabinol) and other cannabinoids in reducing neuropathic pain intensity in various conditions.
In the United States, where cannabis has been made legal for medical purposes, prescriptions for opioids and anti-depressants have dropped by around 30%. Data released by the US Government suggested that prescribing cannabis medicines can also help prevent around 31% of deaths linked to opioid addiction each year.
Moreover, a longitudinal analysis of the number of opioid prescriptions filled under Medicare Part D, showed that when medical cannabis laws went into effect in a given US state, opioid prescriptions fell by 2.21 million daily doses filled per year. With such promising outcomes, the UK cannot carry on overlooking the potential for cannabis medicines to provide an alternative to standard pharmacological treatments.
Consideration for the clinical evidence
There are currently three cannabis medicines that have been through extensive clinical trials and are licensed in the UK to treat specific and rare conditions. Sativex can be prescribed to treat MS-related spasticity, Epidyolex has been approved by the EMA to treat seizures in patients with Lennox-Gastaut syndrome and Dravet Syndrome and Nabilone can be used to treat chemotherapy induced nausea and vomiting where other treatments are not effective.
Whilst the approval of these three medicines is undoubtedly a step in the right direction, they are expensive to access and only a limited number of prescriptions have been issued on the NHS to date.
In fact, whilst the UK currently exports cannabis to the patients of the other 48 countries where medical cannabis is legal for pain treatment, UK patients still do not have access to the medicine manufactured in their own country.
This is largely due to the fact that there still haven’t been any Randomised Controlled Trials (RCTs) in the UK for medical cannabis, and there aren’t any expected until at least 2021. Moreover, guidance from the National Institute for Health and Care Excellence (NICE) remains cautious and calls for more research and large-scale clinical trials.
However, the launch of Project Twenty21 in November 2019, which will see up to 20,000 patients trialing medical cannabis for various conditions including chronic pain and is backed by the Royal College of Psychiatrists, signals a move towards getting definitive evidence to convince policymakers on the positive impact of cannabis.
Though evidence of the efficacy of cannabis is still debated, many laboratory studies have demonstrated promising results. Examples include a preliminary study from the Dent Neurological Institute in Buffalo, New York, which suggested that cannabis medicines do provide elderly patients with relief from chronic pain and other ailments associated with the side effects of Parkinson disease and Multiple Sclerosis.
As the chronic pain problem in the UK continues to deepen and concerns of an opioid epidemic develops, NHS doctors will be looking to help their patients, not block access to care. Already clinical evidence from international studies is being taken on board by some physicians, particularly those looking to issue unlicensed cannabis medicines, however, it is yet to go mainstream.
Continued research in the area is needed to advance NICE guidelines, draw extensive conclusions and create a climate whereby medical cannabis is accepted as a medicine for a variety of health conditions including chronic pain.
There is a great deal that producers, pharmaceutical companies, the NHS, and the wider health ecosystem can learn from the experience accumulated to date. We can strategise based on data, emerging medical research, and conversations with industry experts and stakeholders to drive the efficacy of new models of care and alternative medicines.
Ultimately, it is only with a strong, science-led and regulated industry that we can help remove the remaining stigma around cannabis, produce high quality, consistent, refined products that help the nation with its chronic pain problem and improve the patient experience and access to medical cannabis.
Chief Operating Officer