Growing the pie: how we take cannabis from the fringe to the mainstream

There’s a long way to go, of course. But it’s useful to reflect on how and why patient access has progressed. There are lessons we can learn for the future, and also some signs that the nature of the problem has changed. The next stage of this movement may require different strategies to the ones that have been successful in the past.

At the risk of massively oversimplifying things, here’s one way to look at the evolution of patient access: in the early days, access was basically impossible for a whole bunch of reasons. Prescriber and patient eligibility was restricted; products were insanely expensive and plagued with supply issues; access applications were onerous and took forever to be processed; informed and motivated prescribers were thin on the ground etc.

Since then, many of those issues have been resolved or at least improved. Mostly thanks to effective patient advocacy leading to legislative and regulatory reforms and the streamlining of access processes. Also, industry growth and competition, and the gradual — almost imperceptible — changes in the attitudes and beliefs of politicians and bureaucrats that come with time and experience.

But here’s an issue worth thinking about — how much of that progress would have been achieved without medicinal cannabis clinics and high-profile cannabis prescribers? Of all the patients who have gotten access to medicinal cannabis in Australia, how many of those have gone through a clinic or a well-known cannabis doctor? I reckon somewhere between 70% and 90%, although we’ll never know for sure.

You may think that sounds more like a solution than an issue. And you’d be right — the historical issue with patient access was partly solved by clinics and trail-blazing doctors. But that only takes us so far. Relying on pro-cannabis access facilitators risks keeping cannabis as a fringe area of medicine, and does little to improve the overall knowledge and acceptance of cannabis in the broader medical community.

And in some ways, it can even make that problem worse.

For example, if your average doctor wants to consider medicinal cannabis, they need to independently find and engage with product companies to get information on availability and pricing. In addition to being time consuming, many doctors feel that developing a direct relationship with a drug company is risky because it creates the potential for a real or perceived conflict of interest.

The same goes for most of the available prescriber education — it’s either run or sponsored by drug companies, and that makes things a bit… awkward.

Some companies continue to invest in medical science liaisons to bring new prescribers on board, but this is slow and expensive. For smaller operators, it’s often cheaper to chase a slice of the existing pie by targeting clinic prescribers, rather than grow the pie.

Cannabis clinics specialise in developing close relationships with drug companies. Some clinics are even drug companies themselves. The prescribers that work at these clinics are recruited on the basis that they already want to prescribe medicinal cannabis, and don’t need education to be convinced of that.

Leaving aside the significant benefits that clinics provide to patients through ease and speed of access, these close relationships between drug companies and clinics pose a reputational risk for the sector. Many prescribers that might otherwise be interested in considering medicinal cannabis take one look at what’s going on and run a mile.

This is a problem because, while clinics provide a viable avenue for patient access, the process of engaging with a clinic is more time consuming and expensive for patients than visiting their regular doctor.

It also unnecessarily increases the number of healthcare professionals overseeing a patient’s wellbeing, which fragments patient care and makes it more likely a patient will receive a lower standard of care overall. Not to mention some of the appalling customer service and deceptive conduct that is sadly commonplace.

Solving these problems will take time, but there are some potential solutions already emerging.

First, the issue of product information. While we still don’t have a totally comprehensive (preferably TGA-administered) source of product availability and pricing information, we have benefited from the relatively recent creation of sites like Cannareviews and Honahlee. Although I’m not sure just how widely these platforms are used outside of the clinic networks.

Initially I was concerned that making this kind of information publicly available was a bad look for the industry. In some ways, it could be considered direct-to-consumer advertising, and sometimes partial or outdated information can be less helpful than none at all. But overall, I think the value to non-clinic prescribers, and the benefits of greater industry transparency, far outweigh the likelihood of the regulators taking serious issue with such services.

Second, the problem of independent prescriber education. United in Compassion has done terrific work in this space over many years, and it hopefully won’t be long until the UIC/Caldicott course is made available online.

Many other programs (including some that I have contributed to) have been instrumental in getting the cannabis-curious up to speed. But even the most independent and accurate programs, if they are provided by ‘pro’-cannabis groups, may be avoided by sceptical prescribers. It’s not enough for education to be neutral, it also has to be perceived to be neutral.

That’s a thorny problem, but one we would greatly benefit from solving.