The announcement by Australia’s Prime Minister Scott Morrison of a long-awaited royal commission into suicide among the veteran and defence community shines a spotlight on the challenges they can face from a mental and physical health perspective, and is a welcome move.
Many veterans have experienced extreme situations and may suffer from complex conditions, which include chronic pain and PTSD. Cannabis can be a very effective treatment for many of these patients, improving their quality of life considerably.
The challenge of finding a supportive team, with experience in cannabinoid medicines, and the impetus to undertake the processes necessary to prescribe medical cannabis for them, is just the first step in a long journey for veterans.
Getting approval from the DVA to fund costs for these patients is rarely straightforward, but with the clinical support of the right medical specialist and administrative team, it is possible.
At CA Clinics, our team of specialists and support staff are well versed in each step of the application and approval process for medical cannabis and DVA funding approval.
In my discussions with vets, many have told me that they have suffered enough in their service to our country; and that the physical and mental toll that it has taken on them is often profound.
Accordingly, they report additional hurt and pain caused by the administrative and bureaucratic bottlenecks that come with approvals for effective treatments, including medical cannabis, and the commensurate DVA paperwork. Despite counselling a message of patience to them, many have experienced delays in other approvals before they met me.
Currently, the DVA provides approval for medical cannabis treatment costs for chronic pain patients where there is sufficient evidence to support its efficacy. This has already been established and is embedded within TGA guidelines for prescribing cannabis for this condition. Having to re-prove the case twice for another federal government body, the DVA, is generally not well accepted by the community of veterans I’ve treated.
To summarise, for any condition, a veteran must have the support of a specialist to be given funding for a special condition. For painful conditions, the group of qualifying specialists is a very narrow field.
Despite established evidence surrounding medical cannabis and the role of the endocannabinoid system in pain, finding appropriate specialists supportive of medical cannabis treatments is still a challenge. For many vets seeking out DVA funding without support, this is just one of many hurdles to be overcome.
Educationally, medicinal cannabis is not covered in great detail, if at all, in medical schools. Thus, without understanding or training in this paradoxically novel and ancient medicine, doctors are often hesitant to contemplate prescribing.
To complicate matters further, the Australian and New Zealand College of Anaesthetists’ Faculty of Pain Medicine does not officially endorse cannabis as a treatment for pain. In fact, in a recent media release, this group advised Australian doctors not to prescribe medical cannabis to treat chronic pain, outside of a clinical trial; because of a lack of sufficient evidence from clinical trials to support the use of medicinal cannabis as a treatment for chronic non-cancer pain.
Confining medical recommendations to the Cochrane database could equally reduce or wipe out established helpful treatments across most specialties as they exist currently. The legion of meta-analyses, systematic literature reviews and randomised trials which support the use of medicinal cannabis in chronic pain make the recent press release stand out for all the wrong reasons.
In a single statement, it has stigmatised a highly anticipated, readily accepted and helpful treatment.
Respectfully I, and many colleagues who are prescribing physicians, would disagree with this broad stroke statement. As registered medical professionals, it is our responsibility to assess each patient as an individual to determine the best treatment.
Naturally, interventional pain techniques and medicinal cannabis have never been trialled head-to-head. The limitations on such studies would be hampered by similar roadblocks. Randomised controlled trials, and meta-analytical data may trend to significant differences, but not always achieve it in either groups of therapeutic interventions.
In both cases, careful selection of appropriate candidates for these treatments needs to be considered long before implementation. Sometimes, this means we need to open up our thinking to other forms of evidence; and to accept adjuvant treatment, observational data, with comparative acceptable evidence, in situations which we might not have considered before.
So I call on all of my colleagues to consider joining us in trying to establish a body of evidence about medicinal cannabis, whatever the final outcome of those endeavours. Our team of addiction, rehabilitation, physician, and psychiatric experts are driven to prevent adverse outcomes, and risk-manage any potential for such an event.
This leaves us, in both cases, with the sort of “real-world evidence” collected from observational studies, combined with the existing and emerging randomised controlled trials and multi-centre data collation, to navigate a way forward.
In cases of chronic and treatment resistant chronic pain and PTSD, evidence suggests medical cannabis is both a viable and safe option.
Obtaining approval from the TGA for medicinal cannabis is, in itself, relatively easy and efficient for veterans. The next hurdle in this process is the administrative work involved in getting DVA approval for funding.
Chronic and complex pain conditions are experienced by Aussie veterans at a disproportionately higher rate than the rest of the population. Even when vets can find a pain specialist willing to support their DVA applications, wait times are often lengthy.
Given the expert groups’ position as a whole, getting a supportive recommendation for medicinal cannabis from them is never a certainty. This adds further to the emotional pain, stigmatisation and trauma already experienced by this group of people.
Patients must meet various requirements set by the DVA including the aforementioned supporting documentation from a pain or relevant specialist. Then the prescribing medical cannabis doctor compiles a detailed report with supporting evidence to submit to the DVA.
Having regard for the necessity for the current rules of expert opinions in such military compensation cases, this is not an aberration. However, the delays to treatment for this group can be considerable. From my dealings with veterans, it is often felt very personally.
DVA funding applications can take weeks or months to be assessed. They may be accepted, rejected or request for further information, the latter two outcomes generally resulting in further medical assessment and commensurate administrative work to be completed.
Although challenging, this pathway can be navigated with success for veterans with chronic pain, for the estimated 17.7% of ex-military personnel experiencing PTSD, DVA funding is currently unavailable for medical cannabis.
We understand that PTSD can be a challenging condition to treat with established, PBS-listed medications available to us. In almost all cases, they’ve already been trialled on our veteran patients, and found to be either partially, or completely treatment resistant.
Randomised trials of THC are difficult to implement, due to the clear differences between THC and a placebo. This inevitably draws us back to observational studies and empirical clinical evidence.
Such evidence informs us of a need to consider assessment of individuals on a case-by-case basis. As we work to remedy this, it is unfortunate to report that the DVA still declines funding medical cannabis for PTSD outright.
The healthcare system at large could, and should, serve our veterans as best it can. Whether that be using medicinal cannabis or any other clinically appropriate technique. In the case of medicinal cannabis, referral forms are readily accessible for doctors who would like to refer their patients to a rehabilitation, medical, psychiatric or addiction specialist, all with a special interest in chronic pain and mental health comorbidity, at CA Clinics.
Patients going through the DVA application process with CA Clinics should not feel alone, whether in rural or metropolitan areas of Australia. They are supported through every step of the process.
Given the nature of the evidence and the necessity for more clinical data, some may be invited to participate in ethics-approved clinical research, to improve the journey for both themselves, and for new DVA patients coming through.
This would involve real-world consumer experience utilising established products in a therapeutic environment. A community-based trial of medicinal cannabinoids in the real world, as it were.
The current CA Clinics Observational Study (CACOS) collects data on the safety, efficacy and patient-reported outcomes for medical cannabis including PTSD patients, which may be used to inform future research as well as potential future DVA funding. We are looking to follow approximately 3,000 subjects over four years, with a minimum of 12 months follow-up on each person.
It will inform future researchers on the potential outcomes of cannabis use in all of the established TGA-approved conditions, in which medicinal cannabis can currently be prescribed.
A major outcome of this study is to determine the efficacy, cost and side-effect profile of medicinal cannabis in response to the recommendations by the Australian and New Zealand College of Anaesthetists Faculty of Pain Medicine. More research is needed. CA Clinics will aim to take an active place in carrying out that work.
To summarise, navigating the pathway to medical cannabis and DVA funding approval isn’t simple, but it is possible. We have developed pathways, which we hope will ultimately improve veterans’ access to cannabis treatment, where indicated.
Enhancing the skills and education surrounding medical cannabis for health professionals will ultimately lead to positive and meaningful changes in the lives of Australian veterans. This should, after all, be our paramount goal.