Five years since legislation: A comprehensive overview of UK medical cannabis

To celebrate that it has been half a decade since the landmark legalisation of medical cannabis, we thought we’d take a look at five ways this has impacted and shaped the UK - one topic for each year of legalisation.

The legalisation of medical cannabis in the UK

Five years ago today, on November 1st 2018, the government announced that cannabis-based medicines had been legalised in the UK. Following recommendations from the Advisory Council on the Misuse of Drugs, and advice from England’s Chief Medical Officer, medical cannabis was approved as a suitable, and legal, treatment option for several health conditions, under certain provisions. 

When the legalisation took place, guidelines for the NHS prescription of cannabis-based medicines were established, however, many feel these prescribing protocols are too harsh and restrictive considering the NHS’ obligation as the nation’s universal healthcare provider. 

This is largely because the law change endorsed only three cannabis based products for medicinal use in humans (CBPMs) for prescription on the NHS. These medicines, Sativex, Epidyolex and Nabilone, all have licensing approval as medicines from the Medicines and Healthcare Regulatory Agency (MHRA), and have been approved by the National Institute for Care Excellence (NICE). 

Due to this approval, the NHS feel confident in prescribing these medications in the right cases. But, now, all other cannabis-based treatments are held to the same standard, and so it is extremely rare for the NHS to prescribe unlicensed CBPMs. Unlicensed cannabis-based products can be prescribed in the UK, including oils and flowers, but these are only typically accessible through private medical cannabis clinics and are funded by the patient. 

Both licensed and unlicensed cannabis-products can legally be prescribed by doctors in the UK, so long as they feature on the General Medical Council’s Specialist Register. These products can be produced by cultivators and manufacturers in the UK, provided that they have the proper authorisation and are complying with strict standard operating procedures and EU Good Manufacturing Practice requirements. 

To be considered eligible for cannabis-based treatments, patients need to have tried at least one conventional treatment option that has proven unsuccessful in managing their needs, or has caused unpleasant and unwanted side effects.

Five years of patient access and experiences 

Five years on from the legalisation of medical cannabis, it is still unclear exactly how many patients access prescribed medical cannabis in the UK, and the precise figures are largely gate-kept from the public because of GDPR regulations.

However, our Say No To Pain Report, which was conducted in April 2023, suggests that as many as 50.2% of the population may be living with a health condition that medical cannabis has shown potential in managing. Even though this equates to around 29.6 million people, our report also suggests that less than 1% of those who may be eligible, hold a valid prescription for cannabis based medicines or medicinal cannabis. 

But, there is a large disparity between the estimated current figures of patient eligibility, and the amount of patients actually able to access these medicines in the UK. Without concrete figures, it is difficult to give an accurate depiction of how widespread accessibility is. Last year NHS England did launch a patient registry to keep a record of those receiving cannabis-based treatments in England, but this data is kept private – and even the number of people on this registry has not been released. 

When questioned on this subject earlier this year, the NHS Business Authority stated that they were unable to reveal the number of unlicensed cannabis based products for medicinal use (CBPMs) that have been prescribed by the NHS since their legalisation.

They could, however, reveal that 11,976 licensed CBPMs were prescribed between November 2018 and October 2022 by the NHS, whilst the private healthcare industry prescribed just shy of 90,000 unlicensed CBPMs during the same time frame. It is important to bear in mind that these figures relate to the quantity of products prescribed within four years, not the amount of patients that have received a prescription for CBPMs. 

The same month, the Minister for Health and Secondary Care, Will Quince, expanded on this, and explained the NHS could not disclose the number of unlicensed CBPMs issued, because it attributed to fewer than five patients, and revealing this information could lead to those patients being identified. 

Later in April, MP David Mundell claimed that during 2021, 17,000 people in the UK received a legal prescription for medical cannabis. He said this during a Westminster Hall debate and also cited estimations that predicted that by 2024 there could be as many as 337,000 potential medical cannabis patients in the UK. 

Then, in July 2023, a different figure was stated by MP Crispin Blunt. Whilst filing the Early Day Motion to open up prescribing rights to GPs in the UK, Blunt said as many as 20,000 patients in the UK have a private prescription for medical cannabis, and 1,000 have a valid NHS prescription. 

However, there are also reports that the number may be as large as 32,000. Regardless of the real figure, one thing is clear: the UK government either do not want the general public to be aware of how many people are being prescribed cannabis-based products in the UK, or they do not know themselves. 

Some argue this concealment could be tactical, because it would shed light on the amount of money these individuals spend each month in managing their health conditions, despite living in a country with a national health service. Others argue their reluctance could come from a place of self-serving protection, in case medical cannabis is proven to be dangerous to health in the future. 

With upwards of 15 medical cannabis clinics now available to those in the UK, patient experiences in accessing these treatments using private healthcare systems can vary from clinic to clinic. When the law initially changed in 2018 there were plenty of kinks for these clinics to work out, from keeping a steady supply of medication available, to ensuring that products and healthcare quality remains high. Although substantial progress has been made, five years on, many patients still face issues in accessing high quality, cost-effective cannabis-based medicines. 

Because this industry revolves around people’s health and wellbeing, many feel these ‘kinks’ are not only disruptive and dangerous, but they could have been avoided if the UK had learnt from other nation’s mistakes, like the US and Canada. 

Generally, anecdotal reports show patients who have entered the medical cannabis world recently tend to report more positive experiences than those who have been prescribed cannabis-based medicines for a number of years, due to these industry improvements. But, as the industry has evolved and adapted over time, there are still real issues that persist, such as patients receiving subpar products, unclear pricing structures and delays or disruptions in medication availability, which can have a considerable effect on their overall health. 

Five years of public perception and awareness

In June 2023, we investigated public attitudes and perceptions towards medical cannabis in our first market research report: Say No To Pain. Our results demonstrate, that although almost 84% of respondents were aware that medical cannabis has shown to relieve a number of health conditions, an estimated 16.5 million people still thought medical cannabis was illegal in the UK. This equated to over a third of our survey sample (34.8%), and almost a quarter (23.7%) were unsure of its legal status. 

Despite this confusion over its legality, our findings also suggest around 68% of the UK’s population would consider medical cannabis as a treatment option, but knowledge of which medical conditions qualify for cannabis-based treatments was largely varied. 

These findings propose that in the UK, people are aware of the medicinal and therapeutic potential cannabis can have, and would be willing to embrace it -  but the education and knowledge surrounding its legality, and the large range of conditions it can be used to treat, is severely lacking. 

Another way of analysing awareness of medical cannabis in the UK, and how this may have changed over time, is by looking at Google Search trends data - because the internet acts as a mirror, reflecting what society is interested in. In the UK, medical cannabis was searched for online 19% more in the last year, than it was in 2018 when it was first legalised, showing that as time has gone on, interest has grown. In England alone, interest has doubled in the last year – reaching its peak in the last few months. Going even deeper, between July and September 2023, searches for ‘medical cannabis clinic’ were 197% higher than they were between January and March, which shows how rapidly interest has grown in the last year alone.

It appears that although interest has boomed, the general acceptance of these treatment methods has been present since before the law changed. A survey conducted one week prior to the legalisation of medical cannabis in 2018 found that 76% of people in the UK would take ‘cannabis medicine’ if it had been prescribed by their doctor. These findings of significant support were stable across all age ranges, so long as it had been advised by a healthcare professional, and the lowest level of support came from the 65+ age bracket, but who were still 74% in favour of CBPMs. 

Although currently GPs are not able to prescribe medical cannabis, or cannabis-based medicines in the UK, a survey of attitudes towards these treatment options by GPs in the UK provides insight into the current perspective held by healthcare professionals. This survey of 1005 General Practitioners in the UK (2.9% of the current workforce) found 51% supported the use of cannabis-based medicines as an alternative treatment for patients who have exhausted licensed medicines, and over a quarter believed cannabis-based medicines could improve quality of life. 

However, 48% said they would like clear and concise summaries of the most up-to-date evidence-based research, or GP focussed e-learning (46%) on the subject to help them answer any questions their patients present to them about cannabis-based medicines more confidently.  This study also showed support for cannabis-based treatments varied significantly depending on health conditions, with high levels of support for conditions like multiple sclerosis, cancer pain and intractable epilepsy, but significantly lower levels of support for conditions such as anxiety and depression. 

Recently, in October 2023 Liverpool John Moore University published the UK’s first report of a qualitative survey that interviewed medical cannabis patients about the barriers they face, and their responses relating to awareness are of interest here. This study revealed that there are plenty of issues experienced by patients, and some of the most devastating include accessing medical cannabis because of a lack of funding and a lack of training, in both law enforcement and healthcare professions. In addition to this, issues in supply and problems with stigmatisation and criminalisation for taking their medicine in public were also raised by respondents. 

In our report, we also spoke to our respondents about the societal stigmas, perceptions, or prejudices that may impact their decision to start a course of cannabis-based treatment, or administer their medication in public if they had received a doctor’s recommendation for its use. And the responses were very similar to those of Liverpool John Moore Universities.

We found, the most common societal stigmas that would discourage the use of medical cannabis, even if it had been recommended by their doctor, were being mistaken for acting illegally (34.2%) and having a fear of being questioned by the police (24.5%). Respondents cited other reasons that would influence their decision, such as being worried about getting high or experiencing side effects, being labelled a ‘stoner’, experiencing disapproval from their family, friends, or landlords – among others. 

The fear some patients have about being stopped by the police, or mistaken for acting illegally, are very real and substantiated by fact. As the number of cannabis patients grow in the UK, so do the number of patients reporting negative interactions with the police. 

Instead of feeling protected by the police, many have been prosecuted, arrested, or had their medication confiscated due to misconception, misinformation about protocols, and outdated stigmatisation. 

This has instilled a sense of fear in many patients and has fostered a distrusting atmosphere, leading to many feeling they have to hide their patient status. There has been a loud call from the community to the government and Home Office to instil mandatory training that would ensure medical cannabis patients are treated fairly by law enforcement, free from discrimination, and it is staggering that five years in, this still happens regularly. 

There are also countless reports on community forums where people share their experiences and anecdotes expressing they feel they have suffered from discrimination, prejudice, or stigmatisation from other authorities such as landlords, employers, and entertainment venues. It is clear that education and training is required in many areas, but currently the responsibility is put on patients to educate these organisations and authorities about the legality of medical cannabis, and there is no mandatory responsibility for these agencies to ensure they have safe practices in place that protect medical cannabis patients.

The Cannabis Industry Council have released guidance and information for individuals to share with these relevant parties, such as the use of prescription cannabis at work, and when driving, but many feel this should have come from the government.

Five years of medical cannabis research

In the last five years, there has been a significant increase in the amount of research conducted in the Medical cannabis field, and the UK has contributed to some of the most impressive findings to date. 

Some of these impressive findings include:

• A study published in the British Medical Journal observed an 86% drop in seizure rates in epileptic children when they were treated with whole plant cannabis.
• Great Ormond Hospital in London have also led and participated in two international trials that analysed the effects of CBD on epilepsy. They found children with Dravet Syndrome displayed a 40% reduction in seizures when compared to a placebo. 
• Drug Science’s project T21 that found more than 4 in 5 patients with severe anxiety or depression reported an improvement in their symptoms within three months of cannabis-based treatments. 
• Project T21 also found medical cannabis improved people’s quality of life by over 50% because of the effect it has on their symptoms. 
• Our Say No To Pain Report found that of those living with conditions that medical cannabis has shown potential in treating, 46% live with significant discomfort, and just under a third said their health affects their ability to work and study. 
• Researchers from the University of Aberdeen discovered there is a genetic switch within cannabinoid receptors that may explain why people respond differently to drugs. Further research in this area could help to identify who may benefit most from medical cannabis, and help to tailor treatments to avoid or eliminate unwanted adverse effects. 

However, many feel this is not enough. Just a month before the legalisation of medical cannabis in November 2018, the National Institute for Care Excellence issued a call for research proposals investigating cannabis-based products for medicinal use. Despite this, the National Institute for Health Research website suggests only five funded research programs involving cannabis have taken place during this time, and not one investigates its potential as a medicine for the conditions currently deemed eligible for treatment. 

Instead, these research studies focus on the potential harm cannabis use may cause for society, or the risks it may pose for mental health. Four out of the five are currently active, and one was discontinued last year. The cheapest research project was reportedly given around £110,000 in funding, whilst the highest amount awarded was £1,855,000 – with the total amount awarded exceeding £3.1 million for all five. 

King’s College London have also launched an investigation into the effects of cannabis with the aim of exploring the effects of cannabis use on the brain, particularly the possible risk of developing paranoia and psychosis. Although a reported £2.5 million has been secured in funding, the Cannabis & Me Study is under threat of closing because it is failing to attract a representative sample of the UK population. 

A lack of representative data is a common issue in the medical cannabis industry, and in healthcare as a whole, as the majority of gold-standard randomised controlled trials available tend to generally involve young, white males. Although these studies do demonstrate the potential medical cannabis can have in certain areas, personal biological factors such as age, gender, race, body mass and fitness level all influence how medications interact with our bodies in different ways, because this is influenced by our genes, hormones, metabolism, and so many other factors. 

Although it appears it is easier to secure funding for studies that investigate the potential harms of cannabis, than it is for those that wish to explore its therapeutic benefits – the findings from these studies do help to ensure medical cannabis practices can be as safe as possible. 

Imperial College London have also announced plans to research the effects of cannabis-based medicines in the last few years, and have developed a Medical Cannabis Research Group. Specialising in inflammation, pain, and cancer, the group have announced they are in the development phase of a randomised controlled trial that aims to investigate the potential cannabis-based medicines could have for patients experiencing post-operative pain, nausea, and vomiting. Pending the commencement, results, and reception of this trial, this investigation could widen the scope of conditions the NHS may be willing to prescribe for. 

One trial that is producing updated evidence at regular intervals is Project T21 - which was launched by Drug Science in 2021 with the vision of becoming the UK’s largest observational study of medical cannabis. Over 4,000 patients who are prescribed cannabis based medicines for a range of conditions are currently enrolled and taking part, and T21 have released updated findings, or ‘data nuggets’ every month since July 2021.

Their impressive dedication to continued research has managed to create the largest continuous data-set that has helped to build an evidence base for the use of cannabis-based medicines. Published monthly updates have specialised in mood, anxiety, PTSD, ADHD, depression and sleep, as well as chronic pain, multiple sclerosis, fibromyalgia, epilepsy and Ehlers-Danlos syndrome. One of the founding members of T21, Khrion Life Sciences, have also published two peer-reviewed papers on the efficacy of cannabis-based products. Efforts from industry members like this are helping to propel the industry, but many feel support from the State could speed up and scale up this process considerably.  

Recently, in August 2023, Caledon and LVL Health secured approval from the NHS Research Ethics Committee for another new trial, this time analysing the impact medical cannabis can have on patients with chronic, non-cancer pain. This trial aims to evaluate the effects cannabis-based products can have on quality of life, pain, and sleep using a survey size of 5,000 and had already gained conditional approval from the Medicines and Healthcare Regulatory Agency before being granted NHS approval. Ultimately, the team aims to provide evidence that will show the potential for prescription and reimbursement of these medicines by the NHS and health insurance companies. 

Five years of economic impact of the industry 

Certain vested interests involving powerful politicians initially obscured the facts and figures that show the economic potential of cannabis at the point of medical legalisation in 2018, and this pattern of concealment appears to have continued. 

Five years on, the government remains hesitant to reveal the true financial impact of medical cannabis. So, in order to get an idea, we must rely on expert estimations and piece together several economic accounts and financial records to try to uncover the true economic impact of cannabis legalisation. 

Back in 2019, Prohibition Partners released their report and projections for the UK’s cannabis markets. Here they estimated that by 2024, the medical cannabis market could be worth up to £1billion, and that if the UK had legalised cannabis completely in 2021 the entire cannabis market could generate up to £3.5 billion in tax revenue alone during 2024. 

Although the government has refused to reveal the monetary value associated with cannabis exports, it is well known that the UK has dominated global cannabis exports for a number of years. In 2023, the UK contributed to 43% of cannabis exports worldwide. Whilst the price for these exports remains under lock and key, a calculation using typical street values suggests that since 2018 the UK has produced over £7.1 billion worth of cannabis, with 2021’s haul worth over £2.09 billion alone. 

Although Ireland is not part of the UK, looking into Dublin based Jazz Pharmaceutical’s financial reports shows the incredible potential that just one licensed cannabis-based medicine can have. Jazz Pharmaceuticals are a biopharmaceutical company based in Ireland that make, develop, manufacture, and research medicines, such as Epidyolex - a formulation of pure CBD. Records from 2022 show that Epidyolex alone generated sales of over $736 million in that year, and their other cannabis-based medicine Sativex generated further sales of $16,825. Figures like this propose illustrate that investing in cannabis-based medicines could be incredibly beneficial for the economy. 

Findings like this attribute to the common belief that cannabis could be a ‘cash crop’. 

Further research from 2023 estimates around £3.57 billion is spent by people in the UK illegally sourcing cannabis for a medicinal purpose. With an average spend of £156 a month being funnelled into criminal enterprises, 1.8 million people in the UK are believed to be buying street cannabis in order to manage a health condition they live with. When asked why they were sourcing cannabis in this way, the most common reason stated was because respondents believed it would be too difficult to access legally because of the regulatory frameworks in place. 

Rectifying this issue, raising awareness of the benefits of legally sourcing medical cannabis, such as quality and safety standard testing, and reinforcing the dangers that can come with street cannabis could redirect this money into legal markets. This additional income could then be used to fund further research and clinical trials - instead of organised crime. 

Another report worth mentioning is the Potential Savings from the Legalisation of Cannabis Report, which was published by the Taxpayer's Alliance six months before medical cannabis was legalised in the UK. In May 2018, the alliance released their report which largely focused on the economic impact a fully legalised cannabis market could have, however, there were some useful insights into NHS spending mentioned in this report. The Taxpayer’s Alliance claim the NHS spends around £132.6 million a year on prescribed pain medications, a further £79.98 million on anti-depressants, £21 million on anti-anxiety medications, and £43.2 million on prescribed sleeping tablets in one year alone. 

Here the increasing evidence base that suggest medical cannabis has shown potential in managing a plethora of conditions is noted, and comorbidity amongst medical cannabis patients is common. Generally, studies involving patients with comorbid conditions report an  improvement in various symptoms of different health conditions after starting cannabis-based treatments. Some papers also note once starting cannabis-based treatments, the amount of other prescribed medications, or dosages of these medications, can be reduced or stopped completely. For this reason, many argue that making these options available on the NHS could reduce spending in other areas, and reduce the harms or risks caused by some pharmaceuticals such as opioids. 

Five years of regulatory challenges and outlook for the future

Less than two years into the legalisation of medical cannabis in the UK, there was a surge in news reports exposing the sheer lack of NHS prescriptions that had been issued. The parents of epileptic children who had campaigned so hard for this change in law, as well as organisations like End Our Pain and PLEA repeatedly reported issues in accessing their prescribed medications on the NHS. Many reported spending thousands of pounds every month funding it themselves through private clinics, with families selling their businesses or remortgaging their houses to afford their medication, and many are still facing these issues today. 

A year later, in 2021, MP Jeff Smith first introduced the Medical Cannabis Access Bill with the aim of expanding the current prescribing rights to include GPs to improve access to these options. It also proposed to establish a commission to assess cannabis-based products in terms of their safety, efficacy, and quality. However, the government later blocked this bill. 

The same year, NICE did update their existing 2019 guidelines for prescribing cannabis based medicines because the industry had progressed rapidly. But, now many in the industry are asking for this to be updated again, taking into account the sheer volume of residents in the UK now considered eligible for these treatment options. 

Other industry members have repeatedly called for gold-standard randomised control trials in other areas, investigating the therapeutic potential of medical cannabis managing pain, anxiety and gastrointestinal conditions, in the hope of expanding NHS prescribing restrictions. And until then, it is commonly argued that medical cannabis will not only be impacted in terms of access and bound by rigorous NHS restrictions, but will also continue to be censored, stigmatised and severely limited by laws surrounding its advertisement. 

In the last year, the subject of medical cannabis has been included in parliamentary discussions on a number of occasions. For example, in July 2023 MP Crispin Blunt filed an early day motion, reiterating Jeff Smith’s proposal to allow GPs the right to prescribe cannabis based medicines in the UK. 

Now supported by 17 MPs across the United Kingdom, this EDM asks the government to reconsider the requirements doctors have to meet in order to prescribe medical cannabis, and grant the 36,000 GPs in the UK permission to prescribe these items. 

Currently, only doctors included on the General Medical Council’s Specialist Register can prescribe these products in the UK, and only about 100 are estimated to do so – which is approximately 0.25% of those that can. In October, the Cannabis Industry Council built on this, announcing they were releasing a draft Bill to raise further awareness of this matter amongst members of parliament. 

In August, the Home Affairs Committee released their report. Here, they stated that although there were no plans to legalise or regulate cannabis for recreational purposes at any time in the future because of the risks involved in non-medicinal use, they do support greater provision for medicinal use where there is sufficient evidence it may be a helpful treatment option. The Home Affairs Committee also recommended further research into the therapeutic benefits medical cannabis can have for those living with chronic pain. 

Although the number of cannabis-based medications prescribed by the NHS still remains extremely low in relation to the other conventional medicines, and low in relation to the number of private prescriptions issued, it appears relations with the NHS are slowly moving in the right direction.

In January of this year, Zerenia Clinics announced they had managed to secure one of their patients a reimbursement from the NHS, covering the costs associated with their cannabis medicine and clinic fees. Although since then this has only happened in a handful of other circumstances, many still remain hopeful and optimistic for what this holds for the future. 

Although things have improved, in reality there are still thousands of patients in the UK facing issues in accessing high-quality, cost-effective cannabis-based medicines, free from stigmatisation and/or discrimination, on a daily basis.