Understanding medical cannabis access in the UK

Medical cannabis is an unlicensed medicine in the UK. This means that it has not undergone sufficient clinical trials to be granted a marketing authorisation by the government. For this reason, the NHS rarely prescribes cannabis. The National Institute of Clinical Excellence governs the medicines that the NHS prescribe, and it is their responsibility to improve medical care based on scientific evidence. NICE has deemed there to be a lack of appropriate evidence regarding medical cannabis due to the absence of traditional clinical trials. 

However, even though the NHS only prescribes medical cannabis very infrequently, specialist doctors can privately write a prescription if they believe it is in your best interest and you pass the eligibility criteria. It is a high risk for doctors to prescribe off-licence medicines, which involve particular insurance policies and greater scrutiny with regulatory inspectors. Because of this, fewer doctors are prescribing medical cannabis than the demand requires. If you are reading this as a specialist consultant and are interested in becoming a cannabis prescriber, please get in touch so we can talk to you about the process of prescribing special medications off-licence with us.

Currently, a limited number of products are available in the cannabis-based medicinal products formulary in the UK. Clinics are tasked with sourcing and importing products primarily grown abroad due to the lack of native-grown produce. The supply chain follows the well-carved route of pharmaceutical importation, which is a heavily regulated and bureaucratic process and takes time. New products take a long time to come to market, and due to the shelf life of flowers being shorter compared to traditional man-made single-molecule compounds, coupled with the fact that it is an off-licence medicine, only small quantities can be imported at a time. 

The number of patients demanding products also influences the availability of the products, the amount of choice, and the price. The more patients that clinics sign up, the more stock they can import to meet the registered clinical needs of their patients. So, if people want medical cannabis clinics to introduce a variety of products, they should start using those clinics’ services. It will allow them to have the conversations needed with patient support teams and consultant doctors so that they know what kind of products are missing or in demand in the UK. 

Medical cannabis treatment methods in the UK

Below, we will look at the different types of products, delivery devices and administration methods currently available in the legal UK medical cannabis market. The cannabis-based medicinal products available as we move into 5 years of legal medical cannabis in the UK have much improved from those prescribed to the initial set of patients in 2018/19. 

Cannabis Flowers

Cannabis flowers are by far the most prescribed products on the market. Smoking medical cannabis is prohibited, so it is the doctor's direction to vaporise the cannabis flowers. Inhalation provides the fastest route to symptom relief for most patients. It offers a high level of bioavailability among the available options. 

Phytocannabinoids (cannabinoids found in plants), THC, and CBD mimic endocannabinoids (cannabinoids produced by the body) and are easily absorbed by the body and cross the blood-brain barrier. There are cannabinoid receptor sites all over the human body, and they play vital roles in every major biological system and organ. 

The flowers prescribed are carefully selected cultivars that are suitable to be produced on a commercial scale and meet the needs of patients for one or more conditions. This may be based on the THC and CBD percentages, another cannabinoid or the terpene profile. They are grown under regulated conditions and put through stringent lab tests to ensure they do not contain harmful substances or contaminants like mould, bacteria, heavy metals, pesticides or fungicides. They must be dried to 10% moisture and may be sterilised with irradiation or another method for shelf-life reasons. 

Strain names can sometimes be a point of contention between different industry groups. Cannabis-literate patients who have relied on unregulated sources of cannabis before the legalisation of medical cannabis have experienced strains that work well for them (and ones that do not work so well). However, many of these strain names are unsuitable for medicine and have been changed to be more acceptable. Doctors want to provide reassurance that the treatments are valid and appropriate, and cannabis-naive patients who are new to cannabis medicine may be worried by non-medical sounding names. Legal producers have developed some strains for their medical and commercial suitability. 

Dry Herb Vaporisers

A dry herb vaporiser is an electronically powered device. They may be battery-powered, to allow for mobile use, or they can be mains powered, making them stationary. Ultimately, they both deliver the same outcome - hot air extraction of cannabinoids for direct inhalation.. 

The dry herb vape was innovated to move away from the harmful effects of combustion. Clinical research has taught us that vaporising is around 40% more efficient than smoking and does not destroy any THC because the temperature is controlled. There is only one medically approved vaporiser brand on the market, Storz and Bickel, who manufacture the Crafty, Mighty, Plenty and Volcano devices. Every component and procedure in the manufacturing process meets the necessary standards to pass the test. 

Dry herb vaporisers are now widely available and come in various designs by different producers. The common functionality is that they heat up a regular size dose of herbal medicinal cannabis flowers in a chamber set to a specific temperature. The device will stay on for a set amount of time, creating a uniform administration method. The patient can control how much vapour and cannabinoids they take in by controlling the strength, speed and number of times they inhale during the period the device is on.

Releaf patients can choose to order an Omura vaporiser through the patient platform, either on its own, or as part of The Releaf Starter Kit, so they are ready to administer their medication as soon as it arrives. Find out more about our starter kit here and how you can get one. 

It is advised that patients monitor symptom relief after vaping medication if they need to discuss adjusting the strain or dosage with their doctor in the next appointment. 

Portable dry herb vapes have a limited battery life, so it is advisable to carry a portable battery device at all times or a set of spare pre-charged batteries if the device can switch out batteries. You may also be able to find a battery that has a larger power capacity and lasts longer. 

Cannabis Oil

Cannabis oil contains the active ingredients (THC, CBD and other cannabinoids, terpenes etc) from cannabis that have been extracted into a concentrated form. Cannabis oil is an oleoresin containing resins, terpenes and sesquiterpenes, among other pharmaceutically active naturally occurring ingredients. 

Cannabis oil can be extracted via solvent, pressurised gas or mechanical processes, but in commercial pharmaceutical medicine, solvents such as ethanol and pressurised gas like CO2 are the most utilised options. Cannabis oil has a viscous consistency, is golden in colour and transparency increases with purity. 

Cannabis oil is versatile and can be infused into an almost unlimited number of products, although it is hydrophobic requiring an emulsifier to dissolve in aqueous solutions. It can be vaporised and taken orally, sublingually, as a suppository and applied topically. 

Sublingual Cannabis Tinctures

Sublingual tinctures are a very old method of administering controlled doses of herbal extracts or medical compounds. In the scope of medical cannabis, a sublingual tincture contains cannabis oil concentrates dissolved in a carrier oil. The carrier oil may be a seed oil or an oil extract such as MCT, short for Medium Chain Triglyceride. MCT has two benefits over seed oils: it takes longer to go rancid, giving it a longer shelf life, and some studies indicate it has a greater level of bioavailability than seed oils. 

Tinctures require a pipette to administer one or more drops to equal the desired or prescribed dose. The strength of each drop will depend on how much active ingredient is in the solution of the total product volume. A 10ml bottle contains 200 x 0.05ml drops, and a 30ml bottle contains 600 x 0.05ml drops. 

Sublingual tinctures work by exposing the membrane skin under the tongue and of the gums to the cannabinoids, which are rapidly absorbed. Tincture absorbed through this membrane bypasses the liver and is absorbed directly into the bloodstream. The benefit of this is the effects of the cannabinoids can be felt within 10-15 minutes. The effect is also from Delta 9 THC. 

After several minutes of holding the tincture in the mouth, it can be swallowed, allowing for dual oral action. When THC is swallowed, it is passed through the liver. It metabolises into 11-hydroxy-delta-9-tetra-hydro-cannabinol, which is reported to be around 12 times more potent than Delta-9 THC and takes around 45 minutes to an hour to take effect. 

Epidyolex is the only licenced CBMP tincture and it is made with CBD isolate. The medicine that has passed clinical trials is designed to treat the childhood seizure conditions Dravets Syndrome, Lennox-Gastaut syndrome and tuberous sclerosis complex. It can be prescribed as an adjunctive medicine. 

Cannabis Oil Capsules 

Cannabis oil capsules, often nicknamed cannacaps, are much the same preparation as sublingual tinctures: cannabis oil in a carrier oil designed to deliver a specific dose of cannabinoids. The difference is they are encapsulated in a gel-based pill and are to be swallowed, meaning the cannabinoids are processed and metabolised by the liver before entering the bloodstream. 

Some of the benefits of cannacaps are they can come in higher single doses than tincture drops and avoid having to taste the cannabis oil, which can be earthy, peppery and bitter. Due to the augmented strength of 11-hydroxy-delta-9-tetra-hydro-cannabinol, it is also very effective for people treating chronic pain conditions. 

The downside is the oral bioavailability of cannabinoids can be relatively low in some people, so they can prove ineffective for some patients. They also take 45 minutes to an hour to kick in, so patients looking for immediate relief may not find cannacaps as useful. However, some patients find a combination of inhaled and oral cannabinoids meets their pain relief needs. 

Cannabis Concentrate Vapes

Concentrate vapes consist of cannabis oil and terpenes combined in a cartridge designed for a vape pen battery device. The cannabis oil contains THC, and the terpenes provide modulation that can steer the outcome of symptom relief for patients with different conditions. Terpene profiles can be naturally derived from cannabis or constructed with separate pure terpenes derived from fruit and other sources and reconstructed to mimic strains. 

The cartridge has a heating element often referred to as an atomiser. Cartridges are similar technology to e-cigarettes; only these cartridges are designed to work for cannabis oil's viscosity and with elements that meet medical grade specifications. Inhalation duration can be controlled by holding down and releasing the activation button. Some vape pen devices time out after a set number of seconds to deliver a consistently controlled low dose every time. 

Concentrate vape's benefits come in the form of being discreet as they do not draw as much attention as dry herb vaporisers. They are ready to use at the touch of a button, and reloading them is simple, requiring magnets or a small screw thread. Their controlled dosage delivery makes them favourable to many patients looking for effective, hassle-free pain and anxiety-relieving solutions. They also have a lower level of smell, which dissipates faster than flowers in a dry herb vape. 

Cannabis Lozenges

Another product that can be made by infusing cannabis oil into other traditional forms of administration is lozenges. Cannabis lozenges have recently become available in the UK medical cannabis market, creating excitement that more innovative oral products may be on the horizon. Cannabis lozenges are hard-boiled, gelatin or pectin-based sweets with a set mg dose of THC, CBD or both. They can be sucked, allowing for a slower release as they dissolve in your mouth over time or eaten whole. 

The benefit of lozenges is they are discreet and easy to administer without people realising you are taking medication. Another not-so-obvious benefit is they are helpful for patients who find it hard to swallow pills or are unable to cope with the taste of sublingual tinctures. 

Cannabis Buccal Spray

THC and CBD can also be delivered in a form of mouth spray. The targeted route of administration is the buccal membrane and the sublingual mucosal membrane. Buccal refers to any of the skin inside the cheeks and behind the lips that touch the teeth. There is only one CBMP that uses this administration method and that is Sativex, produced by GW Pharmaceuticals who were bought out by Jazz Pharmaceuticals. It contains a 1:1 10% solution of THC and CBD. The MHRA issued marketing authorisation for Sativex in June 2010 allowing specialist consultants to prescribe it as an add-on medication for symptom improvement for spasticity in Multiple Sclerosis. 

Cannabis-based medicinal products not yet available in the UK

Below are some of the cannabis-based medicinal products that exist and are available in other countries but have not yet been imported or produced in the UK. If doctors discover a greater and genuine clinical need for these kinds of products, it will allow clinics and pharmacies to take the necessary steps to start introducing them into their formularies. 

Cannabis Transdermal Patches

Transdermal patches, also known as transdermal delivery devices (TDD), have not yet been made available on the UK medical market. They are made of multiple layers with different membranes to protect the medication, hold the active ingredients and improve skin permeability. The aim of a transdermal patch is to deliver small doses of activated cannabinoids over a timed release period by absorption into the skin. 

Cannabis Topical Balms

Topical cannabis balms are creams or ointments with cannabis oil infused as one of the main active ingredients. The theory is that they work locally by interacting with cannabinoid receptors on the skin's surface and within the tissue. One advantage balms have over patches is that they can cover larger areas simultaneously. Topical cannabis balms will not enter the bloodstream, so they will not negatively affect cognition.

Cannabis Wafers

One of the least known methods of administering cannabinoids is through wafers. They are dissolvable tablets that melt completely in the mouth within 5 to 15 seconds, allowing most cannabinoids to be absorbed. 

Wafers and other buccal medications are quite common in medicine and provide a non-invasive way to quickly administer molecules quickly into the bloodstream. 

Cannabis Suppositories 

Suppositories are another traditional method of administering medications. Suppositories are large pills designed to absorb easily when inserted into the rectum with an applicator that ensures you insert it at the right distance. They require the preparation with the active ingredient to be inserted 10 cm into the rectum. Insertion into the rectum allows the medicine to absorb directly into the bloodstream, bypassing the liver. 

Vaginal suppositories are tablets inserted into the vaginal canal to deliver the medicine close to the area that needs treatment. The skin membrane inside the vaginal canal, known as the vaginal epithelium, has the same properties as the inside of the mouth and underneath the tongue. Due to the wide surface area, it provides an excellent environment for slow, steady and high rates of absorption. 

Cannabis Inhalers

Only at concept-stage, the idea is to deliver a metered dose of medicine through one puff of an inhaler in a similar way to how steroids are delivered for asthma patients. Problems that have presented themselves are the consistency of the cannabinoids, the size of the dose, the effectiveness of the device and, of course, with any medical product - funding, but a study has shown limited promising results for some acute and chronic pain patients.

CBMP Roundup

The catalogue of products currently available in the UK is expanding every month. The greater the number of patients receiving a prescription in the UK, the wider the choice of products will become. The range of flowers and the quality is increasing with the increased awareness gained from more doctor-patient interactions. The price of products will eventually come down over time as patient numbers grow and order quantities increase. The number of new products being prepared for the market is improving too. New innovations continue to bring increased hope for discreet, hassle-free administration options, with onlookers unaware that it is cannabis medicine. 

Don't let the stigma surrounding medical cannabis prevent you from getting a suitable treatment. Releaf provides tailored monthly packages, specialist consultations for medical cannabis, and a unique medical cannabis card for protection, all based on your medical cannabis prescription.