As cannabis patient numbers continue to grow in the UK, so does the volume of discourse on how to best prescribe CBMPs (cannabis-based medicinal products). Many doctors accept that a bespoke, individualised patient-led approach by clinicians is an effective way forward, while some argue that the industry needs more prescribing guidelines to navigate the complexity of prescribing. Some suggest restricting under-25s from being prescribed flower with more than 25% THC, while others support restricting monthly limits to 40, 60, or 80 grams per month per patient.
Yet, it is widely accepted – to anyone who has done an inkling of research – that the Endocannabinoid System (ECS) is individual to each patient. What works for one person does not necessarily help another, even if they exhibit the same symptoms. What’s more, many cannabis patients have been self-medicating for years, having developed a unique understanding of how cannabis and its myriad of constituent compounds work best for them. As a result, the cannabis industry faces a unique conundrum: The Hybrid Patient. Instead of rejecting them, clinics need to learn how to embrace them and serve them best.
What is a Hybrid Patient?
The Hybrid Patient is eligible for a prescription and often sources their medication both through a specialised pharmacy on prescription and from the illegal market. They do this because they perceive that medical cannabis may not meet their needs on quality, accessibility, consistency, choice or price, but they still want medical supervision and protection from persecution and prosecution.
Some Hybrid Patients struggle with medicating as prescribed using a dry herb vaporiser. This can be due to tobacco addiction or, as some patients feel, they can’t get the desired medical effects from vaping alone. They may find symptom control better managed by combustion or taking edibles.
So, how do clinics navigate the complexity of the Hybrid Patient while still treating them for their symptoms, and adhering to strict prescribing regulations for unlicensed medications, while listening and acknowledging patients’ experience of medicating with cannabis?
The easy answer, and what some clinics seem to adopt, is the approach of “it’s not my problem.” If patients aren’t willing to adhere to clinic policy, then they can find a solution elsewhere. Yet this approach risks causing wider harm.
There are an estimated 1.8 million medical users of cannabis in the UK who aren’t prescribed through clinics. We risk alienating these people with a hardline, blanket approach of our way or no way. Over the past few years, the industry has improved access and consistency, and quality has had a marked improvement. Prescribers and producers, as well as many patients, agree that the flower available through the legal system is better than that accessible to many outside of it. As patient numbers increase, prices are reducing and becoming more competitive with the illegal market. But if clinics continue to refuse hybrid patients, then all these achievements amount to nothing, as cannabis patients get left out in the cold.
The more challenging answer is to adopt a system of harm reduction. Implementing an agreed treatment plan with the patient to not only improve symptom control, but to also reduce the risk to health. This is two-fold: reducing and ultimately replacing combustion with legal administration methods and decreasing and eliminating the patient’s need or desire to access cannabis illegally.
The transition from old habits to new can take time for many patients. Source: Depositphotos
The clinician and the clinical team can provide kindness, patience and encouragement to implement a harm reduction approach. Tobacco addiction is one of the hardest substances to quit. The withdrawal alone is hell, and lapsing is easy to do. It is wrought with failure. Once tobacco-free, the next challenge for the patient is to move away from combustion altogether and embrace dry herb vaporising.
Countless patients have gone from spliffs to vaporisers and will vow that they could never go back to combustion. It’s a tough path, and a lengthy one, requiring more input from the clinic and team. But when a patient succeeds, they invariably celebrate their achievement and enjoy better health overall. It’s not unusual that when patients fully switch to vaporising their flower, they reduce their monthly prescription amount as they find they use less, a strong motivating factor that can be emphasised by doctors.
Understanding the legacy market
To understand the Hybrid Patient, cannabis prescribing professionals need to understand the legacy market.
Many Hybrid Patients will have spent years, if not decades, self-medicating from illegal growers, and like patients, no two dealers are the same.
For some, cannabis will have come from well-meaning enthusiasts who grow for fun or passion. Some will give cannabis away for free, or sell on at a reasonable price to make their own flower affordable or free. Take the example of Bob and Babs down the road, with their spare room grow. They cultivate their plants with love, care and attention. They have taught themselves about the plant and its properties and have become a wealth of information that they happily pass on to their customers. Some cannabis consumers will argue that Bob and Babs beat the industry on accessibility. When particular products run out at a pharmacy, when a prescription has been rejected, or when meds turn up under par, Bob and Babs are there with a ten-bag or eighth in hand. The patient needs relief, and they can deliver within the hour. Bob and Babs are nice, caring individuals who take pride in their craft.
Clinics have a duty of care to include Hybrid Patients, to avoid them taking risks and to help them make informed, safe choices for themselves that reduce harm.
Many in the prescribing industry will argue that Bob and Babs are outliers and that most self-procured cannabis comes from criminals with no thought for patient care. Yet within the cannabis community, there are legacy craft, artisan cultivators, who are far removed from the dodgy, county lines gang, electricity-stealing back market producers. Sadly, those nefarious suppliers do exist as well – prohibition and punitive regulation create a vacuum where they can thrive. Doctors and clinicians need to realise that Hybrid Patients, in desperation, may put themselves at risk to access the medication that they need. This could be physical danger, meeting unknown people, or the risk of being scammed online by unscrupulous scallywags, or worse: the risk of consuming tainted, subpar cannabis. Tales of synthetic THC or spice sprayed on plants to give an extra ‘high’. Plastic beads found in cannabis to increase weight and profit. Urinating on plants in the belief that it helps growth and potency. The list of dodgy practices is endless and scary to consider.
Clinics have a duty of care to include Hybrid Patients, to avoid them taking risks and to help them make informed, safe choices for themselves that reduce harm. While the consultant is ultimately the expert in their speciality, the Hybrid Patient is an expert in their health and their needs, and sometimes, not always, they may already know what works best for them.
Implementing more restrictive guidelines, such as monthly limits or prescribing parameters and refusing to prescribe from other pharmacies, makes the Hybrid Patient run for the hills and into the arms of Bob and Babs, or something even worse.
