Medicinal cannabis prescribing

Medical and nurse practitioners who have or planning to change their scope of practice to include treating patients with medicinal cannabis, must ensure that they have the necessary knowledge, skill and training to provide safe clinical care.

Good patient care includes

• Assessing patients thoroughly, taking into account their medical history, views and conducting an appropriate physical examination, including taking patient physiology into consideration. Before prescribing medicinal cannabis, it is particularly important to conduct a full assessment that includes a social, mental health and substance use history. This cannot be achieved in a short online consultation.
• Formulating and implementing a suitable management plan, that includes arranging investigations and providing information, a diagnosis, treatment and advice.
• Facilitating coordination and continuity of care. This means communicating (with permission) with the patient’s usual treating practitioners.
• Maintaining adequate medical records. We have seen evidence of inadequate documentation and the use of pre-filled medical record templates. Medical records must be accurate and include all the information necessary to facilitate continuity of patient care.
• Providing treatment options based on the best available information and only recommending treatments when there is an identified therapeutic need and/or a clinically recognised treatment, and a reasonable expectation of clinical efficacy and benefit for the patient.

With a few exceptions, such as the treatment of certain childhood epilepsies, muscle spasms and pain symptoms associated with multiple sclerosis, some neuropathic pain and chemotherapy-induced nausea and vomiting in cancer, there is little evidence to support the use of medicinal cannabis.

Patient demand is not an indication to prescribe medicinal cannabis. Medical and nurse practitioners should only prescribe it when there is an evidence-supported clinical indication and when other treatments have not worked. Medicinal cannabis should never be a first line treatment and there must always be an exit strategy, formulated at the beginning, for situations when the medicinal cannabis product is not helping to manage the patient’s symptoms, or the goals of treatment are not reached.

• Prescribing appropriately and safely includes:
  • prescribing medicinal cannabis products with the same care and diligence you would prescribe any other Schedule 8 drug
  • obtaining the necessary approvals from the Therapeutic Goods Administration (TGA)
  • complying with state, territory and jurisdictional laws and regulations, including using government real-time prescription monitoring service (RTPM) or equivalent, and My Health Record. This includes in the jurisdiction of both the prescriber and patient
  • checking what other medicines the patient is taking
  • not prescribing excessive quantities or providing early repeats
  • not prescribing a range of products that allow the patient to ‘test’ what they prefer – you would not do that for an opioid or antihypertensive
  • ensuring your contact details are available on prescriptions so the dispensing pharmacist can contact you if they need to
  • not self-prescribing or prescribing for family and others close to you.

The TGA has approved only two medicinal cannabis products for specific purposes. When prescribing an unapproved Schedule 8 product such as THC containing medicinal cannabis, the prescriber has an additional responsibility to inform the patient that they are being prescribed an unapproved product and provide them with information about the potential benefits and harms, so the patient can make an informed decision about their treatment. This should be documented in the medical record and the prescriber must be prepared to explain to the Medical or Nursing and Midwifery Board why the prescribing was appropriate.

• Gaining the patient’s informed consent. The patient must be informed that, unless they are prescribed one of the two TGA-approved medicinal cannabis products, their prescribed medication is not approved and has not been assessed by the TGA for safety, efficacy and quality. Informed consent takes into account the risks and benefits of that treatment verses other available treatments or no treatments at all, based on the individual circumstances. Practitioners must provide the patient with information about the medicinal cannabis product, possible side effects and treatment goals, and a plan to discontinue treatment with this product if benefit is not demonstrated.
• Reporting any side effects (adverse events) from therapeutic goods that are, or contain, medicinal cannabis to the TGA through the Adverse Event Management System (AEMS). 
• Recognising potential conflicts of interest, informing patients about the conflict and not allowing any financial or commercial interest to adversely affect the way you treat patients. Conflicts of interests are inherent if you are working in an organisation that prescribes and dispenses a single medication. A declaration of a conflict on a website is not sufficient, and you must be prepared to explain how a declared conflict is not impacting patient care.
• If you are doing a telehealth consultation, ensure you are complying with your Board’s codes and guidelines, including
  • confirming the patient’s identity, including date of birth
  • continuously assessing the appropriateness of using telehealth for the consultation and making arrangements for the patient to be seen in-person if necessary
  • accepting responsibility for evaluating information used in assessment and treatment, irrespective of its source. This applies to information gathered by a third party who may have taken a history from or examined the patient and to information provided by the patient, for example in an online questionnaire
  • not prescribing or providing health care if you have never had a real-time consultation with the patient. Asynchronous prescribing and health care is not supported by the Boards. The Boards do not consider an online chat to be a synchronous consultation.

Ahpra and the Medical and Nursing and Midwifery Boards are working with other regulators to understand prescribing patterns. We may investigate the practice of practitioners with high rates of prescribing any scheduled medicine, including medicinal cannabis, even if we have not received a complaint.

The following real examples show poor practice in prescribing medicinal cannabis:

• practitioners who have each issued more than 10,000 prescriptions for Category 5 medicinal cannabis products in six months
• consultations lasting between a few seconds and a few minutes, making a proper patient assessment impossible
• prescribing without a legitimate indication, including because the patient requested it
• not taking a mental health or substance use history from patients who have a past history of schizophrenia and have developed psychotic episodes after taking prescribed medicinal cannabis
• not checking the identity of the patient, including prescribing for people under the age of 18
• prescribing excessive quantities of medicinal cannabis in each prescription
• providing multiple prescriptions for a single patient so they can ‘try which one suits them’
• not checking the (RTPM) systems and therefore not being aware of other medications prescribed
• self-prescribing or prescribing for family members
• having a conflict of interest by only prescribing the product supplied by the company you are associated with.