Medicinal cannabis doctors on notice over drug-induced psychosis and rapid fire prescribing
Australia’s medical regulator is releasing new medicinal cannabis guidelines to crack down on poor practices that have harmed patients and prioritised profits over welfare.
The medical watchdog is cracking down on doctors writing thousands of scripts a month for medicinal cannabis, with consultations lasting seconds, prescribing to children, to patients who just ask for the drug and to those who end up suffering psychosis.
In an attempt to rein in a booming industry based on huge numbers of scripts written for products that have not been tested for efficacy, the Australian Health Practitioner Regulation Agency and the National Boards will on Wednesday release the nation’s first official guidelines for the prescribing of medicinal cannabis.
The guidelines formalise existing rules and remind prescribers, which includes doctors and nurse practitioners, of their professional and ethical obligations, with Ahpra pointing to a list of “poor practices” including practitioners who self-prescribe and write scripts for friends and family.
“We don’t prescribe opioids to every patient who asks for them, and medicinal cannabis is no different. Patient demand is no indicator of clinical need,” warned Medical Board of Australia chair Susan O’Dwyer.
However, according to Ahpra, eight practitioners issued more than 10,000 medicinal cannabis prescriptions in just six months, while one practitioner is believed to have issued more than 17,000 in the same period.
“I think it’s extremely concerning,” Ahpra chief executive Justin Untersteiner told The Australian. “I can’t see how a practitioner that has prescribed 10,000 medicinal cannabis prescriptions in six months could possibly be meeting their obligations and I can’t imagine that they would think that they’re meeting their own obligations.
“We’ve already taken action against 57 medical practitioners, pharmacists and nurses who have not met their requirements. And we currently have another 60 under active investigation.”
He reiterated that while the majority of doctors and nurses were practising ethically, authorities were worried about a rise in wrongdoing. In an extraordinary move, Ahpra has also warned it will actively monitor real-time prescribing patterns to identify doctors or nurse practitioners who are writing excessive numbers of scripts, even in instances where the agency has not received an official complaint.
Other examples of poor practice identified by the regulator include practitioners not taking a mental health or substance use history from patients who have a past history of schizophrenia, resulting in patients developing psychotic episodes after taking prescribed medicinal cannabis, not checking a patient’s identity – including whether they are under 18 – prescribing excessive levels of cannabis in a prescription, and prescribers with a conflict of interest, who prescribed only one company’s product.
The guidelines and accompanying advice appear to particularly target practitioners working in telehealth and for companies that only prescribe and dispense single products – such as medicinal cannabis – the likes of which have seen unprecedented growth.
Mr Untersteiner said doctors and nurse practitioners who worked for single-product businesses still needed to meet their professional obligations, warning it appeared some were putting profits ahead of patient welfare.
“I think it’s a fair assessment to say that is an area of concern,” he said. “They should be formulating and implementing suitable management plans, which means looking at a range of different treatments.
“Even when a practitioner is working with one of those businesses, they have an absolute obligation to be looking holistically at patient treatment and that should mean, in many cases, looking outside of the products that are supplied by that particular business. If they’re not doing that, they’re unlikely to be meeting their professional obligations.”
Concerns have also been raised that some business models essentially coach patients in what to say in order to get a prescription.
Dr O’Dwyer said practitioners needed to reflect on their own standards. “They really need to be able to justify to themselves, and justify to the medical board or to the nursing and midwifery board, how it is that their practice is complying with good medical practice and how it is that they’re meeting all of their professional responsibilities,” she said.
“If they’re not able to do that, then they probably really need to consider whether or not that is a role for them.”
The release of the guidelines comes at a time when some of the medicinal cannabis industry’s major players are lobbying government officials and the drug regulator to relax safeguards. In Australia, only two medicinal cannabis products are officially registered for use. All other products, which make up the majority of what is sold to patients, are untested for efficacy and available only through “special access” pathways with approval from the drug regulator.
As reported by The Australian, a newly formed collective has argued cannabis prescription should be moved from a “system of exception” to “everyday care” which would make access even easier. Combined, it’s setting the scene for an showdown between big business and government agencies.
According to the guidelines, practitioners should only prescribe medicinal cannabis if they have the necessary knowledge, skills and training to provide safe clinical care. They must also maintain records which should not be pre-filled and, when granted permission, should inform the patient’s regular doctor of their treatment.
Practitioners are also obliged to inform patients and only recommend treatments when there is an identified therapeutic need and/or a clinically recognised treatment, and a reasonable expectation of clinical efficacy and benefit.
“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,” the guidelines state.
Prescribers must also ensure patients provide informed consent, meaning that unless a person is prescribed one of the two TGA approved medicinal cannabis products, they must be aware that what they are being prescribed has not been approved or assessed for safety, efficacy or quality by the TGA.
The guidelines further reiterate that patient demand is not an appropriate reason to prescribe a medication.
For practitioners conducting telehealth, which includes online prescribing services, the guidelines state practitioners should also be complying with their medical board’s codes and guidelines.
That includes confirming the patient’s identity, continuously assessing the appropriateness of using telehealth for the consultation and making arrangements for the patient to be seen in-person if necessary. They also needed to accept responsibility for evaluating information used in assessment and treatment, irrespective of its source.
That also 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.
“Asynchronous prescribing and health care is not supported by the boards. The boards do not consider an online chat to be a synchronous consultation,” the guidelines state.
It is also an issue highlighted by Avant, a major provider of medical indemnity for doctors in Australia which warns such practices could compromise insurance cover.
“Asynchronous telehealth, or ‘tick box’ medicine, where requests for medication are submitted by text, email, live-chat or online, is discouraged by the Medical Board and may not be covered under your medical indemnity policy unless there has been an in-person, phone or video consult,” an Avant spokesman said.
“Like any other medication, medicinal cannabis should only be prescribed when it is clinically indicated and necessary for the patient.
“A doctor’s duty to exercise reasonable care extends to prescribing, with a thorough clinical evaluation and discussion of the risks and benefits required before making the decision it is appropriate to prescribe.”
Medicinal cannabis was legalised in Australia in stages starting in 2016. It came with big promises for people with epilepsy. However, it quickly evolved to allow doctors to prescribe it to patients for a range of ailments if they believe it to be necessary.
Both the Medical Board and Ahpra are welcoming feedback to the guidelines.
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