It’s 8am on a Tuesday morning when the alarm sounds in the bedroom of Adrienne’s London flat share. As she blinks open her eyes, the 24-year-old account executive tugs at the handle of her bedside cabinet. Beyond the foil of a paracetamol packet and the nozzle of a lavender pillow spray, her fingers feel their way to a tiny white bottle. She presses the pipette, measuring out the correct dose – perfected over months of trial and error –before syringing a few drops of cannabis oil beneath her tongue. It smells like grass and tastes as woody as the moss on a forest floor. She lets the liquid sit for a few moments before throwing off her duvet and hauling herself out of bed ahead of another working day. Who is using medical cannabis? Read the word ‘cannabis’ and you can almost smell the always earthy, sometimes sickly funk. But while even the most health-conscious can recall the furtive tokes of teenage parties, it’s increasingly being used therapeutically. With the peak still years away, one report forecasts that the global medical marijuana market, valued at just shy of $10bn in 2022, will reach $54bn by 2030*. The motivation for taking it to relieve symptoms – rather than to laugh uncontrollably before ordering an extra-large Domino’s with jalapeños – vary. Some use it to soothe the impact of a searing migraine, others to dial down the nausea that accompanies a chemotherapy session, to reduce the likelihood of an epileptic seizure or, like Adrienne, to make the agony of an endometriosis flare-up more manageable. What’s more, there’s a good chance they’re doing so legally. Medical cannabis became legal in the UK – and available for unlicensed prescription through a specialist NHS doctor – in November 2018. If you can get it. And it’s a big ‘if’. From the tiny number of conditions for which the Medicines and Healthcare products Regulatory Agency (MHRA) has now licensed cannabis-based medications to a hesitancy among doctors to write prescriptions, it’s notoriously difficult to access. As a result, much of the spiking demand is either being met by the for-profit medical world or the neighbourhood dealer. Meanwhile, some scientists caution that hype is being used to fuel a nascent market before enough robust data has been gathered. And so, five years on from the legalisation of medical cannabis, who exactly is benefiting? Grass roots Before cannabis oil became an integral part of her morning routine, Adrienne’s endometriosis symptoms would see her often obliterated by five-day flare-ups: bed bound, barely able to eat and struggling to sleep. It was in the wake of her stage 4 diagnosis – the most severe form of the disease – that she turned to medical research. Alongside studies showing cannabis to be an effective intervention for the condition, she found hundreds of testimonials online from sufferers who were using it with some success, legally or otherwise. In September 2022, she found Mamedica, a private medical-cannabis clinic. Today, Adrienne syringes a 0.3ml dose of cannabis oil under her tongue three times a day. (Even if you’ve got a prescription, smoking medical cannabis remains illegal. Instead, it can be vaped or ingested orally via a mouth spray or as a liquid.) Kicking in an hour later, it manifests differently to the high you might associate with a joint. The ambient anxiety of living with a chronic illness is quietened, but her faculties remain. ‘It’s almost like going for a massage,’ she explains. ‘Your body feels relaxed, but your mind is still there. There’s no buzz, no tingle.’ The drug, she says, has been a game changer. It dials down the intense nausea that accompanies her episodic flare-ups, soothes her enough to drift off to sleep and keeps her at a healthy weight by rekindling her appetite when she’s in agony. For anyone living with chronic pain, these effects will sound alluring. But while anecdotal evidence of cannabis’ role in pain management abounds, consistent scientific data is pending. In order to prove that any form of the drug works (strains and strengths differ and there are myriad cannabis-based medicines) and is more effective than a placebo, it must undergo Randomised Control Trials (RCT). The comprehensive analysis is considered the gold standard for scientific evidence, but the expense and complexity involved in studying cannabis means there are only three condition-specific cannabis medications that have been scrutinised sufficiently. Those on the front line of cannabis research are building a picture of how it interacts with the body, though. ‘Cannabis contains a host of chemical compounds called cannabinoids,’ says Amir Englund, a cannabis scientist at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. How does medical cannabis work in your body? There are more than 140 cannabinoids, most of which we know very little about; the most well known and studied are THC, the substance that makes you feel high, and CBD (cannabidiol), a non-psychoactive ingredient that is found in products from gummies to tampons. The oil Adrienne uses contains both of these compounds, though some cannabis medicines focus purely on CBD. The question of how compounds like these exert an influence on your brain can be answered by looking at the endocannabinoid system. Endocannabinoids are chemical compounds produced by your body that behave similarly to the cannabinoids found in cannabis. These regulate systems in your brain and balance your mood. (Ever felt stoned levels of chill after yoga? Some believe these practices activate your endocannabinoid system.) You also have endocannabinoid receptors; CB1 receptors are mainly located in your central nervous system – your brain, spinal cord and nerve endings– while CB2 receptors are mostly found in your immune cells. When THC binds to these receptors, it produces those wavy feelings. But because endocannabinoids help regulate pain signalling, mood and sleep, says Dr Englund, it’s thought that compounds in cannabis can reduce some symptoms, too. Smoke and mirrors If the way cannabis interacts with the body is opaque, the UK’s legislative landscape is hazier still. Cannabis-based medicines were made legal in November 2018, in response to tireless campaigning from the mothers of two children, Alfie Dingley and Billy Caldwell, living with severe forms of epilepsy. Both had been using cannabis oil, which their families had sourced in countries where it was legal, to drastically reduce, or even halt, the number of seizures they experience. CBD-containing products were legalised, with the caveat that they couldn’t be marketed as medicines. Procuring ‘whole plant’ cannabis products including THC for medicinal use was legalised, too, with medications containing the compound also becoming available for unlicensed prescriptions (in which a medication that has not yet been given a licence by the MHRA is thought by a doctor to be the best shot for treating a condition). To ease a handful of conditions, the MHRA granted licences for three cannabis-based medicines: epidyolex, a form of cannabis oil for two severe, rare forms of epilepsy – including the types the children suffered from; nabilone, a capsule containing a synthetic form of THC, for vomiting and nausea caused by chemotherapy; and sativex, a cannabis-based spray for those with multiple sclerosis-induced muscle spasms and stiffness. This year, the National Institute for Health and Care Excellence (NICE) also recommended epidyolex for seizures linked to tuberous sclerosis complex. While campaigners met the law change with optimism, a disconnect has emerged between anticipated access and reality. In January, data* revealed that 90,000 unlicensed prescriptions for cannabis medicines were issued between November 2018 and July 2022 in England; prescribing an unlicensed medication is legal and common across a range of conditions, as is prescribing off-label – when a specialist prescribes a drug recommended for one condition (say, MS) to treat another (say, migraine). But most of these off-label and unlicensed prescriptions for cannabis medicines came from private clinics, with fewer than five of them being dispensed via the NHS. In the same period, just under 12,000 licensed prescriptions for cannabis-based medicines were prescribed via the NHS. So why are the rates of NHS prescribing so low? Well, if you’re suffering from one of the conditions the MHRA has licensed a medicine for, you’ll need to have tried two conventional treatments first – and gain access to a specialist in your condition who is allowed to prescribe for you. Even then, getting your hands on the medication is challenging: supply chain issues abound (the UK imports its medical cannabis, even though it’s the world’s biggest exporter of marijuana for medical and scientific purposes). If you’re suffering from another condition, the hurdles are greater still – you can only be prescribed a medication either off-label or unlicensed. ‘While doctors are allowed to prescribe unlicensed medications, they take personal responsibility when doing so,’ adds Dr Englund. In the absence of approval from the MHRA, ‘personal responsibility’ involves examining a complex evidence base themselves, then, if they believe the evidence to be convincing enough, monitoring the patient for side effects. As such, he explains, it can put the prescriber at risk of potential legal action should the patient come to harm and the justification for the prescription is said to have been poor – a risk many doctors simply aren’t willing to take. This is where private clinics such as Mamedica have stepped in. As with any form of private healthcare, this one comes at a price. Adrienne pays £155 for her 50ml bottle of cannabis oil, which lasts three to four months. But the average pain patient at Mamedica spends far more: around £200 on medication monthly, on top of an estimated £450 on clinic fees during their first year, which covers a consultation with a specialist and follow-up appointments. (Although an access scheme for those on means-tested benefits and veterans takes this down to a one-off cost of £200.) The prescription isn’t a flat fee, either; the price attached to strains of cannabis and specific formulations vary wildly. While researching this piece, WH came across stories of people at some clinics paying thousands a month – albeit not at Mamedica. ‘You can access cannabis-based medications if you can find a suitable private-sector doctor and you have the money for the charges,’ notes Crispin Blunt MP, chair of the Conservative Drug Policy Reform Group. ‘Or you take your chance on the street, or growing your own medicine.’ The situation, as he sees it? ‘An unfair mess.’ Joint account Desperation. That’s the word Ami* chooses to explain her decision to start sourcing cannabis from a dealer to help manage her debilitating migraine symptoms. The acute attacks saw the consultant, 33, miss birthdays, hen dos and countless days off work, alongside the anxiety of feeling she was letting people down. She uses the drug alongside medications and lifestyle changes (she quit drinking, took up yoga and swapped city living for a small town in Somerset). Her prescription migraine medication works half the time. When it doesn’t, she takes a few puffs on a small joint. ‘Really, what I need to do when I’ve got a migraine is sleep until it stops – and sometimes the pain is so bad that I can’t,’ she says. ‘So, helping me sleep through it is amazing; helping me feel less nauseous is amazing. I’ll still have a headache, but I’ll feel more comfortable and more relaxed in it. And I’ll be able to take care of myself a bit more, rather than just writhing around in pain.’ The dose is key – taking too much can amplify the dizziness and nausea she experiences – and while she could afford to go private, the cost is just one deterrent; fear of judgment for turning to cannabis – even legally – is another. Instead, she sends a text to a number she got off a friend. Hours later, it’s at her front door. Ami isn’t an anomaly. A 2022 YouGov survey estimated that 1.8 million people in the UK are sourcing cannabis illegally to relieve a range of mental and physical health conditions. While it isn’t known how many of these people are women, research consistently shows that females are more likely to suffer with chronic pain. And for women sourcing weed on the street, safety is, inevitably, a concern – meeting a stranger or climbing into an unknown car being riskier for women than men. But it isn’t the only concern in cannabis procured on the street; levels of psychoactive THC can vary. How can cannabis be harmful? For a 2020 study by the Addiction and Mental Health Group at the University of Bath, researchers investigated concentrations of THC in over 80,000 street samples collected across seven countries, including the UK. In herbal cannabis, they found that THC concentrations by weight increased by 14% between 1970 and 2017, which, according to the researchers, represented an increased risk of harm to users. Such findings are particularly troubling in the context of emerging evidence linking THC at high doses with psychosis. ‘In a large European study we found that a possible side effect of cannabis with over 10% THC for some users is developing a psychotic illness,’ says Marta Di Forti, a psychiatrist and leading expert on cannabis and psychosis at King ’s College London, who tells WH she sees people like this in her clinic every week. The individuals who come to her are young adults – the vast majority of whom have been smoking illegally sourced weed recreationally on a daily basis, often since their early teens – but as some within the industry rhapsodise about cannabis’s potential, concerns about side effects cannot be ignored. Compound interest All the experts WH interviewed for this piece agreed that, five years on from this legislation, the situation is unclear. ‘The difficulty patients experience in accessing cannabis-based medicinal products is quite alarming,’ says Blunt, who adds the caveat that the onus is on NICE – together with the MHRA – to educate doctors on prescribing practices and to license products. While the former is straight forward, the latter is more of a challenge; the Randomised Control Trials (RCTs) needed for licensing are, he notes, ‘notoriously expensive’. ‘The government has allocated some money towards [medical cannabis] research, but more is always welcome,’ says Dr Englund, stressing the need for slow, careful science. ‘We can’t exempt cannabis from the rigorous scientific testing we require from all potential new medicines. The regulations ensure that we understand how effective medicines are and the possible side effects.’ As for the potential of some cannabis-based medications? He’s optimistic, but cautiously so. ‘It’s not a panacea for all human ills.’ This polarisation of views on the issue is one Dr Di Forti rejects, too. ‘I think that for the same reason that cannabis can cause psychosis, it can be used for therapeutic reasons.’ Any medicine has side effects, she says, giving the example of chemotherapy – a treatment with a litany of negative reactions, but which few people would turn down. ‘[With cannabis], the difference between keeping you safe and causing you harm is knowing what[side effects] to look for, making sure you’re careful with the dose and identifying groups who are more likely to develop side effects[people with a family or personal history of conditions such as schizophrenia and other psychotic disorders and those under 18].’ It’s not always the case that every person in these groups can’t take the drug, she adds, but that they would need close monitoring from a psychiatrist and be made aware of the risk. The future of medical cannabis in the UK is murky. As it stands, the private sector is poised to soar, while the NHS continues to stagnate in a labyrinth of prescribing blocks. Without funding for the lengthy and expensive trials necessary before medical regulators are able to recommend cannabis-based medicines for more conditions, the two-tier system will only become more pronounced. More still might seek their dose via the unregulated illegal market, where quality issues abound – and the risk of criminal prosecution is real. But while concerns about the triggering of mental health issues are valid, there’s clearly potential in that grassy vegetation. What’s alarming is that, without serious change, only those in the green stand to benefit.

Review

The article mentions the difficulties in obtaining prescriptions for medical cannabis from the NHS, which may be due to the requirement for patients to have tried conventional treatments first. As a result, private clinics like Mamedica have emerged to provide these treatments, albeit at a cost.

Ami’s story highlights how some individuals resort to sourcing cannabis on the street to manage their conditions, despite concerns about safety and the varying levels of psychoactive THC in street-bought cannabis.

The article also touches on the need for more rigorous scientific research, including Randomised Control Trials (RCTs), to establish the efficacy of various cannabis-based medications and better understand their potential side effects.

It’s clear that the medical cannabis landscape in the UK is complex and evolving, with both challenges and potential benefits. Access, research, and regulation are all important aspects to consider as medical cannabis use continues to grow.

You might be interested in learning more about medical cannabis and its various uses. Speaking of medical cannabis, you might be interested in the Wikipedia article on medical cannabis. This article provides comprehensive information about the benefits, uses, and potential side effects of medical cannabis. Additionally, if you want to understand the current medical cannabis landscape in the UK, the Wikipedia article on the legal and medical status of cannabis can provide valuable insights. It delves into the regulations, challenges, and potential benefits associated with medical cannabis