Health regulators have sounded the alarm over profit-driven overprescribing, with thousands of scripts and rising patient harm prompting urgent national guidance.
Australian Rheumatology Association president Dr Sam Whittle has welcomed new national regulatory guidance on prescribing medicinal cannabis.
Australia’s medical watchdogs stepped in this week to release the guidance in response to growing alarm over unsafe medicinal cannabis prescribing they say is leading to significant patient harm.
This has included cases of psychosis severe enough to require emergency care.
The move by the Australian Health Practitioner Regulation Agency (AHPRA) and the national boards also follows reports of over-servicing, unethical prescribing linked to profit-driven business models, and shockingly high script counts.
In one case, a single practitioner issued more than 17,000 prescriptions in just six months.
The guidance reminds prescribers that medicinal cannabis should be treated as a medicine and to be as careful and diligent when prescribing medicinal cannabis as they are when prescribing other drugs of dependence.
“We don’t prescribe opioids to every patient who asks for them, and medicinal cannabis is no different,” said Medical Board of Australia chair Dr Susan O’Dwyer.
“Patient demand is no indicator of clinical need.”
Dr Whittle told Rheumatology Republic the association supported the guidance.
“In terms of what the concerns are that the medical board has described today, I think it’s hard to disagree with what they’re saying; that they’re really concerned about people who appear to be prescribing outside of an accepted medical prescription framework,” he said.
“And I absolutely agree that prescribed cannabinoids ought to be considered like any other prescription medicine, and that needs to be accompanied by a proper clinical evaluation, a consideration of all the other options in a shared care, shared decision-making framework.”
The guidance addresses the regulator’s concern that profits are being prioritised over patient safety, and it aims to support practitioners to provide safe care, particularly for those patients at most risk of harm.
AHPRA CEO Justin Untersteiner said the regulator was particularly concerned about single-purpose clinics and online platforms using brief consultations and scripted questionnaires to push cannabis products.
“Some business models that have emerged in this area rely on prescribing a single product or class of drug and use online questionnaires that coach patients to say ‘the right thing’ to justify prescribing medicinal cannabis,” said Mr Untersteiner.
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“This raises the very real concern that some practitioners may be putting profits over patient welfare.”
The guidance urges practitioners to treat medicinal cannabis like any other high-risk medication, and to avoid using it as a first-line treatment. Safe prescribing includes full patient assessments, mental health screening, coordination of care and a clear exit strategy.
Guidance for the safe prescribing of medicinal cannabis includes assessing patients thoroughly, formulating and implementing a management plan, facilitating coordination and continuity of care, maintaining medical records, recommending treatments only where there is an identified therapeutic need, ensuring medicinal cannabis is never a first line treatment, and developing an exit strategy from the beginning.
AHPRA and the National Boards were working with other regulators like the Therapeutic Goods Administration (TGA) and state and territory authorities to understand prescribing patterns and stay ahead of emerging trends.
Mr Untersteiner said current prescribing data raised red flags that some practitioners were not meeting their professional obligations, including eight practitioners who have issued more than 10,000 scripts in a six-month window and the practitioner who appeared to have issued over 17,000 scripts.
“We will investigate practitioners with high rates of prescribing any scheduled medicine, including medicinal cannabis, even if we have not received a complaint,” he said.
Dr Whittle said the guidance was well-supported by the ARA’s position statement on the use of cannabinoids for arthritis and other musculoskeletal conditions in adults, released in March this year.
“The ARA considers that there should be evidence of efficacy and safety from high-quality randomised controlled trials (RCTs) before any potential intervention for arthritis and other musculoskeletal conditions is adopted into clinical practice. Furthermore, advice regarding the role of any intervention should weigh RCT evidence for efficacy against potential harms detected in RCTs and longer-term observational data,” the statement reads.
“The current body of evidence for the use of cannabinoids for the treatment of arthritis and other musculoskeletal conditions is limited and provides low to moderate certainty evidence for marginal benefits which, for many, may be offset by harmful effects. As such, the adoption of cannabinoids into routine clinical practice in rheumatology is not supported by the ARA.
“The ARA recognises that the use of cannabinoids as a therapy for persistent musculoskeletal pain is a topic of increasing interest to consumers, clinicians, researchers, and other stakeholders. The ARA also acknowledges the importance of the lived experience of people with persistent musculoskeletal pain, many of whom have used cannabinoids for treatment of their pain or have considered doing so, and the current relative lack of highly effective and safe pharmacological options for the treatment of persistent pain.
“There are important legal and practical considerations associated with prescribing cannabis (e.g. driving laws, workplace safety) which also need careful consideration.”
Dr Whittle told RR that cannabinoids should be treated no differently to other pharmacological treatments and put through rigorous and high-quality trials to determine their efficacy.
Importantly, he said such trials would also determine whether there were potentially harmful interactions with other drugs.
This was particularly pertinent in rheumatology given the wide variety of biologics and other targeted pharmacological treatments prescribed by specialists.
“Prescribed cannabinoids ought to be considered like any other prescription medicine, and that needs to be accompanied by a proper clinical evaluation, a consideration of all the other options,” said Dr Whittle.
He supported the crackdown on prescribers who were not meeting professional obligations.
“If there are these single prescription clinics that are doing that, that’s well outside the norms of accepted practice, and it ought to be cracked down on,” he said.
“We know that there are harms associated with it, and we know that the benefits are unclear, but are likely to be small at best, but also that if it’s being prescribed as a medicine, it’s going to interact with other prescription medications, and that needs to be taken into consideration, particularly in an outpatient cohort who are likely to be on multiple other prescription medicines.
“And it needs to be properly communicated to the other members of the of the treating team.
“If we’re operating in a paradigm where we’re primarily sharing care between the rheumatologist, the general practitioner and the allied health practitioners involved in a patient’s care, and then suddenly there’s an extra clinic that’s prescribing one medicine and one medicine alone, that’s likely to be disruptive to our standard model of care.”
For the full ARA position statement see here.
The guidance on medicinal cannabis prescribing is published on the AHPRA website. It builds on existing regulatory guidance about safe care, including each board’s code of conduct and their guidance on telehealth and virtual care.
