States Assembly | P-113-2018

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STATES OF JERSEY

MEDICINAL CANNABIS: RIGHT TO PRESCRIBE BY MEDICAL PROFESSIONALS

Lodged au Greffe on 9th October 2018 by Deputy M. Tadier of St. Brelade

STATES GREFFE

2018 P.113

PROPOSITION

THE STATES are asked to decide whether they are of opinion

that all medical professionals with the right to prescribe should be permitted to prescribe –

Cannabis;
Cannabis-derivatives;
individual Cannabinoids;
pharmaceutically-created Cannabis-derived products (including Dronabinol, Epidiolex, Nabilone and Sativex); and

to request the Minister for Health and Social Services to present the relevant changes to the law necessary to give effect to this decision to the States Assembly no later than 28th February 2019, consulting, as appropriate, on the details of implementation with the Misuse of Drugs Advisory Council.

DEPUTY M. TADIER OF ST. BRELADE

REPORT

On 2nd May 2017 the then Minister for Health and Social Services, Senator A.K.F. Green, made a statement to the Assembly entitled –

Advice received from Jersey's Misuse of Drugs Advisory Council'.

This was as a consequence of the conclusions of what is commonly referred to as The Barnes Report, Cannabis: the Evidence for medical use', authored by Professor Michael Barnes and Dr. Jennifer Barnes.

A principal conclusion of that Report stated –

"It is clear from this review that cannabis does have medicinal value and continuing placement of cannabis under Schedule 1 of the (U.K.) Misuse of Drugs Act, which thus states it is of no medicinal value, is inaccurate and misleading.".

The Minister's full statement can be read HERE (see Appendix 1) and the Barnes Report HERE.

The Case for Medicinal Cannabis

The Barnes report itself is some 170 pages long, but states in its conclusion (page 130) that –

"This paper has shown that there is good evidence for the efficacy of at least one formulation of cannabis in:

Pain – both chronic pain and neuropathic pain
Spasticity – mainly in multiple sclerosis but there is no reason why it should not be just as efficacious in spasticity secondary to other neurological disorders
Nausea and vomiting – particularly in the context of chemotherapy
Anxiety.

We find there is moderate evidence for efficacy in:

Parkinson's disease
Sleep disorders
Fibromyalgia
Post-traumatic stress disorder
Appetite stimulation – most of that evidence in the context of HIV infection.

There is some limited evidence of efficacy, but clearly further studies are required, in:

Epilepsy (particularly the drug resistant childhood epilepsies)
Bladder dysfunction in the context of neurological disorders, especially
multiple sclerosis
Glaucoma
Control of agitation in dementia
Tourette's syndrome.".

The report goes onto state (page 133) –

"Whilst there are alternative medications for most of the indications we have studied in this paper, *many of the alternative medical treatments do give rise to significant, and often troublesome, side effects. This is particularly the case with regard to the prescription of *opioids for pain.".

*(my emphasis) Its very final remarks are –

"Overall, there is good evidence for the use of cannabis in many important conditions that effect many thousands of disabled people in the UK. Generally, cannabis and cannabis products are safe and well tolerated. It is clear from this review that cannabis does have medicinal value and continuing placement of cannabis under Schedule 1 of the Misuse of Drugs Act, which thus states it is of no medicinal value, is inaccurate and misleading. We consider that the evidence firmly suggests that cannabis should be a legal product for medicinal use, as long as the quality of the product is guaranteed and the supply chain secured and that medical users are, as far as possible and practicable, entered into proper long term studies of both efficacy and side effects."

Commenting later on his report, Professor Michael Barnes made further public calls for the introduction of medicinal cannabis and the rescheduling of the drug which is currently classed as having no therapeutic medicinal value.'.

Writing in the Guardian (see Appendix 2), on 13th September 2016, Michael Barnes said –

"My report shows that there is strong evidence that medical cannabis helps with chronic pain; spasticity (common, disabling and painful after stroke or brain injury and common in those suffering from multiple sclerosis, as examples); for nausea and vomiting, especially during chemotherapy; and for the management of anxiety. There is also evidence of usefulness in sleep disorders, for appetite stimulation (in HIV, for example), fibromyalgia, post-traumatic stress disorder, severe childhood epilepsies and bladder problems and even for control of some cancers. The list goes on.

Much more powerful and potentially dangerous prescription medicines are prescribed routinely by doctors. Every drug prescribed has positive and negative effects and the doctor's job is to weigh those risks and benefits, explain that balance to the patient and allow an informed choice. It would be no different in the case of medical cannabis.".

The UK has accepted that cannabis does have medicinal value and, at the time of writing (7th October) it is understood that the Home Office will announce the "rescheduling" of cannabis in parliament within the next 2 weeks, and patients will be able to obtain prescriptions for medical cannabis products within a matter of weeks.

The Jersey situation

Despite Jersey being the first place in the British Isles to make an announcement that medicinal cannabis would be rescheduled, this has still not happened. The former Minister for Health and Social Services, Senator A.K.F. Green, had said he hoped to be in a position to bring the changes by autumn 2017. A year later, potentially thousands of Jersey residents who suffer from chronic pain and other debilitating conditions are still waiting to be prescribed a medicine which they and their doctors know would alleviate their pain and, in some cases, treat their underlying conditions.

I am expecting an argument from the Minister for Health and Social Services about who can prescribe medicinal cannabis. Currently, Sativex is the only cannabis-derived medicine that is prescribed in Jersey. It is, relatively speaking, very expensive [1] and not effective for many conditions. In 2014, the NICE [2] recommendation was not to offer Sativex to treat spasticity in people with MS because it is not a cost-effective treatment.

Sativex is the brand name for the drug known as Nabiximols'. It can currently only be prescribed by a Hospital Consultant and dispensed by the Hospital Pharmacy. It is not clear to me why this is the case. G.P.s are able to prescribe much stronger, dangerous and addictive medicines, including opioids.

I understand from my conversations with a cross-section of individuals in Jersey, with varying conditions, that the process one has to go through to even be considered for Sativex is a long and arduous one.

This is why I am proposing that G.P.s should have the ability to prescribe pre-approved medicinal cannabis products to patients who, in their professional opinion, would benefit from them. This appears to be in line with the statement made by the former Minister for Health and Social Services (Senator Green) in May 2017, who said –

"In light of this report, Jersey's Misuse of Drugs Advisory Council recommended to me that I may wish to consider reclassifying some defined cannabis-based products as they are identified, so that where doctors consider it clinically appropriate they can legally prescribe them to patients. I intend to act on this advice, which represents a measured and proportionate change to the current arrangements.

At present, doctors cannot prescribe such products because cannabis is included in both Schedule 1 of the General Provisions Order of the Misuse of Drugs Law, and the Designation Order of the Misuse of Drugs Law along with other substances with no recognised medical use.

Reclassifying specified cannabis-based products would allow medical practitioners to prescribe these appropriate, quality assured products. The products could only be prescribed by an authorised prescriber, and only supplied from a pharmacy.

One has to remember that certain controlled drugs such as morphine, diamorphine (heroin) and Fentanyl – in Schedule 2 – are currently legally prescribed by medical practitioners and other, authorised, qualified prescribers. The change I am proposing would, in effect, apply the same rules for these cannabis-based products, which would be treated as prescription- only medicines. Any use which had not been authorised/prescribed by a medical practitioner and supplied by a pharmacy would still be unlawful.".

There is nothing in this statement that suggests that the medicines should only be prescribed by Hospital Consultants or that the Hospital Pharmacy would be the only authorised dispensary. A reasonable reading of the Minister's statement is that these medicines would be prescribed like any other prescription drug and dispensed in the same way.

I ask members to support this proposition, which seeks to end the delay upon delay we have seen in implementing this important change, so that we may help the many hundreds of our constituents who are suffering from a myriad of serious and often painful and debilitating conditions, and to give a clear steer to the Minister and Legislative Drafting Office, that these legislative changes must be given priority.

Financial and manpower implications

It is not anticipated that there should be any significant financial implications arising from this proposition. Whilst it is true that there would be a cost for prescribing new products, it is likely that these would simply be replacing other medication which is, in many cases, already being prescribed for symptom and pain control, albeit – in some cases – less effectively.

"STATEMENT TO BE MADE BY THE MINISTER FOR HEALTH AND SOCIAL SERVICES ON TUESDAY 2ND MAY 2017

Advice received from Jersey's Misuse of Drugs Advisory Council

I am making this statement to ensure clarity and avoid misunderstanding about some changes I am intending to introduce, which will remove the legal barrier currently preventing the medicinal use of specific cannabis-based products.

To avoid any potential confusion or misinterpretation, there is no consideration being given to legalising cannabis, legalising self-medication' or allowing recreational use. Cannabis will remain a controlled substance as now.

Last month, Jersey's Misuse of Drugs Advisory Council (MDAC) discussed the issue of cannabis for medicinal use. This was in response to the publication in 2016 of the first authoritative scientific review of the subject. The authors of Cannabis: the Evidence for medical use' were Professor Michael and Dr Jennifer Barnes, and it has become known as the Barnes Report.'

A principal conclusion of the Barnes Report was that:

The Report stated that certain cannabis-based medicinal products may have more potential for medicinal benefit, in certain medical conditions, than was previously believed to be the case.

In light of this report, Jersey's Misuse of Drugs Advisory Council recommended to me that I may wish to consider reclassifying some defined cannabis-based products as they are identified, so that where doctors consider it clinically appropriate they can legally prescribe them to patients. I intend to act on this advice, which represents a measured and proportionate change to the current arrangements.

It is not yet clear what specific products might be of the appropriate quality to reclassify, or which prescribers should be authorised to prescribe, and I have asked for further clarification on these issues from the M.D.A.C. I have also asked for further advice regarding the arrangements for sourcing and importing these products. Once I have all this information, which I hope to receive by the autumn, and I am content that it is appropriate to proceed, I will look to progress legislation accordingly.

While a number of countries have legalised the use of cannabis-based products for medicinal purposes, the U.K. and France have yet to do so and it would remain an offence to bring such products into these jurisdictions if travelling from Jersey.

The move I am making is a small cautious step and in no way heralds the liberalisation of Jersey's drugs laws. This is only about legalising specific cannabis-based medicines for clinical use. Therefore it is not about permitting the smoking of cannabis.

The Barnes Report states that "the medical recommendation would be that cannabis should not be taken as a smoked product" and therefore does not include the use of smoked cannabis or any form of street' cannabis. Such activity would remain illegal here in Jersey.

I must stress again that reclassifying certain cannabis-based products in this way would not make herbal cannabis legal. Cannabis and cannabis resin would remain class B controlled drugs and cannabinol and its derivatives would remain class A controlled drugs. Unauthorised production, manufacture, importation, possession and supply would remain offences with the same penalties as currently.

This means it would still be illegal for individuals to use cannabis for recreational purposes, to grow cannabis, or to import cannabis or cannabis-derived products themselves, or to self-medicate. Any use which had not been authorised/prescribed by a medical practitioner and supplied by a pharmacy would still be unlawful."

Article written by Professor Michael Barnes, published in The Guardian 13th September 2016

"We must legalise access to medical cannabis as a matter of urgency Mike Barnes

My report proves the drug can alleviate suffering for many sick people. The government must have the political courage to accept the scientific rationale.

You're effectively using the essential ingredients of cannabis right now. You and everyone else. That's because our brains, and other parts of the body, have a natural endocannabinoid system that is now known to assist with how we deal with pain, the control of movement, the protection of the brain after damage and a host of other functions. Our increasing knowledge of this natural endocannabinoid system now gives a solid scientific rationale for why cannabis has so many positive medicinal effects. And as well as this recently understood scientific rationale, there is a substantial body of clinical evidence that medical cannabis works. My review of that evidence is published today by the UK all-party parliamentary group on drug reform as part of their inquiry into medical cannabis.

My challenge to the government is to have the political courage to accept the scientific rationale, accept the evidence and move to legalise access to medical cannabis under prescription here in the UK as a matter of urgency.

Cannabis has been a useful medicine for centuries, with known use dating back to 4000 BC in ancient China.

Currently, the government has cannabis classified as a Schedule 1 drug, a classification for substances judged to have no medicinal value. This is irrational and incoherent. The evidence is plain to see and has been compelling enough for a large number of countries to legalise access to medical cannabis including the Netherlands, Germany, Spain and 25 US states.

My report shows that there is strong evidence that medical cannabis helps with chronic pain; spasticity (common, disabling and painful after stroke or brain injury and common in those suffering from multiple sclerosis, as examples); for nausea and vomiting, especially during chemotherapy; and for the management of anxiety. There is also evidence of usefulness in sleep disorders, for appetite stimulation (in HIV, for example), fibromyalgia, post-traumatic stress disorder, severe childhood epilepsies, bladder problems and even for control of some cancers. The list goes on.

And this issue matters to a lot of people. Estimates by the campaign group End Our Pain put the number of people in the UK taking cannabis primarily for medical reasons at one million. Many have found that "regular" prescription medicines just don't work for them, or have debilitating side-effects. As access to cannabis in the UK is illegal, all these people are at risk of prosecution. These people would be regarded as patients in those countries with a more enlightened approach, but here they risk being treated as criminals.

The usefulness of medical cannabis is unquestionable; but is it safe? Certainly there are some potential short-term effects such as dizziness, drowsiness, dry mouth, balance problems and sometimes confusion. These effects, however, are largely induced by the psychoactive component – tetrahydrocannabinol (THC). This is the chemical that causes the "high" sought by recreational users. The other main chemical is cannabidiol (CBD), which is neither illegal nor psychoactive and indeed counters the effects of THC. That's why medical cannabis will be produced in controlled conditions to ensure the right balance between CBD and THC.

What about the threat of long-term problems, such as triggering schizophrenia? The evidence is conflicting but nevertheless some cannabis products (mainly those high in THC) can induce transient symptoms similar to the symptoms of schizophrenia and exacerbate symptoms in individuals already suffering from psychosis. I would expect a doctor not to prescribe medical cannabis in such cases.

Cannabis has been a useful medicine for centuries, with known use dating back to 4000 BC in ancient China. It was also widely used in ancient Indian, Greek and Roman cultures. Medicinal use was first properly documented by Dioscorides in the first century AD. It has certainly gone through periods of being in and out of fashion. A particular period of enthusiasm was during the 19th century when, for example, Sir John Russell Reynolds recommended it for period pain suffered by Queen Victoria.

The government now has the scientific rationale and the evidence. And through the campaigning efforts of End Our Pain and others, we have the powerful personal testimonies of those that are suffering. Let's act. Let's legalise access to medical cannabis now."

Medicinal Cannabis: right to prescribe by medical professionals (P.113/2018)