Medicinal cannabis prescribing under scrutiny as regulators respond to patient harm

The Regulators have released updated expectations for prescribers, following a surge in reports of adverse outcomes, including cases of cannabis-induced psychosis requiring emergency care. The rise in ethical concerns surrounding commercial ‘single purpose’ dispensaries has also triggered calls for greater diligence and accountability among practitioners.

The Chair of the Medical Board of Australia, Dr Susan O’Dwyer said: 

'Medicinal cannabis should be treated as a medicine – not a lifestyle product. 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.'

The guidance reiterates that medical cannabis must be prescribed with the same level of caution and clinical judgement as any other drug of dependence. This includes carrying out thorough assessments, maintaining clear records and formulating appropriate treatment and exit plans.

Most importantly, the Regulators have said that medicinal cannabis should never be considered a first-line treatment. Its use must be based on a clear, evidence-based therapeutic need – not marketing influence or patient pressure.

Ahpra has also flagged concerns about business models that rely solely on prescribing and dispensing cannabis-based medicines. In particular, the use of online questionnaires designed to coach patients into saying the ‘right things’ to justify a prescription. This raises real concerns that patient welfare is taking a ‘backseat to profit’.

There have also been instances of extremely highly prescription rates. One practitioner reportedly issued more than 17,000 scripts in six months, while eight others exceeded 10,000 during the same period – far exceeding expected levels. 

Going forward, Ahpra has made it clear that they will be investigating high-prescribing practitioners of any scheduled medicines – even where no formal complaint has been made – as the data suggests many may not be meeting professional obligations. 

The Regulators have identified a number of concerning patterns of unsafe practice, including:

• consultations lasting only seconds or minutes, compromising patient assessment
• prescribing without legitimate clinical justification
• inadequate mental health and substance use assessments
• failing to check real-time prescription monitoring (RTPM) systems
• issuing excessive quantities or multiple products for a single patient
• prescribing to minors or without verifying the patient’s identity
• self-prescribing or prescribing to family members
• failing to collaborate with a patient’s existing healthcare providers
• prescribing only products supplied by affiliated companies

These practices not only breach professional standards but also expose vulnerable patients to serious harms, including psychosis and addiction.

The Regulators have released detailed expectations for both medical and nurse practitioners involved in prescribing medicinal cannabis or adding it to their scope of practice. They insist that practitioners must have adequate training and high standards of care and have released the following guidelines:

• Comprehensive patient assessment: Practitioners must undertake a thorough patient assessment that includes physical, mental health, social, and substance use history. Quick online consultations are inadequate.
• Suitable management plans: They must formulate and implement a suitable management plan that includes arranging investigations, providing information and a diagnosis treatment and advice.
• Coordination and continuity of care: If permission is given, practitioners must communicate with the patients usual treating practitioners.
• Medical records: They must develop and maintain accurate, complete medical records. The use of prefilled medical record templates is inadequate.
• Evidence-based prescribing: Prescribe medicinal cannabis only when there is strong clinical justification and an identified therapeutic need with a reasonable expectation of clinical efficiency and benefit identified for the patient. It should not be a first-line treatment.
• Safe prescribing practices:
  • treat medicinal cannabis like any other Schedule 8 drug
  • obtain necessary TGA approvals
  • follow state and federal regulations, including RTPM use
  • avoid excessive prescribing or ‘trial-and-error’ product sampling
  • do not provide excessive quantities or provide early repeats
  • ensure your contact details are available on prescriptions so the dispensing pharmacist can contact you if required
  • never prescribe to yourself or close associates.
• Unapproved products: Inform patients when prescribing unapproved cannabis products, document the discussion, and obtain informed consent.
• Informed patient consent: Clearly explain risks, benefits, side effects and treatment goals. Provide a discontinuation plan if the treatment is ineffective.
• Adverse event reporting: Report any side effects to the TGA.
• Conflict of interest: Disclose and manage any conflicts, especially if working in a business that businesses that both prescribe and dispense.
• Telehealth standards: Ensure you are complying with your Board’s codes and guidelines including identity verification, assess telehealth suitability and avoid asynchronous care or prescribing without a real-time consultation.

If you need help understanding these guidelines or assistance drafting and updating your policies and procedures for prescribing medicinal cannabis, please reach out to our team for assistance.