Navigating a New Mess in Medical Cannabis Prescribing across Australia
Article Written by Pharmacist Michael Thorp
Read time: 4-5 mins
Integrating medical cannabis into the Australian landscape continues to present a range of legal, logistical, and therapeutic challenges nearly a decade into legalisation. Amongst these challenges, script substitution is an emerging concern for prescribers, pharmacists, and patients - even if they are yet to realise it.
Here, we explore the issues this author has witnessed surrounding script substitution in the context of medical cannabis in Australia, examining its implications for the healthcare industry and proposing potential options for how prescribers and pharmacists might navigate these complexities to improve patient outcomes.
Script Substitution: A Legal and Ethical Gray Area
At its core, script substitution is a pragmatic response to a still nascent industry and supply shortages. As a naturally grown product, medicinal cannabis is subject to more frequent supply issues than conventional pharmaceuticals. Supply fluctuations aren’t uncommon, whether due to regulatory delays, logistical issues, or unpredictable spikes in demand.
In Australia, pharmacists may substitute a product if the prescribed product is not available with an alternative in consultation with the prescribing doctor. However, the legal and ethical boundaries of this practice are murky.
Historically, the ambiguity of state legislation has resulted in varied interpretations of what constitutes "unavailability" and what level of "consultation" is required between pharmacists and prescribers. I have observed instances where the definition of “unavailable” has been stretched to include products that were simply out of stock in a particular pharmacy yet still available to order from a supplier.
The Evolution of Substitution Practices
The ambiguity surrounding script-swapping or substitution has forced the industry to develop informal practices to manage the issue. Initially, the status quo involved pharmacists making time-consuming phone calls to prescribers. Often, this was nigh on impossible, resulting in protracted periods where patients were unable to access their medication, leading to distressed patients and pharmacy staff.
Over time, a more streamlined approach developed, where doctors would implicitly allow substitutions by failing to mark the "substitutions not permitted" box on the script. Other prescribers might include notations like "substitutions allowed +/- 2% THC" or would specify one or more products that they saw as acceptable substitutions.
Some would even list multiple products directly on the script, indicating that any of the listed items could be dispensed. This practice provided pharmacists with a degree of autonomy while ensuring that the prescriber’s intent was respected.
As these practices evolved, so too did the risks. This landscape relies heavily on mutual trust between doctors and pharmacists. Yet the reality is that some pharmacies have taken certain liberties with the process and potentially taking other less altruistic factors into account in their dispensing (such as profitability or affording patients the ‘service’ of being able to choose whatever they wanted).
In other examples, patients would specifically request scripts for products that were known to be out of stock at the time of prescribing. With full knowledge of the system, individuals have been able to select their own products at the time of dispensing – a situation that just defeats the entire purpose of the prescriber/patient relationship.
While such behaviour is not widespread, it does underscore the need for clearer guidelines and stricter enforcement.
Changes in Queensland and New South Wales
Recognising these issues, both Queensland and New South Wales recently introduced legislative changes to tighten control over the substitution process. In these states, the law now requires that any substitution must be authorised by a new script from the prescriber. This effectively removes pharmacists’ ability to make autonomous substitutions, closing loopholes that had previously existed.
While this change represents a step forward in ensuring prescriber management over patient treatment, it also places additional burdens on an already overworked healthcare system. In a field where doctors often operate through telehealth clinics and are difficult to reach in real-time, requiring a new script for every substitution could lead to delays in patient care. Patients may be left without their medication for extended periods, creating a new set of challenges to be addressed.
Consequences of Unwarranted Script Swaps
When pharmacists initiate substitutions without proper consultation, the implications can be significant. Firstly, prescribers lose control over their patients’ treatment plans. Anecdotal evidence suggests that some patients have received entirely different products than those prescribed, in some cases without any consultation or informed consent.
Asides from undermining the doctor-patient relationship and creating confusion for patients, changes in phytochemical constitution of the medication can pose potential risks for the patient’s health, especially in complex cases.
Additionally, fragmentation of patient records is a growing concern. The current implementation of eScripts means that a patient’s Active Script List (ASL) only shows the most recently dispensed product, not the originally prescribed one - which only becomes visible to the pharmacy when the script is selected for dispensing. This makes it difficult to track a patient’s treatment history and therapeutic outcomes with any real accuracy. Real-Time Script Monitoring (RTSM) systems like Q Script and Safe Script compound this issue, as they have even less ability to track scripts over time without clear notations made when dispensing, further complicating efforts to uphold continuity of care.
Stock-Outs and Impacts on Patient Care
One of the most frequent drivers of script substitution is the recurring issue of stock-outs. By merit of how the product is produced (naturally grown rather than synthetically created), there is always a higher risk of supply not meeting demand.
To add to this mix, the regulatory process of importing products from overseas (where most of our medical cannabis products originate) means that unexpected logistical delays are common.
Maintaining stock is not even achievable in the realm of conventional pharmaceuticals, so it definitely isn’t realistic in the cannabis space.
In such situations, substitution can be a necessary evil, yet clearly, not all products are easily interchangeable. Even slight variations in cannabinoid content can have a significant impact on a patient’s symptom relief and therapeutic outcomes.
Script substitution is a nuanced practice in the realms of pharmaceuticals and is far more complex in the medical cannabis arena. The knowledge and understanding of pharmacists to autonomously substitute cannabis prescriptions shouldn’t be relied upon. Extremely knowledgeable and educated pharmacists do exist, but the dearth of available training combined with a broader scarcity of scientific understanding of cannabis inhibits the accuracy of script substitution in medical cannabis prescriptions.
Flower products, in particular, are most commonly substituted, as they are the most prescribed form of medicinal cannabis and the most susceptible to supply chain disruptions. However, the range of differentiation between flower products—especially in terms of THC and CBD content—means that substitutions are rarely straightforward.
A Path Forward: Balancing Flexibility and Control
Given the unique challenges posed by medicinal cannabis, the industry is in urgent need of clearer, more effective substitution protocols. Recent legislative changes in Queensland and New South Wales have addressed some of the issues, but there is still much room for improvement.
Pharmacists must be better trained in the complexities of cannabis therapeutics. The knowledge gap between prescribers and pharmacists can be quite significant, and the risks of inappropriate substitutions will remain high until more comprehensive, local education programs are available. Moreover, better tools for tracking stock availability and substitutions are needed to ensure that prescribers have full visibility of their patients’ treatment history.
Ultimately, our collective goal should be to strike a balance between flexibility for pharmacists to manage stock-outs and prescribers' ability to retain control over their patients’ care. This will require ongoing collaboration between government, industry, and healthcare professionals to create a framework that maintains quality patient care.
Conclusion: A Call for Thoughtful Reform
The concerns around script substitution in the Australian medicinal cannabis landscape is symbolic of the broader challenges the industry faces. While substitution may be an unavoidable necessity in certain cases, its practice requires full transparency from pharmacies to patients and prescribers. Collaboration and education are the gateways to ensure medicinal cannabis meets its potential as a therapeutic treatment while maintaining quality patient care.
Michael Thorp is an experienced pharmacist specialising in medicinal cannabis patient care at Carina Day and Night Pharmacy in Queensland. Drawing on his comprehensive pharmaceutical background, he provides evidence-based guidance to patients navigating medicinal cannabis treatments. Working directly on the front lines of patient care, Michael takes a holistic approach to consulting with patients, offering detailed counseling on dosage, potential interactions, and optimal usage patterns.
Disclaimer: This information is shared with a global readership for educational purposes only and does not constitute medical or business advice. All patient-related information has been de-identified OR fictional to protect privacy. Nothing in this article is intended to promote the use or supply of medical cannabis to members of the public.