Life changer - The first 7 years of prescribing medical cannabis. Part 1
Article Written by Dr Stephen Gipps
Read time: 5-6 mins
Over the past seven years, I've navigated the challenges of integrating a once-stigmatised treatment into mainstream medicine. What follows is a brief story of my experience prescribing medical cannabis in Australia since 2017 and encouragement to fellow GPs - practising and emerging.
From the early beginnings, when we were all learning the SAS B ropes, to becoming an Authorised Prescriber, my personal story of prescribing medical cannabis has proven to be an enriching experience and a potent addendum to my medical practice.
A Nascent Industry: Navigating the TGA in the early days
I did it the hard way back in 2017, jumping in the deep end. After carefully assessing the patient eligibility criteria, applying to TGA for a Special Access Scheme B (SAS) submission felt intimidating - as though I had to put on a lawyers hat and make a rigorous case submission. The earnest was on me to advocate for the patient to be able to trial this terribly stigmatised S8 classified, non-TGA-approved product.
At that time, I recall a patient with Multiple Sclerosis looking for relief from muscle spasms and associated pain. My application was for a Cannatrek 10:10 THC 10mg with CBD 10mg oral oil. This should have been an easy application; the indication was clearly within the guidelines given the patient had failed all other treatment options.
However, this initial application was rejected on the basis that Sativex was already approved by the TGA for Multiple sclerosis-associated muscle spasms without needing SAS approval. I would have happily prescribed Sativex but for the cost, which at the time was roughly tenfold the cost of a plethora of equivalent products obtainable under the SAS B scheme.
In responding to the TGA application rejection letter I tried to argue the cost issue, but it fell on deaf ears. The TGA would not consider cost at all!
I had to find another angle. That ended up being some other secondary indication in the patient’s symptom picture that Sativex was not specifically indicated for. At that time what I found was that in future applications, when prescribing a 1:1 oil for MS patients, supplying other relevant secondary indications in my applications avoided dragging out the process.
However, I soon realised that this kind of case was the exception, and the vast majority of subsequent applications were quite straightforward without pushback from the TGA.
After trialling just a handful of patients, the feedback was consistently positive enough to confirm that medical cannabis was worth pursuing further. SAS B submissions became very familiar, albeit with a small 1-3-day turn around time.
Patient Demographics and Trends
Initially, most patients came to me seeking relief for musculoskeletal conditions: Osteoarthritis, fibromyalgia, neuropathy, PTSD-related muscle tension pain, and chronic injury or post-surgical related pain.
Many patients came self-referred, soon followed by referrals from Rheumatologists and GPs, psychologists, paediatricians and neurologists. This expanded my patient base quickly, with diverse patients coming for their Rheumatoid or Psoriatic Arthritis, Autism, Seizure disorders and neurodegenerative diseases. Some qualifying under SAS B only because of secondary or associated conditions. After that, and into the present, recalcitrant anxiety and insomnia patients started presenting, some with depression, which is also assisted.
The classic patient I see nowadays is a middle-aged or older adult with osteoarthritic or spondylotic pain, anxiety, or insomnia - often a combination of two or three of these. My standard approach would typically start with a CBD:THC oil 1:1 or possibly up to 4:1. The majority of people I start on this simple regime, once titrated to their optimal dose, have astounding results to report at follow-up 2-6 weeks later.
Achieving optimal treatment outcomes may involve utilising different CBD:THC ratios and/or product forms, which may be discussed in a subsequent article. For now, the key point is that many patients do really well on an individualised dose of 1:1 oil and remain fairly close to this dose long term.
Another typical scenario is a veteran with PTSD and chronic pain, or a younger orthopaedic chronic injury patient. As you may have encountered, these patients frequently struggle with opioid side effects, accelerated use and diminishing efficacy.
Cannabis can be incredibly effective in many of these patients in offering a chance to reduce or potentially entirely stop opioids, benzodiazepines, muscle relaxants, antidepressants, etc. This is entirely gratifying for both patient and prescriber. In cases that also utilise allied therapies such as physiotherapy, osteopathy, exercise physiotherapy, and occupational therapy, outcomes only get better.
Patient Outcomes
Whilst a couple of patients have failed to respond well, typically, these patients had unrealistic expectations, looking for a panacea type effect. Some would cautiously stay at too low a dose, fearing even a mild dose escalation, therefore not achieving a therapeutic dose. Others took too much too quickly - despite prescriptive advice and caution. In these cases, adverse reactions included tachycardia, paranoia, dry mouth, insomnia from overstimulation or dream states - which cease quickly upon reducing or pausing medical cannabis.
However, feedback was, and continues to be, incredibly encouraging for the vast majority. After just a few weeks of initial dose titrating, a significant portion of patients report feeling incredible relief and being extremely grateful.
For my geriatric patients, I have spouses declaring that “they got their spouse back.” Individuals are now happier and more content compared to their grumpy, sallow, checked-out disposition prior. With pain significantly relieved, anxiety lessened, appetite returned, and sleep satiated, there is often a dramatic and pleasing change for both the patient, spouse, and other family members.
It follows and has been my experience, that there is massive scope for the broad application of cannabinoids in nursing homes and aged-care situations. The potential for mitigating the use of sedatives, anxiolytics, antidepressants and the overuse of behavioural restraint by augmenting or replacing these medications with the soothing, restorative and uplifting potential of cannabinoids is immense.
This is part one of a two-part article - the second article will be published next month.
Dr. Stephen Gipps is a seasoned medical practitioner with over four decades of diverse experience since 1984. His expertise spans general practice, natural and alternative medicine, occupational medicine, musculoskeletal injury and degeneration, and pain management. Dr. Gipps holds a Bachelor of Medicine and Bachelor of Surgery (MBBS) from UNSW and completed additional medical training in the USA, achieving high percentiles in USMLE exams. Currently serving as the Managing Director and CEO of CannAgeWell.com, he has a particular interest in medical cannabis, offering advisory services to emerging companies in this field. Dr. Gipps' broad experience includes roles as a medical advisor for various health-related companies and a stint as a licensee for Exclusiv Brigitte Kitchens.
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.
