Scroll to top

Response to NHSE Review & NICE CBMP Guideline – Part 2: NHS England Review

Jon L - August 21, 2019 - 52 comments


Part 2: Barriers to accessing cannabis-based products for medicinal use on NHS prescription

Following on from our Part 1: Overview yesterday, this is a more detailed analysis of the NHS England and NHS Improvement’s report on the Barriers to accessing cannabis-based products for medicinal use on NHS prescription. 

The Good

The creation of a specialist clinical network is an excellent idea which will help cascade knowledge across the medical profession efficiently, but why should this be limited to the paediatric space alone? CPASS feel the scope should be broadened to include all indicated disciplines that can service the entire medical profession and all patients. 


The recommendation that NHS England (NHSE) and the Department of Health and Social Care (DHSC) should work together to develop clear information for patients on cannabis-based medicinal products is another good idea. CPASS will be publishing a guide for patients built on over 20 years of medical and patient experiences from abroad in the Autumn. We look forward to sharing this and working with them on progressing this as we have with Health Education England’s e-learning tool for doctors, due to be published shortly. 


Another welcome recommendation is for NHSE and The National Institute for Health Research (NIHR) to work together on alternative trial design(s) for CBMPs to include patients who cannot be enrolled into a standard RCT due to having consumed this medicine before.  RCT’s are inappropriate for CBMPs as different patients require different cannabinoid balances for best effect. We encourage them to look carefully at the timely proposals from The Centre for Medicinal Cannabis: Breaking The Embargo 


Whilst we agree that NIHR should support research into the NICE Guideline five priority research areas they should be encouraged to broaden scope into areas where the highest proportion of patients are reporting benefits such as depression (17%), anxiety (16%), insomnia (9%). In addition, the qualification criteria for research awards need to be relaxed to encourage more research into these areas. 


Finally, on the positive side, CPASS look forward to helping NHSE and DHSC on building a national UK patient registry across all indications, though not just for patients prescribed a CBMP,  as there will be a great deal of good data to be gained from extending this to those who currently have no choice but to self medicate from the criminal market. 

The Bad

The report states that the use of cannabis with a high concentration of THC has harmful effects on mental health which is untrue. The evidence suggests an increased risk for a very limited proportion of people and for which causation has never been established. In fact, the single evidence example given in the report has been thoroughly challenged in the Lancet and elsewhere so we ask why has this not been referred to? Does this reflect a lack of thoroughness or a biased selection of evidence? It should be noted that this evidence is based on the self-reported illicit use of street cannabis for which the levels of THC/CBD and presence of other impurities such as pesticides and heavy metals remains unknown. This cannot be considered quality evidence which reflects very badly on the credibility of this review. 


We have major concerns over the lack of explanation for why Sativex® and shortly Epidyolex® should be treated as exceptions to all other CBMPs by being given their own schedule (4ii) in the MDA:


  • Sativex® is a blend of full plant extracts to make a 1:1 THC:CBD product and is no different to other available similarly balanced products. 
  • Epidyolex® is purified CBD and little more. As an isolated compound, CBD is already available at less than 100th of the price online or on the high street. 


There is no scientific or medical basis for these exceptions and we challenge our authorities to properly justify this or change it. If all CBMPs were placed into Schedule 4ii, it is likely that doctors would find it easier and as such be more willing to prescribe them 


Whilst it is pleasing that over 100 young patients have access to Epidyolex® through an early access programme, no reference has been made to how patients are progressing. We are aware of concerning reports by parents, that the medicine is causing unpleasant side effects and a few reports that patients are plateauing and their seizures returning after a few months. Surely, this needs proper investigation before it is approved for wider use? Specifically, we would like to understand why so many patients are reportedly requiring the maximum recommended dose of CBD which is about 10x the dose of CBD than in other effective products from around the world which contain small amounts of THC along with other cannabinoids?


The focus on intractable paediatric epilepsy is also of concern to the vast majority of patients. Whilst recognising the urgency for this patient group, they only constitute around 1% of all epilepsy patients and epilepsy represents only 1% of patients with chronic conditions who could benefit from CBMPs. Focusing only on 1 in 10000 patients cannot possibly give anyone a true picture of the challenges being faced nor the benefits being experienced by patients in the UK. 


This is justified, in the report, by citing intractable paediatric epilepsy as having the “Strongest arguments” for progression but offers nothing as to why. What evidence is this based on? We suspect that it is a mixture of political and public pressure which are surely not good bases for prioritisation? Chronic Pain is clearly and by some margin “stronger” with 28 million sufferers in the UK today according to the British Pain Society and with potential efficacy in 80% of patients. It is of great concern that “The vast majority of the clinicians” told the inquiry that the lack of good quality RCT data demonstrating adequate safety and clinical-cost effectiveness of CBPMs for all indications is a major hurdle to prescribing. 


The Royal College of Physicians have repeatedly stated that on the basis of the evidence they have reviewed, there is only a 24% efficacy which is roughly equivalent to placebo, but there are two glaring issues drawing any conclusions from this: 


Firstly, out of the 20000 available studies, only 20 were selected for review, dismissing the other 99.9%. Secondly, RCT’s of a single CBMP versus placebo can never measure true effectiveness as individual patients require different ratios of the main active ingredients, THC and CBD for the most benefit. Where variable trials have been undertaken around the world, efficacy is in excess of 80%, making it orders of magnitude more effective than other currently available pain medications.  Not only that but with significantly less unwanted side-effects. 


The next issue of concern is that “Most clinicians told us that products containing THC would not be prescribed in their trusts, primarily because of the lack of evidence, knowledge about the products and long-term safety data.” Several clinicians referenced the higher risk of impaired mental health from long term exposure to THC and the need to “proceed with caution”.


Whilst we would expect all areas of medicine to “proceed with caution” there is no evidence that low doses of THC are associated with any risk and such unevidenced opinion should not be included in an evidence-based review. The standards for evidence for both the benefits and the risks must match if we are to achieve the best analysis. All the evidence that highlights potential and increased risks are based upon anecdotal reports of illicit consumption of very high THC, zero CBD street weed and cannot be applied to the use of a quality and prescribed CBMP under the supervision of a medical professional. Perhaps this argument would benefit from the knowledge that THC at up to 10mg/kg has been consumed by the UK public for many years in Hemp Seed Oil products, ironically, all of which are in breach of the 2001 Misuse of Drugs Act. There have been no reported instances of anyone ever having had any negative consequences from consuming hemp seed oil during the decades that it has been available on every high street store or supermarket. Is this not evidence?


In addition, when assessing risk vs benefit, surely it is wrong not to include the fact that any decision not to prescribe a CBMP to a patient is, in effect, a decision to send the patient back to the criminal market for their medicine prolonging their exposure to all the associated risks. Surely, every patient who is already acquiring and consuming street cannabis to alleviate their symptoms would be at less risk if they were prescribed a quality controlled CBMP under the supervision of a medical professional? 


We need to be efficient in producing efficacy and safety data as many CBMPs will have an identical safety profile and could be grouped into two or three “product groupings” such as: 1: High THC, 2: Low THC, 3: 1:1 and surely we can use the safety data gathered from Sativex® over the last few years since it was approved as it is a 1:1 CBMP whose results could be applied to ALL similar products? 


It is another concern that Healthcare Trust costing boards are making decisions based on the price of Sativex®, which is 5-10 times more expensive than other similar and available CBMPs.


Pharmacists raising concerns around the difficulty in knowing which products are of good quality and consistency is an education issue rather than a practical or logistical or as there are many CBMPs available right now that qualify. The recommendation that DHSC and MHRA should work to provide access to information on good quality products can be fixed very quickly through proper engagement with Licensed Producers (LPs) and by looking again at the product marketing regulations that apply to the specials category of medicines. CPASS already have good working relationships with many LPs and would be happy to help gather this information together.


In summary, there is room for optimism with some of these recommendations as long as they are accepted and implemented, however, if access for patients is to be improved significantly, then there is still too much reliance being placed on our existing “world-class” systems which are simply inappropriate for the approval and prescribing of CBMPs. Healthcare providers have a moral obligation to support the well-being of patients, whom, without access will continue to expose themselves to the inherent risks of the criminal market to source low-quality medicine. CPASS believe that this review would have benefited more from hearing much more from the voices of all patients and patient groups and recommend that a further review take place. We shall be raising all of these points with the inquiry team directly and will report back on any responses we get.

Jon Liebling – CPASS Co-Founding Director

Read Part 3 here: NICE Guideline for Cannabis-Based Medicinal Products


Register your interest in CPASS here:

Follow us on Social Media:

[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][/vc_column][/vc_row][vc_row][vc_column][vc_empty_space][norebro_social_networks icon_layout=”outline” alignment=”left” type_links=”custom” facebook_link_custom=”” twitter_link_custom=”” instagram_link_custom=”” youtube_link_custom=””][/vc_column][/vc_row]

Related posts


  1. Ahaa, its pleasant conversation on the topic of this post
    here at this web site, I have read all that, so now me also commenting here.
    I like it when people get together and share views. Great
    site, stick with it! I’ve been surfing online
    greater than 3 hours nowadays, yet I never found any interesting article like yours.
    It is beautiful value enough for me. In my opinion, if all
    web owners and bloggers made excellent content material as you did, the web can be much more useful than ever before.

  2. Ahaa, its nice discussion on the topic of this article here at this web site, I have read all that, so now me
    also commenting at this place. Amazing! This blog looks exactly like my old one!
    It’s on a completely different subject but it
    has pretty much the same layout and design. Outstanding choice of colors!

    Does your website have a contact page? I’m having trouble locating it but, I’d like to shoot you an e-mail.
    I’ve got some recommendations for your blog
    you might be interested in hearing. Either way, great site and I look forward to seeing it grow over time.

  3. I am sure this article has touched all the internet people, its really
    really good paragraph on building up new webpage.
    Ahaa, its nice conversation concerning this paragraph here
    at this weblog, I have read all that, so now me also commenting at this place.

    I simply couldn’t leave your web site prior to suggesting that I really enjoyed the standard information an individual supply on your visitors?

    Is gonna be again frequently to check out new posts

  4. I have been browsing online more than three hours today,
    yet I never found any interesting article like yours.
    It’s pretty worth enough for me. In my opinion, if all site owners and bloggers made good content
    as you did, the net will be much more useful than ever before.

    Hey just wanted to give you a quick heads up. The words in your post seem to be running off the screen in Chrome.
    I’m not sure if this is a format issue or something to do with
    browser compatibility but I figured I’d post
    to let you know. The design and style look great though!

    Hope you get the issue resolved soon. Thanks Hi there!

    This article couldn’t be written any better! Going through this post reminds me of my previous
    roommate! He constantly kept talking about this.

    I most certainly will forward this information to him.
    Pretty sure he’s going to have a very good read. I appreciate you for sharing!

  5. Thanks for one’s marvelous posting! I quite enjoyed reading it, you may be a great author.
    I will always bookmark your blog and will often come back later in life.
    I want to encourage yourself to continue your great work, have a nice afternoon!

  6. Incredible! This blog looks exactly like my old one! It’s on a totally different
    subject but it has pretty much the same page layout and design. Superb choice of colors!

  7. I seriously love your website.. Pleasant colors & theme.
    Did you develop this website yourself? Please reply back as I’m trying to create my very
    own website and want to find out where you got this from or just what the theme is named.


  8. Why people still make use of to read news papers when in this technological world everything is
    existing on web?

  9. Everything is very open with a precise explanation of the
    issues. It was definitely informative. Your site is very helpful.
    Thank you for sharing!

  10. Undeniably imagine that which you said. Your favorite reason seemed to
    be at the web the simplest factor to take into account of.
    I say to you, I definitely get irked while folks think about issues that they just don’t recognize about.
    You managed to hit the nail upon the highest
    and outlined out the entire thing with no need side effect , other people can take a signal.

    Will probably be back to get more. Thanks

  11. You’re so awesome! I do not think I’ve read something like that before.

    So wonderful to find someone with some genuine thoughts on this subject matter.
    Seriously.. many thanks for starting this up.
    This web site is something that’s needed on the internet, someone with a bit
    of originality!

  12. .

    Howdy! I just would like to offer you a big thumbs up for the great info you have got right here on this post.
    I’ll be coming back to your blog for more soon.

  13. “I really enjoy the blog.Really thank you! Keep writing.”

  14. Very energetic post, I loved that a lot. Will there be a part 2?

  15. … [Trackback]

    […] Read More here: […]

  16. It is appropriate time to make a few plans for the long run and it
    is time to be happy. I’ve learn this submit
    and if I could I want to counsel you few fascinating things
    or tips. Maybe you could write subsequent articles referring to this article.
    I desire to learn more things approximately it!

  17. hdWRVp Lots of people will be benefited from your writing. Cheers!

  18. There?s definately a great deal to know about
    this subject. I really like all of the points
    you made.

  19. An outstanding share! I’ve just forwarded this onto a colleague who was doing a little homework on this.
    And he actually bought me breakfast due to the fact that I found it for him…

    lol. So let me reword this…. Thank YOU for the meal!!
    But yeah, thanks for spending some time to discuss
    this subject here on your website.

  20. I blog frequently and I truly appreciate your content.
    This article has really peaked my interest. I’m going to book mark your blog and keep checking for
    new details about once per week. I opted in for your Feed
    as well.

  21. My brother recommended I might like this web site.
    He was entirely right. This post actually made my
    day. You cann’t imagine simply how much time I had spent for this information! Thanks!

  22. Undeniably consider that which you said.
    Your favourite reason seemed to be at the net the easiest factor to have in mind of.
    I say to you, I certainly get irked while other folks think
    about concerns that they just don’t know about. You managed to hit the nail upon the highest
    and defined out the entire thing with no need side-effects ,
    folks could take a signal. Will likely be back to get more.
    Thank you

  23. This article is actually a nice one it helps new
    the web users, who are wishing in favor of blogging.

  24. I am curious to find out what blog system you are utilizing?
    I’m having some minor security problems with my latest site and I’d
    like to find something more secure. Do you have any suggestions?

  25. I’m truly enjoying the design and layout of your website. It’s a very easy on the eyes which makes it much more pleasant for me
    to come here and visit more often. Did you hire out a designer to
    create your theme? Excellent work!

  26. It’s amazing to pay a quick visit this site and reading the views
    of all colleagues on the topic of this post, while I am also zealous of getting know-how.

  27. Appreciating the persistence you put into your blog and in depth information you
    present. It’s awesome to come across a blog every once in a while
    that isn’t the same unwanted rehashed information. Fantastic read!
    I’ve bookmarked your site and I’m adding your RSS feeds to my Google account.

  28. Appreciating the persistence you put into your blog and in depth information you present.
    It’s awesome to come across a blog every once in a while that isn’t the same unwanted rehashed information. Fantastic read!
    I’ve bookmarked your site and I’m adding your RSS feeds to my Google account.

  29. I enjoy reading through a post that can make people think.
    Also, thank you for allowing me to comment!

  30. Therre iis definatly a lot tto learfn abot ths topic.
    I love alll oof the points yyou have made.

  31. It’s very simple to find out any topic on net as compared to books, as I
    found this piece of writing at this website.

  32. There is definately a lot to know about this issue.
    I really like all of the points you have made.

  33. Hi, i read your blog occasionally and i own a similar one
    and i was just wondering if you get a lot of spam remarks? If so how do you reduce it, any
    plugin or anything you can advise? I get so much lately it’s
    driving me insane so any help is very much appreciated.

  34. Thank you for the auspicious writeup. It in fact was a amusement account it.
    Look advanced to far added agreeable from you!
    By the way, how can we communicate?

  35. I really love your blog.. Excellent colors & theme.
    Did you create this website yourself? Please reply back as I’m attempting to create my own site and would like to know where you got this from or just what
    the theme is named. Many thanks!

  36. I’ve been browsing online greater than three hours nowadays,
    yet I by no means found any fascinating article like yours.
    It’s lovely worth sufficient for me. In my view, if all website
    owners and bloggers made just right content as you probably did, the internet will probably be much more helpful than ever before.

  37. Blog commenting still works for sure. I have been doing SEO for years. I studied the google updates all the time and I guarantee you guys that blog comments work ? Great article btw!
    Great advice, a lot of people are still stuck in the 2010’s methods of SEO/Marketing. This article is definitely up to date on which methods are working best right now. Thanks for sharing this. ?

  38. I wanted to thank you for this very good read!!
    I absolutely loved every little bit of it.

    I have got you bookmarked to check out new things you

  39. There is definately a lot to know about this subject. I love all the points you have made.

  40. It’s perfect time to make some plans for the future and it’s
    time to be happy. I have read this post and if I could I desire to suggest you few interesting things or advice.
    Perhaps you could write next articles referring to
    this article. I wish to read even more things about it!

  41. It is perfect time to make a few plans for the future and it’s time to be happy.
    I’ve learn this post and if I could I want to suggest you few attention-grabbing things or advice.

    Perhaps you could write subsequent articles referring to this article.
    I desire to read even more things approximately

  42. I simply couldn’t go away your site prior to suggesting that I actually loved the usual info a person provide for your guests?

    Is gonna be back incessantly to investigate cross-check
    new posts

  43. Ahaa, its good conversation about this article at this place at this blog, I have read
    all that, so now me also commenting here.

  44. I truly appreciate this blog article.. Fantastic. ..This post
    posted at this site is actually nice.

  45. I like the valuable information you provide in your articles.
    I’ll bookmark your blog and check again here regularly. I’m quite certain I will learn plenty of new stuff right here!
    Good luck for the next!

  46. Keep up the exceptional work !! Lovin’ it!|

  47. I’ve read several excellent stuff here. Certainly worth bookmarking for revisiting.
    I surprise how a lot effort you put to create this type of magnificent informative website.

  48. Thank you for the auspicious writeup. It in fact was once a enjoyment account it. You are really great blogger, your are sharing most clearly points, that’s helping me a lot.

Post a Comment

Your email address will not be published. Required fields are marked *