Regulators step in as medicinal cannabis prescriptions soar

Concerned by reports of patients presenting to EDs with medicinal cannabis-induced psychosis, Ahpra has put practitioners on notice that regulators are stepping in. Guidance from Ahpra and the National Boards has also been released, to help practitioners meet their obligations when prescribing medicinal cannabis.

The announcement and guidance release follows evidence that poor practice is leading to significant patient harm in the prescription of medicinal cannabis. Ahpra noted evidence of over-servicing and ethical grey areas around single-purpose dispensaries, which led the regulator to clarify the expectations of practitioners working in the industry.

The guidance

In the guidance, prescribers are reminded that medicinal cannabis should be treated as a medicine and to be as careful and diligent when prescribing medicinal cannabis as they are when prescribing other drugs of dependence. The guidance aims to support practitioners to provide safe care, particularly for those patients at most risk of harm, and also addresses the regulator’s concern that profits are being prioritised over patient safety.

“We don’t prescribe opioids to every patient who asks for them, and medicinal cannabis is no different,” said Dr Susan O’Dwyer, Medical Board of Australia Chair. “Patient demand is no indicator of clinical need.” Nurse practitioners within the industry are also being urged to combine the guidance with their professional practice framework when conducting assessments.

“Nurses and other registered practitioners must provide holistic care in all areas of their practice,” said Adjunct Professor Veronica Casey AM, Chair of the Nursing and Midwifery Board of Australia. “They must take their professional responsibilities with them no matter where they work.”

Ahpra advised that safe prescribing of medicinal cannabis includes:

• assessing patients thoroughly;
• formulating and implementing a management plan;
• facilitating coordination and continuity of care;
• maintaining medical records;
• recommending treatments only where there is an identified therapeutic need;
• ensuring medicinal cannabis is never a first-line treatment; and
• developing an exit strategy from the beginning.

Regulator red flags and response

Practitioners are also being warned of the inherent conflict of interest for practitioners working in an organisation that only prescribes and dispenses a single medicine, Ahpra CEO Justin Untersteiner said.

“Some business models that have emerged in this area rely on prescribing a single product or class of drug and use online questionnaires that coach patients to say ‘the right thing’ to justify prescribing medicinal cannabis,” Untersteiner said. “This raises the very real concern that some practitioners may be putting profits over patient welfare.”

With current prescribing data raising red flags that some practitioners are not meeting their professional obligations, Ahpra and the National Boards are working with other regulators like the Therapeutic Goods Administration (TGA) and state and territory authorities to understand prescribing patterns and stay ahead of emerging trends. Red flags include one practitioner who appears to have issued more 17,000 scripts and eight practitioners who have issued more than 10,000 scripts in a six-month window.

“We will investigate practitioners with high rates of prescribing any scheduled medicine, including medicinal cannabis, even if we have not received a complaint,” Untersteiner said.

Cases of poor practice in medicinal cannabis prescribing

According to Ahpra, cases of poor practice in prescribing medicinal cannabis include:

• consultations lasting between a few seconds and a few minutes, making a proper assessment impossible;
• in six months, practitioners who have each issued more than 10,000 prescriptions for medicinal cannabis products;
• failing to fully assess a patient’s history of substance use disorders and/or mental health prior to prescribing, leading to serious adverse outcomes such as psychotic episodes requiring inpatient admission as a result;
• not checking the identity of the patient, including prescribing for people under the age of 18;
• prescribing without a legitimate indication, including because the patient requested it;
• in each prescription, prescribing excessive quantities of medicinal cannabis;
• providing multiple prescriptions for a single patient/person so they can ‘try which one suits them’;
• not checking real-time prescription monitoring (RTPM) systems and therefore not being aware of other medicines prescribed;
• not coordinating care with a patient’s other treating practitioners — especially where a patient’s history or other prescribed medicines suggest they are not a suitable candidate for treatment with medicinal cannabis;
• prescribing for family members or self-prescribing; and
• having a conflict of interest by only prescribing the product supplied by the company the practitioner is associated with.
   

The guidance on medicinal cannabis prescribing is available here, via the Ahpra website. This guidance builds on existing regulatory guidance about safe care, including each board’s code of conduct and their guidance on telehealth and virtual care.

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