Cannabis prescriptions: A challenge for doctors and pharmacists
A truly exciting transformation has taken place: Cannabis, previously known in Germany only for its misuse, has been legally available to patients since the beginning of March in public pharmacies, maintaining consistent quality and for specific medical indications upon prescription. An illegal drug has become a legal medicine! This change raises numerous questions for doctors and pharmacists regarding its handling.
In this context, the described mechanisms of action and the actual evidence for the efficacy of cannabis and its constituents are of particular interest. Cannabis can be used and consumed in numerous different forms: by inhalation, in the form of finished medicinal products (including extracts), or possibly even purely in the form of isolated, efficacy-determining constituents. When cannabis (flowers) is handled as a drug in a pharmacy, all aspects of prescription-based handling must be considered and regulations followed. Experiences with prescribing and dispensing cannabis, which will be available by the time of the event, will also be presented.
The aim of this event is to provide safety and a sound basis for handling the situation in medical and pharmacy practices.
Contents:
- efficacy-determining ingredients and mechanisms of action
- Characterization of the different cannabis strains
- The role of cannabis in various indications
- Evidence base of existing application forms
- Prescribing aid for doctors
- Aspects of narcotics law: maximum prescription quantities, prescription validity period, etc.
- Risk of abuse, side effects and interactions, contraindications
- Special features of the recipe
- Health insurance approval, cost coverage by statutory health insurance
- Initial experiences with prescribing and handling cannabis
Dr. Christian Ude , pharmacist, Darmstadt;
Prof. Dr. med. Dipl.-Psych. Hartmut Göbel, specialist in neurology, pain therapist, Kiel
Cannabis has anti-inflammatory, antiemetic, muscle-relaxing, sedative, appetite-stimulating, analgesic, and antidepressant effects. Since March 2017, cannabis has been officially approved for use in Germany for serious illnesses without specific indications; the costs can be reimbursed by health insurance companies after individual approval.
Previously, the active ingredient THC (delta-9-tetrahydrocannabinol) was used in Germany. CBD (cannabidiol) is also available. The new legal regulations now allow the flowers to be prescribed as well.
The two main active ingredients have different mechanisms of action:
- THC: Analgesic, muscle relaxant, antiemetic, appetite stimulant, psychoactive (mood enhancement, euphoria, talkativeness, altered perception, etc.), panic, anxiety, dysphoria, psychoses, memory and concentration disorders, tachycardia, tremor, ataxia.
- CBD: Anti-inflammatory, muscle-relaxing, antiemetic, anticonvulsant, antipsychotic, anxiolytic, neuroprotective.
CBD counteracts the psychoactive effects of THC; therefore, medical cannabis should contain THC and CBD in a balanced ratio. The ready-to-use spray Sativex contains 50% THC and 50% CBD. When using cannabis flowers, care should be taken to ensure that the proportion of the two active ingredients is balanced.
Contraindications include: psychoses, affective disorders, anxiety disorders, childhood and adolescence, as irreversible cognitive damage is to be expected. Pregnancy, cardiac arrhythmias, hypertension.
Insured individuals with serious illnesses are entitled to cannabis treatment if no alternative therapy is available, established treatments are ineffective or insufficient, and if there is a prospect of improvement through this therapy. The initial prescription must be approved by the health insurance company. This requires a reasoned application from the physician. It may only be refused in exceptional, well-founded cases.
The physician is obligated to collect data for a monitoring study. This data is collected for a post-marketing surveillance study.
Prescriptions can include finished medications such as Sativex, Canemes, or Marinol, as well as dronabinol (THC), oily cannabis extracts, and cannabis flowers. The latter can be ground up and vaporized before inhalation.
More extensive scientific findings are currently only available for the accompanying treatment of spasticity, nausea and vomiting during cytostatic drugs and chronic pain.
Possible effectiveness is discussed for loss of appetite and weight loss in HIV, schizophrenia, Parkinson's disease, Tourette syndrome, epilepsy, and chronic inflammatory bowel diseases.
Statutory health insurance companies can reimburse the cost of therapy upon a justified application from the treating physician. The decision as to whether a patient requires cannabis treatment rests with the treating or prescribing physician. However, reimbursement must be approved by the health insurance company. The necessity of the treatment must be established, contraindications must be ruled out, and the minimization of psychoactive effects through a targeted combination of active ingredients should be ensured.
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