Medical cannabis supply

Codes, Guidelines and Policies

Meeting your professional responsibilities

Medicinal cannabis can legally be prescribed by medical and nurse practitioners in Australia. There is evidence of poor practice in prescribing and supply of medicinal cannabis that is leading to significant patient harm.

Most medicinal cannabis products prescribed in Australia are unapproved. This means they have not been assessed by the Therapeutic Goods Administration (TGA) for safety, quality, performance or effectiveness. Many of the medicinal cannabis products prescribed in Australia contain THC (delta 9-tetrahydrocannabinol), which makes them Schedule 8 medicines¹ due to the risks of misuse/abuse and potentially addictive properties.

Pharmacists are required to supply Schedule 8 medicinal cannabis with the same care and consideration as they do when supplying opioids and other Schedule 8 medications.

National Boards are concerned that profits are being prioritised over patient safety in some medicinal cannabis practices. Business models have emerged that appear to use aggressive and sometimes misleading advertising that targets vulnerable people. Some of these practices only offer the prescription and supply of a single product or class of drug and use online questionnaires that coach patients to say ‘the right thing’ to justify prescribing. While these models may work well for access, there is an inherent conflict of interest for pharmacists working in an organisation in which a single medication is prescribed and dispensed.

Supplying medicinal cannabis products without in-person interaction or direct communication with the patient, may give rise to additional challenges which must be addressed appropriately in the interest of patient safety.

This guidance aims to support pharmacists to practise safely and meet their professional responsibilities, including the code of conduct. More details and links to TGA resources is available on the further information page.

¹Schedule 8 medicines are titled ‘Controlled Drugs’ and are defined as ‘substances which should be available for use but require restriction of manufacture, supply, distribution, possession and use to reduce abuse, misuse and physical or psychological dependence’

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Guidance

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Safe and appropriate supply of prescribed medicinal cannabis includes:

complying with state, territory and jurisdictional laws and regulations, including using government real-time prescription monitoring service (RTPM) or equivalent and contacting the prescriber if a prescription is not legally valid
determining the prescriber's intentions as to the patient's medicinal cannabis, including the dosing instructions and confirming them with the prescriber if they are unclear
reviewing the medication history and other relevant patient information, to ensure that the medicinal cannabis is safe and proper for the patient to use and that where possible, all other relevant considerations of the patient's health, including the use of any other prescription and non-prescription medicine such as complementary and alternative medicine, are taken into account
counselling the patient, or the patient's agent, sufficiently to allow a proper understanding of all the information required by the patient to use the medicinal cannabis safely and effectively including to seek further advice about their medicinal cannabis usage if their healthcare or other relevant circumstances change
exercising independent judgement to ensure the medicinal cannabis is safe and appropriate for the patient
contacting the prescriber to discuss any concerns and seek clarification.

Pharmacists must also ensure their practice is:

compliant with relevant pharmacy practice standards and guidelines
aligned with the conduct expected of pharmacists as set out in the Code of conduct and the codes of ethics for pharmacists
compliant with all relevant Board guidelines for pharmacists.

Applying the Code of conduct, good patient care when asked to supply medicinal cannabis includes:

considering the balance of potential benefit and harm in all clinical management decisions
communicating effectively with patients to ensure they have enough information to make an informed decision about their current and future care
practising within an evidence-based and patient-centred framework
facilitating the quality use of therapeutic products based on the best available evidence and the patient’s needs
making decisions to supply medicines that are not influenced by financial gain or incentives.

With a few exceptions, such as the treatment of certain childhood epilepsies, muscle spasms and pain symptoms associated with multiple sclerosis, some neuropathic pain and chemotherapy-induced nausea and vomiting in cancer, there is little evidence to support the use of medicinal cannabis.

If the pharmacist decides not to supply the prescribed medicinal cannabis, the patient and the prescriber should be informed about the reasons for the decision and any alternative options that may meet the patient’s needs. Appropriate documentation should be kept about the action taken and the reasons.

The TGA has approved only two medicinal cannabis products for specific purposes. When supplying an unapproved Schedule 8 product such as THC containing medicinal cannabis, the pharmacist should confirm that the patient is aware that they have been prescribed an unapproved product that has not been assessed by the TGA for safety, efficacy and quality.

Pharmacists should also report any adverse events (side effects) from therapeutic goods that are, or contain, medicinal cannabis to the TGA through the Adverse Event Management System (AEMS).

It is important to recognise potential conflicts of interest, inform patients about any conflicts and not allow any financial or commercial interest to adversely affect the way you supply medicines to patients. Conflicts of interests are inherent if you are working in an organisation that prescribes and dispenses a single medication. A declaration of a conflict on a website is not sufficient, and you must be prepared to explain how a declared conflict is not impacting patient care.

If you are supplying medicinal cannabis products without in-person interaction or direct communication with the patient, there may be additional challenges and issues to consider including:

confirming the patient’s identity and date of birth
determining whether it is appropriate to use telehealth for the consultation and making arrangements to see the patient in-person if necessary
clarifying and confirming that you have accurate information about the patient, for example if the information was provided in an online questionnaire.

A word of caution

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Ahpra and National Boards are working with other regulators to understand prescribing and dispensing patterns. We may investigate the practice of practitioners even if we have not received a complaint. Ahpra and National Boards have also published guidance to help practitioners meet their obligations when prescribing medicinal cannabis.

Specific examples of poor practice

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The following real examples show poor practice in dispensing medicinal cannabis:

Supplying excessive quantities of prescribed medicinal cannabis.

Dispensing medicinal cannabis on repeat authorisations without the patient requesting an additional supply.
No counselling or inadequate counselling given to the patient on safe and effective use of the medicinal cannabis.
No consultations conducted with patients while dispensing medicinal cannabis.
Supplying multiple prescribed medicinal cannabis products for a single patient at the same time, so they can ‘try which one suits them’.
Not checking the relevant RTPM system and therefore not being aware of other prescribed and dispensed medications.
Brand substitution of medicinal cannabis products that is not compliant with legislation.
Storage of medicinal cannabis that is not compliant with legislation.
Not appropriately managing a conflict of interest.