By Katya Kowalski, with additional reporting by Sarah Sinclair, Cannabis Health
The UK’s medical cannabis industry has at times felt like a broken record. Once the hype of the law change subsided and fizzled out, the industry has been in a loop of difficulty trying to reduce the number of patients on the illicit market.
When medical cannabis was legalised in 2018, there was an expectation that patient numbers would grow quickly, with the reported 1.4 million people already medicating illicitly, seeking out legal prescriptions. However, now almost five years on, that hasn’t been the case.
It’s evident that the UK’s rescheduling of cannabis is a classic example of where just because something has changed on paper, it hasn’t necessarily shifted in practice. Why is that? What explains all of this?
Industry barriers
There are several barriers facing the medical cannabis industry and there isn’t a panacea of a solution which would solve all the problems. There’s systemic issues with how the industry has been set up, persistent stigma amongst the public, resistance from doctors, structural issues with the supply chain and a lack of public awareness around it being legal.
All of those barriers listed above are important and pertinent but something which looms over us is the fact that there are still so many patients medicating illicitly in the UK.
Cannabis is complicated and has a long history and legacy which should not be disregarded with the introduction of a legal market. But the criminalisation, exploitation, and total lack of regulation is problematic and is exactly what drug reform seeks to combat. So from this perspective, it is vital we move toward bringing legacy patients on to the legal market when at all possible.
There are of course plenty of reasons for why legacy patients choose to continue sourcing their medication illicitly. It might be cost, quality, service related or the ease at which they can get their medicine illegally without having to come into contact with the confusing system of medical cannabis in the UK.
The industry should have a core focus around bringing legacy patients into the legal framework making their business seem more attractive than the illegal market.
The reason why patients stay on the legacy market is because there is something the legal market isn’t offering or doing as well as. Legal markets need to meet the demands of patients. This isn’t just an issue in the UK, but across Europe and North America. I think there is often a certain naivety in the industry that because something is legal there will be an automatic move to this. In order for legal to be better it has to actually be made better.
We need pragmatism for approaching this issue with a reality check around how we approach it.
One of the major limitations of the UK industry is that its own marketing and patient onboarding focus has been amongst the cannabis “naive” to normalise it and break the stigma as a medicine. This is all well and good but the UK cannabis industry needs to get the support and backing from legacy market patients to really see a shift in the number of those legally prescribed.
There are still a range of key barriers facing the patient community.
As one patient told Cannabis Health last year:
“I don’t think people are choosing one market over another, I think people are choosing discretion, reliability and the easiest route to access.”
When asked why they had chosen to return to – or remain on – the legacy market, patients cited cost, quality, lack of choice and unreliability as the key challenges they had come across in the legal system.
Many feel the quality and consistency is not as good as what they can access on the street, particularly if they know the person who is cultivating and have a longstanding relationship with them.
This is coupled with the fact that they may experience delays to receiving their prescription and there have been a number of reported quality control issues, such as finding mould or powdery mildew in flower-based products.
While some patients have returned to the illicit market to source all their medication, others use it as a ‘backup’ for when they run into these issues.
According to one patient:
“My experience increasingly is that it’s impossible to maintain a steady supply, so there’s always a backup needed.”
And while it is not an option for everyone, some patients say they have found that the most effective way to access their medication consistently is to grow their own.
A former legal medical cannabis patient said:
“I researched my prescription seeds and bulk-purchased them for an entire year, saving money by growing my own medical supply.
Not only is it cheaper, it’s far more effective. I know what I’ve grown and fed my plants, and my stock levels aren’t an issue.”
Lack of awareness
Access is severely limited by the fact that 84% of the British public are unaware that medical cannabis is available on prescription. This certainly contributes to many still accessing the illicit market without the knowledge there is a legal route.
Latest figures estimate there are approximately 25,000-32,000 legally prescribed medical cannabis patients in the UK. However, approximately 1.8 million people are self-medicating with cannabis illegally to treat a medically-diagnosed chronic health condition. The discrepancy between the number of legal and illegal patients sheds light on a problem with the current framework, showcasing several barriers around patient access.
However, this discrepancy in patient numbers and lack of awareness is coupled with strict MHRA regulations around advertising of medical cannabis products, due to them being unlicensed specialist medicines. This makes it incredibly difficult to raise awareness of its legality. Nevertheless, illegal marketing has successfully side-stepped this, with the example of ‘Dispenseroo’ an illicit cannabis delivery startup, attracting customers through its advertising campaign on the London Underground.
The fact that legal medical cannabis operators are unable to advertise their services due to guidelines, many cannabis users are continuing to access the illicit market with no knowledge of a legal pathway.
Alongside these issues, cost is a massive barrier to patients given it is only available privately, making it difficult for the legal route to compete with the illicit market due to additional fees associated with a legal prescription, including consultation fees. The starting cost of a medical cannabis prescription per month is around £250 starting at £5 per gram, which is the lowest possible price, only available through special access schemes, such as the Project Twenty21 Scheme or the Sapphire Clinic’s Access Programme.
Prices of cannabis on the illicit market in the UK range between £5-10 per gram. Though at first glance the street cost of cannabis is similar or even slightly more expensive, the total cost of legal medical cannabis is still significantly higher once the clinics appointment charges, prescription and consultation fees are added. Current framework of scheduling means that patients’ prescriptions need to be reviewed on a monthly basis, leading to exceptionally high costs, making it difficult to compete with the illicit market. The costs for medical cannabis prescriptions have been going up as a result of the cost of living crisis, which could be resulting in patients returning to the illicit market.
A patient survey conducted by PLEA (Patient-Led Engagement for Access) last year found that a large proportion of patients are using their benefits to fund their prescription, with many paying more than £350 a month, on top of repeat prescription fees and consultation costs.
“I just can’t afford a legal private prescription, yet it’s literally saving my life,” said one patient.
So, what should be done about these barriers facing patients to accessing the UK’s medical cannabis system?
It is worth noting that although there are many issues with UK medical cannabis, lots of them being a result of the industry directly, some of the issues are larger and related to the systems and regulations of cannabis – thus the government. The legal industry is in a difficult position to compete with an aggressive illicit market. Patients place a lot of blame on the industry which in this case can be a little uncalled for.
At the moment there are chronically ill patients using medical cannabis to manage their symptoms, and are being criminalised. Given there is a legal pathway for access, there should be a greater amount of support and incentives for patients from the illicit market.
Volteface has made several policy recommendations that could be implemented to ensure that the industry is more sustainable going forward with patients sufficiently protected from harm.
These solutions should take the form of:
- A police referral system that provides a pathway for diverting users caught with illicit cannabis (who qualify for a legal prescription) to receive information on how to access a legal prescription.
- The creation of an information portal containing unbiased information about medical cannabis access in the UK, as a resource for patients to make an informed decision and raise awareness about the legality.
- Current content online, particularly work that has been funded by the government such as Talk to Frank should have updated information and signposting on medical cannabis. For instance, the page on cannabis contains no information about the fact it is legal on prescription for a range of conditions in the UK.
- There should be serious consideration into a government led awareness campaign about the legality of medical cannabis to divert and reduce the illicit market. It would be in the government’s favour to get behind an initiative that looks to reduce police time and criminality.
The current regulatory environment for medical cannabis in the UK is not conducive to compete with the illicit market from a cost, quality and delivery perspective. These issues are unique to cannabis as we don’t see the same amongst other medicines.
Cannabis is unique in having been available for decades illegally and only several years legally. Due to this, there needs to be a consideration around a unique regulatory environment for which medical cannabis operates in, to sufficiently eliminate the illicit cannabis market in the UK making the legal route more sustainable, affordable and popular – in turn increasing patient access.
Better accessibility to medical cannabis in the UK needs to be prioritised in order to save police time, reduce the amount of money made by organised criminal gangs and reduce the criminalisation of vulnerable populations that are self-medicating using cannabis.
It would have always been naive to assume that the simple introduction of a legal market would dissolve the illicit one. In order to see real change for the better, we need innovative, wide-ranging solutions to kickstart the market and that requires engagement with policy makers to truly improve the patient experience.
You can read Katya Kowalski’s submission from Volteface for the Home Affairs Select Committee here.
Hear more on the crucial elements of building a legal infrastructure during the panel Legacy vs Legal in Europe at Cannabis Europa. Discover how we prepare the illegal market for legalisation – ensuring improved social healthcare, safety, accountability; and at what cost? Volteface Head of Operations Katya Kowalski will be speaking with Alex Rogers of ICBC, Katrina Ffrench of UNJUST C.I.C., Lewis Koski of METRC and Robert Veverka of Legalizace. 
Cannabis Europa London, 2-3 May 2023, will welcome business leaders, investors and politicians to The Barbican Centre for Europe’s most influential B2B cannabis industry conference and exhibition.