Patients in Ireland continue to face obstacles in accessing medical cannabis treatment despite evidence and international models that demonstrate how an effective medical cannabis programme could operate in the United States and the European Union. Patients in Ireland face stigmatisation, delays and unreliable access to medical cannabis treatment, which is expensive and often not reimbursed by the State.
Three years after announcing plans for a medical cannabis programme and two years after introducing legislation for medical cannabis, the government has finally announced funding for a programme in Ireland, the Medical Cannabis Access Program (MCAP).
Minister for Health Stephen Donnelly described the purpose of MCAP as to “facilitate compassionate access to cannabis for medical reasons, where conventional treatment has failed”.
Under MCAP, a medical consultant can prescribe a cannabis-based treatment for three conditions:
- spasticity associated with multiple sclerosis;
- intractable nausea and vomiting associated with chemotherapy; and
- severe, refractory (treatment-resistant) epilepsy.
Somewhat confusingly, MCAP will run in parallel to the existing ministerial license regime, which allows patients and their medical consultant to apply to the Department of Health for a specific license for them to be prescribed medical cannabis treatment.
Licensing regime delays and denies patient care
To date, just 55 patients have received a license for medical cannabis from the Department of Health, while only 16 are being reimbursed for the cost of their treatment. Even with a license, patients were not able to obtain medical cannabis in Ireland until last year. Patients, or their families, were required to make regular trips to the Netherlands to fulfil their prescriptions there.
Campaigner Vera Twomey, for example, had to undertake an 18-hour trip to the Netherlands every three months to purchase cannabis treatment for her daughter who suffers from Dravet’s Syndrome, a severe form of epilepsy.
When the outbreak of Covid-19 stopped international travel within the EU, the Minister for Health at the time, Simon Harris, signed-off on a temporary programme that would deliver prescribed medical cannabis products to patients in Ireland; this programme was made permanent by Minister Stephen Donnelly in December 2020.
“When we experienced the peace of having the medication delivered to us, we were almost like any other normal family with a medication”, said Ms Twomey in an interview last December, “whereas prior to that, we were treated as if we were different by being made to travel for it.”
The current licensing requirement for medical consultants both dissuades consultants from recommending medical cannabis while also preventing GPs from prescribing medicine for their patents in a quick and timely manner.
In Barnette’s view, the Irish government should be very clear in relation to what its goals are with the medical cannabis programme.
“If the goal of the programme is to provide care and let people get access to the medicinal properties of cannabis, then set up a programme that seeks to achieve that and try to not overregulate something that is already in the community already,” says the DC dispensary owner.
Barnette would encourage the Irish government “to keep a same-day situation” and believes that “if the people wanted a medical marijuana programme, they should be allowed to go to a doctor and get the care they need. It should not take two, three, four or five weeks to get access to programme”.
The conservative approach adopted by the Irish government will no doubt trickle down to medical practitioners and given the specific license that medical practitioners are required to apply for, it is likely that medical practitioners, particularly those unfamiliar with cannabis medical treatment, may be slow to prescribe it.
“A lot of doctors initially were not willing to see people and recommend cannabis, so we had to go through a whole education process with the doctors. It made people completely dependent on physicians and their willingness to engage in this type of medicine as a type of care, so that was a difficult part to sort”, says Barnette.
MCAP and licensing regime not aligned
MCAP does not properly align with the existing licensing regime and as a result, certain medication that patients have been prescribed and are obtaining from the Netherlands is not provided for under MCAP.
Currently, only three medical cannabis treatments have been licensed for importation to Ireland under MCAP:
1. Aurora High CBD Oil Drops;
2. CannEpil; and
3. Tilray Oral Solution.
Twomey has highlighted that the majority of medical cannabis patients in Ireland use Bedrocan which they source from the Netherlands under their licenses from the Department of Health. The campaigner has described the omissions of Bedrocan from MCAP as “a grave error”.
In an interview earlier this month, Twomey said that the government has “set up a programme that did not include the medications being prescribed to the vast majority of patients in the Republic of Ireland”.
Ban on Irish grown cannabis plants will keep costs high
MCAP does not permit cannabis plants to be grown in Ireland, nor does being part of the programme mean that patients are automatically entitled to have their treatment reimbursed by the HAS.
Twomey has noted that certain families who are purchasing cannabis treatment under the ministerial license regime from the Netherlands are not being refunded at all for the cost of treatment. Some of these families are rationing the treatment as they are unable to afford the number of recommended doses.
Noreen O’Neill whose son has severe epilepsy has spoken to the media about how, while she is eligible for MCAP, the cost of the recommended treatment totals €1,200 per month.
Ensuring a reliable, low cost and high-quality supply of medical cannabis treatments is challenging in a restrictive legal environment.
Morgan Fox who represents the National Cannabis Industry Association in the US has said that in those US states with limited qualifying conditions for access to medical cannabis “the cannabis can be very expensive because there is limited competition, high costs of operation and high barriers to entry, and those costs trickle down to the patient”.
Fox notes that the main way to lower the cost of medical cannabis products and ensure a steady supply is to permit marijuana for adult use in general and not just for medical purposes.
Patients who move to Ireland effectively denied treatment
MCAP is only available for a very limited number of medical conditions, despite medical cannabis commonly being used to treat a wide range of conditions in the EU and the US, including chronic pain.
Ireland has an international workforce and many workers will have lived in US and EU states with more expansive medical cannabis programmes.
In Ireland, patients may find that their conditions do not come within the limited conditions provided for under MCAP or may have to undertake alternative treatment before an Irish doctor is satisfied that “conventional treatment” has failed.
Those who found medical cannabis to be an effective treatment for their conditions may feel they have little option but to resort to the unregulated black market or to risk transporting medical cannabis products across borders without a license. Once someone purchases cannabis on the black market, as well as committing a criminal offence, they lose the protection of regulations on labelling and potency limits.
Compassion and pragmatism should guide the approach to medical cannabis
As with any medical treatment, the side effects of cannabis should by no means be ignored, particularly the potential harms to mental health. But neither should we ignore the reality that many people with chronic pain conditions who could benefit from medical cannabis are already self-medicating with alcohol or opioids.
The devastating impact of opioids has been well documented while the National Institute on Alcohol Abuse and Alcoholism notes that a person must take alcohol at a level consistent with binge drinking in order to alleviate chronic physical pain.
In a 2019 survey undertaken by the University of Limerick, a majority of the Irish patients surveyed supported legalising medical cannabis for chronic pain.
Legal medical cannabis products are subject to selling restrictions, as well as labelling and potency laws that ensure that users and doctors are clear about the strength of the product.
Limiting legal medical cannabis to a small fraction of those who could benefit from it in Ireland will not stop others from using it. It just means that many will look to remedies available on the grey or black market, or to alcohol.
“The reason that no one is selling Jack Daniels or single malt scotch in the alleyway is that you have a regulated alcohol system that is designed to allow people to have access to alcohol”, notes Barnette.
Irish policy on medical cannabis should put patient care first. The current policy prioritises political caution over medical compassion and care for patients and their families.