Medical cannabis: intoxication on prescription?

The law amending narcotics and other regulations should make things much easier for physicians and patients. First and foremost, it should enable severely ill patients with easy access to medical cannabis products. Since the entry into force of the law on 10 March 2017, a good half year has now passed. What has changed? How does the regulation of medical marijuana work, and what are the guidelines for doctors? We take a look into the practice and give you valuable tips for dealing with cannabis drugs.

Overview: What regulations regulate the medical use of cannabis?
The debates on the use of hemp for medical purposes took years. But in January 2017, the Bundestag then unanimously adopted a bill that should allow seriously ill cancer and pain patients to get cannabis flowers with a corresponding prescription from the pharmacy – at the expense of health insurance. For the patients, this completes a complicated and often expensive procedure. Before the change in the law, patients first had to apply for an exemption permit from the Federal Office for Prostitution (BOPST) of the Federal Institute for Drugs and Medical Devices (BfArM). Only then could they acquire cannabis products and treat themselves under medical supervision.

Doctors of all disciplines can prescribe medical marijuana
With the new law, an exemption according to § 3 (2) of the Narcotics Act (BtMG) is no longer necessary for patients. Whether cannabis is prescribed as a drug, now decide the treating physicians in consultation with their patients. Special qualifications or permits are not required. In principle, every doctor, no matter what specialty, can issue the prescription for medical cannabis. For the reimbursement by the health insurance, however, this must first approve the treatment.

The legal regulations in detail: Areas of application consciously kept open
In the first place, the doctor has to comply with the provisions of the Narcotics Prescription Ordinance (BtMVV) and the new requirements of § 31 of the Fifth Social Code (SGB V). The new regulations have been deliberately kept open by the legislator in order to do justice to the broad therapeutic spectrum of cannabis and to transfer the responsibility for the treatment to the doctor.

When do health insurances pay the costs of cannabis therapy?
The health insurance companies have to approve the treatment and bear the costs if the insureds are entitled to the supply of cannabis. The legislator formulated the requirements of this claim in § 31 (6) SGB V. Thereafter, the patient must suffer from a “serious illness” for whose treatment an alternative “generally accepted medical standard” performance is either unavailable, or”In the individual case according to the reasoned assessment of the treating contract doctor or the treating contract doctor, taking into account the expected side effects and taking into account the disease state of the insured or cannot be applied” . For the prescription of cannabis products, there simply needs to be “a not altogether remote prospect of a noticeable positive effect on the course of the disease or on serious symptoms”.

In contrast to the comparatively low hurdles on the part of the prescribing physicians, the health insurances are only allowed to refuse approval in “justified, exceptional cases”. But when is therapy with cannabis drugs useful and how should a prescription look concrete?

The therapeutic area of ​​application: In which diseases can cannabis help?
To date, scientists have failed to reliably determine which disease pictures cannabis can be an effective indication. The therapy with medical cannabis is therefore unfortunately still based on empirical principles and individual, always to be readjusted attempts to bring about a relief of the symptoms. Nevertheless, the beneficial effects of marijuana are widely accepted today for many diseases, although the specific indication is often dependent on individual factors.

There are many illnesses and symptoms that could be treated with medical marijuana positive treatment results. Chronic – often neuropathic – conditions, such as pain and spasticity in multiple sclerosis or symptoms of Tourette’s syndrome, are among the most common. In addition, the therapeutic spectrum ranges from dermatological diseases to psychiatric illnesses such as anxiety disorders, depression or obsessive-compulsive disorder. Despite the wide range of therapeutic applications, the success of cannabis therapy in any of the diseases mentioned is safe. Difficulties in the indication also prepare the many different varieties and income options of marijuana.

How cannabis can be prescribed as a medicine
The Narcotics Prescription Ordinance (BtMVV) sets a maximum quantity of 100 grams in 30 days for cannabis in § 2 (1). However, since there are many different types of cannabis with a considerably different active ingredient content (tetrahydrocannabinol content), the amount of THC to be taken by the patient can vary between 100 and 22,000 mg per 100 grams of cannabis (source: Dtsch Arzelbl 2017, 114 (8): A 352- 6). Which cannabis strains with which THC content for which symptoms develop the greatest effectiveness, so far no reliable information that may even never exist. Therapy should, therefore, begin with a cannabis strain of comparatively low THC content and a correspondingly low dosage, which can be adjusted upwards if necessary. The required amount of THC can vary considerably from patient to patient. Patients should, therefore, be prepared for treatment that cannabis therapy may take some time and several adjustments to be effective.

Cannabis can be taken either orally (in the form of processed cannabis products such as oils or tablets) or by inhalation (either by smoking or by vaporizing with an inhaler). Taking by inhalation leads to a faster effect, the oral intake has a significantly longer duration of action. Here, too, the advantages and disadvantages of the various options for taking care of patients should be discussed with patients.

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