Between the Gaps

Most of us have experienced it at some point.  Either starting a new job. Learning a new language. Walking into a party alone. We recognise that uncomfortable feeling of not quite knowing what's expected, of watching other people behave with confidence while we're left wondering whether we're about to make a fool of ourselves. There is something quietly unsettling about walking into a situation where everyone else seems to understand the rules except you. Beginning treatment with medicinal cannabis can feel a bit similar. There are unfamiliar words, unfamiliar products and unfamiliar processes. Patients quickly discover that people talk about 'flowers', oils, resins, wax, shatter, terpenes and cannabinoids and a whole library of three letter CBx acronyms, as though everyone ought to know what those things mean. At first, that unfamiliarity can feel overwhelming, but I don't think that's the really difficult part.

                Being new at something is a familiar experience. Most of us have developed ways of dealing with it. However we approach it, we've all been beginners before. The greater challenge is something far less obvious. The healthcare system carries with it a whole bunch of assumptions that we rarely notice because they've served us well throughout our lives. We assume that doctors, pharmacists and other health professionals are all, united and working together towards, (more or less) the same therapeutic goal. We assume that medicines have travelled through a long and carefully regulated testing pathway before they reach us, and that if something changes, or goes wrong, along the way, someone will notice, someone will explain it, and someone will make sure it still serves the purpose for which it was prescribed. Those assumptions are the product of generations of medicine refining itself. They're one of the reasons modern healthcare is as safe as it is. Medicinal cannabis sits within that same healthcare system, but it has arrived there in a rather unusual way. Over a remarkably short period of time, the established medical system has had to adapt to accommodate hundreds of new products, unfamiliar patterns of prescribing, rapidly changing commercial relationships and a public whose expectations have often been shaped as much by popular culture as by medicine. None of that is anybody's fault. It's simply the environment in which medicinal cannabis has developed.

                Whenever two systems are joined together, however, there is almost always a small gap, or a leak. Occasionally they allow something important to slip quietly from one person to the next. This article is about those gaps. I don't think the system is fundamentally broken or health professionals and the people working within it are uncaring, and certainly not because I think that medicinal cannabis is unsafe. My concern is that patients often don't realise the 'gaps' are there at all, or that it's a problem that applies to them personally. It’s the unseen risks that are the most unexpected and often the most damaging because of that.

The basic industry system model that we'll use is:

Patient →Prescriber →Pharmacy →Supplier →Product Company→ Manufacturer/Grower

1) Patient →Prescriber

                In medicine it begins with the patient and the consultation. When you finish your first appointment and hang up the phone, how do you know whether it was a good consultation? There's no benchmark for what "good" actually means. Which questions might have been important, which alternatives could have been discussed or what a thoughtful medicinal cannabis consultation ordinarily looks like, but I think we can still describe the problems that might get in the way.

Figure 1. The First Gap – Patient ↔ Prescriber

PATIENTWhat can influence the consultation?

PRESCRIBERWhat can influence the consultation?

·         Seeking a product rather than treatment for a medical problem. ·         Incorrect expectations about what cannabis is meant to achieve. ·         Embarrassment, stigma or fear leading to incomplete or inaccurate descriptions of symptoms. ·         Asking for a product rather than discussing the underlying illness. ·         Expecting there to be one 'best' product before treatment begins. ·         Relying heavily on internet advice, social media or marketing. ·         Misunderstanding legal or regulatory restrictions. ·         Poor follow-up or failure to report what actually happened after treatment. ·         Mistaking access to cannabis for comprehensive medical care.

·         Misunderstanding the patient's problem or treatment goals. ·         Incomplete assessment of symptoms, function or contributing factors. ·         Failing to recognise that stigma, embarrassment or fear may cause patients to under-report symptoms. ·         Knowledge and experience gaps. ·         Expecting certainty where treatment is inherently individualised. ·         Failure to individualise treatment. ·         Practice model influencing clinical decisions. ·         Commercial influences affecting prescribing decisions. ·         Limited familiarity with available products leading to a narrow range of prescribing. ·         Poor therapeutic collaboration, or collaboration becoming product negotiation. ·         Failure to define treatment goals and measurable outcomes. ·         Poor follow-up, review or modification of ineffective therapy.

The consultation depends upon both people understanding the same problem, pursuing the same therapeutic goal, and communicating honestly enough to reach it. There are quite a few potential problems listed, but some of them are less obvious and worth focusing on.

                The context in which you see a particular doctor is an important one that’s easy to overlook and might actually determine more than you realise about the eventual outcome. If you're seeing somebody who's part of a clinic that is built on a particular ‘model’ or has close relationships with certain brands or providers, then regardless of your wants, needs, circumstances, or even your condition, the outcomes around treatment are somewhat decided. Some clinics function in a way that's possibly closer to something like a ‘drive through’. These are doctors who practice in a manner that I call 'commercial prescribing', where their objective is to see as many patients as possible in as short a time as possible. Importantly, some people have come to expect that model. It’s not for me, but when both parties are aware and understand what’s going on… I might not like it, but I suppose it can have a role. However, this is one of those areas where the difference between the assumed historical expectation of a provision of ‘care’ versus the newer idea of being provided with a very limited ‘service’ can be confusing. I once had a mechanic find a problem unrelated to the reason I’d come in, one that would have made me lose a wheel, but he noticed and fixed it. Those sorts of incidental diagnoses happen all the time in medicine. While there may be a fair place for a more limited commercial practice, most people place their health and well-being quite high in their hierarchy of needs. If they enter not knowing the nature of the ‘service’ agreement, and without a full understanding of the risk, that’s when that form of practice becomes potentially harmful. It’s not harmful because of what’s done, but because of what isn’t. It's similar to if the mechanic had just fixed my handbrake and went on his way. Patients don't always understand what’s not happening, in more service-based encounters,  but frequently rely on assumptions or expectations, borrowed from conventional treatment, that may not necessarily apply.

                An alternative, more common variant of commercial treatment I call 'facilitation'. This is when a doctor, working for a vertically integrated clinic, is there to simply facilitate access or sale of a product. Here the profit is not from the doctor seeing patients, but from the medication sale. A commercial relationship with the medication manufacturer means that the doctor is effectively financially subsidised from profits made 'further down the track', related to product sale.   Both types of system undermine not only the legitimacy of the consultation process but also incentivise prescribing decisions.

Obviously, there are many other behaviours that can negatively influence the process at this point, from diversion and resale, addiction, and other forms of misuse, but it's not meant to be an exhaustive list, just something that highlights problems that patients might encounter so they can better avoid them.

                Finally, one of the commonest, less obviously harmful, shared misconceptions I encounter, is the belief that somewhere there is a way to predict exactly which product is going to work best for every patient or condition. I wish that were true. It makes sense to think that way, because that's how we're told conventional medicines work, where years of extremely detailed testing give a degree of certainty around likely effects and outcomes. With thousands of cases, where everything is measured and reported, there's a strong, predictable understanding of how a drug works. Medical cannabis prescribing is exceptionally unusual. That sort of formal testing hasn't happened; those protections (and the decades they would take) were bypassed, and in many ways, this prescribing experiment, is the trial. For good or for bad (and there is both), that needs to be remembered by both patients and doctors. Very similar patients with apparently similar problems can respond very differently to the same treatment. Prescribing works best when that uncertainty and individual response are expected and understood. It can be dealt with honestly within a therapeutic relationship where treatment can be adjusted as those individual responses become clearer. Possibly that's the first gap worth recognising, that between patient and prescriber and the distance that has to be crossed before two people can begin working on solving the same problem, together. Rethinking terms, where a successful medical relationship isn't something illustrated by definable, fixed outcomes or calculated endpoints, but is instead a responsive, dynamic foundation that allows a treatment relationship to grow and develop, with time and circumstance, responsive to the individual's needs.

Next:  Prescriber →Pharmacy

“Saying that flowers or cannabis products are interchangeable on the basis of THC alone is much the same as comparing cask or bottled wine on the basis of alcohol content, or bananas and oranges on the basis of sugar content.”