The introduction of medical cannabis in the United Kingdom in November 2018 marked a significant milestone in the long and contentious history of cannabis policy. After decades of prohibition, cannabis was reclassified to allow its use for medicinal purposes, creating widespread public optimism that patients would finally gain access to this long-debated therapy. However, two years after legalization, the reality fell far short of expectations. Despite growing evidence of therapeutic potential and high public demand, only a handful of prescriptions had been issued by the National Health Service (NHS), leaving patients frustrated and many forced to seek cannabis from illicit sources. The article “Medical Cannabis in the UK: From Principle to Practice” by Schlag et al. (2020) explores this disparity between principle and practice, analysing the scientific evidence, ethical challenges, regulatory barriers, and potential future directions for medical cannabis in the UK. This essay critically examines these dimensions, highlighting the tension between patient need, scientific uncertainty, and institutional caution that continues to shape the medical cannabis debate.

At the heart of the issue lies the historical and political trajectory of cannabis itself. Once regarded as one of the world’s oldest medicines, cannabis was criminalised in the mid-twentieth century largely for political reasons rather than empirical evidence of harm. Its reintroduction as a medicinal substance, therefore, represents a partial correction of that political error. Yet, as Schlag et al. observe, the move from prohibition to prescription has been hampered by a lack of clinical evidence stemming from its former classification as a Schedule 1 drug. The National Institute for Health and Care Excellence (NICE) guidelines currently sanction only three cannabis-based medicinal products (CBMPs): Sativex for multiple sclerosis spasticity, Nabilone for chemotherapy-induced nausea and vomiting, and Epidyolex for severe, treatment-resistant epilepsy. For patients suffering from chronic pain, anxiety, or other debilitating conditions, this narrow scope of approved treatments is profoundly disappointing, especially when many report significant benefits from unlicensed or illicit cannabis use. The mismatch between clinical caution and patient experience reveals a deeper tension between traditional evidence-based medicine and the growing field of patient-reported outcomes.

Scientific research on medical cannabis remains in an early stage. The 2017 report by the National Academies of Sciences, Engineering, and Medicine (NASEM) summarised that substantial evidence supports cannabis’s efficacy in treating chronic pain, chemotherapy-induced nausea, and multiple sclerosis spasticity. Moderate evidence exists for improving sleep outcomes, while only limited evidence supports its use for conditions like anxiety, Tourette’s syndrome, or post-traumatic stress disorder. Schlag et al. highlight that the lack of large-scale randomised controlled trials (RCTs) has constrained acceptance by regulators and physicians alike. Yet, the absence of such data is itself a consequence of cannabis’s legal status, which for decades restricted research access. The authors argue that while RCTs remain the gold standard for clinical evidence, other forms of evidence — such as observational studies and patient-reported data — must also be valued. Indeed, real-world evidence from countries such as Canada and Germany demonstrates widespread patient satisfaction and quality-of-life improvements associated with medical cannabis. Studies have reported reductions in pain, anxiety, and opioid use, suggesting that cannabis may offer a safer alternative or adjunct to existing therapies. However, these findings remain controversial, as critics question the reliability of self-reported outcomes and warn against overgeneralisation.

Despite growing international support for medical cannabis, the UK faces unique barriers to implementation. One of the most prominent issues is the lack of physician education. Most British doctors have received no formal training in prescribing cannabis-based medicines, leading to uncertainty about dosages, formulations, and potential interactions. Schlag et al. cite initiatives such as the Academy of Medical Cannabis and Drug Science’s MyMedic platform as important steps toward filling this knowledge gap. Nevertheless, the inertia within medical education remains a key bottleneck. The reluctance of doctors is compounded by restrictive clinical guidelines that position cannabis as a last-resort treatment, permissible only when conventional medicines have failed. These guidelines, produced by authoritative bodies such as the Royal College of Physicians and the British Paediatric Neurology Association, create an environment of medical conservatism that discourages experimentation and innovation.

Another significant obstacle is the fear of adverse psychological effects, particularly psychosis and dependency. Public discourse around cannabis has long been dominated by the association between high-potency cannabis and mental illness, largely based on studies of recreational use. However, Schlag et al. argue that these concerns are often exaggerated or misapplied to medical contexts. The psychosis risk is primarily linked to high-THC, low-CBD street cannabis, whereas regulated medical formulations contain balanced cannabinoid profiles designed to mitigate such risks. Furthermore, data from Health Canada and other countries indicate a low incidence of dependence among medical users. Nonetheless, the perception of cannabis as a dangerous drug continues to influence prescribing behaviour, creating an implicit bias against its medical application. Overcoming this stigma requires not only education but also robust regulatory oversight to ensure product safety, dosage consistency, and responsible use.

Economic factors further complicate access. Because most NHS doctors refuse to prescribe cannabis, patients must rely on private clinics, where treatment can cost up to £40,000 per year. These prohibitive expenses reflect both import restrictions and the lack of domestic production infrastructure. Until recently, UK regulations required individual import licenses for each patient, causing delays and increasing costs. Although new provisions for bulk importation were introduced in 2020, the system remains inefficient compared to other European countries such as the Netherlands or Germany. Schlag et al. suggest that the high cost of medical cannabis is paradoxical, given that it has the potential to reduce healthcare expenditure by lowering reliance on opioids, benzodiazepines, and other costly medications. A comprehensive cost-benefit analysis might reveal that broader access to cannabis could be not only therapeutically beneficial but also economically rational.

Beyond logistical and economic barriers, the article raises fundamental ethical questions. The authors emphasise that the rigid insistence on RCT evidence as the sole criterion for legitimacy may inadvertently harm patients who have exhausted conventional treatments. In such cases, patient autonomy and the principle of informed choice become ethically significant. Denying access to potentially beneficial treatments due to bureaucratic inertia or evidentiary conservatism can be viewed as a moral failure of the healthcare system. Schlag et al. argue that while clinicians must act cautiously, they also have an ethical duty to balance potential harms against the immediate suffering of patients. The reclassification of cannabis as a Schedule 2 substance implies legal recognition of its medical potential; therefore, withholding it on procedural grounds risks undermining public trust in the healthcare system. Moreover, when patients turn to illicit markets due to lack of access, they expose themselves to unregulated and potentially harmful products, highlighting the urgent need for a controlled but compassionate prescribing framework.

The authors propose several strategies for reconciling these competing imperatives. Education and monitoring are at the forefront of their recommendations. By collecting systematic data on prescriptions, patient outcomes, and adverse effects, regulators can bridge the gap between clinical trials and real-world practice. Initiatives such as Drug Science’s Project Twenty21 aim to create Europe’s largest medical cannabis registry, offering valuable insights into usage patterns and efficacy. Such registries could serve as dynamic feedback systems, allowing doctors to make evidence-informed decisions even in the absence of traditional RCTs. Schlag et al. also advocate for developing a hierarchy of evidence specific to cannabis-based medicines, recognising that their diversity of formulations and effects defies simple categorisation. The authors note that cannabis should not be treated as a single drug but rather as a family of compounds with complex pharmacological interactions, requiring a more nuanced approach to research and policy.

Communication with the public is another crucial component. The 2018 rescheduling generated widespread misunderstanding, with many patients assuming that cannabis would become readily available through the NHS. The resulting disappointment has eroded confidence in both the government and the medical establishment. Schlag et al. call for clearer, more transparent communication strategies that explain what medical cannabis can and cannot do. Overhyping its benefits risks creating false hope, while excessive caution perpetuates stigma and frustration. An informed public dialogue, grounded in scientific honesty and empathy for patient experience, is essential for building a sustainable framework.

In conclusion, Schlag et al.’s analysis reveals that the legalisation of medical cannabis in the UK has so far been more symbolic than substantive. While the rescheduling from Schedule 1 to Schedule 2 was a necessary first step, systemic barriers have prevented meaningful patient access. The article makes a compelling case for reform on multiple fronts: expanding the evidence base beyond RCTs, improving physician education, reducing economic barriers, and developing ethical and regulatory frameworks that prioritise patient welfare. The central message is that progress requires balance — between caution and compassion, between evidence and experience, between science and social justice. Cannabis is not a miracle cure, but neither should it be dismissed as a dangerous relic of counterculture. As the authors conclude, medical cannabis policy must evolve in a safe, ethical, and evidence-informed manner, ensuring that those who could genuinely benefit are no longer left behind. The challenge for the UK is not whether to allow medical cannabis, but how to implement it responsibly — transforming principle into practice and rhetoric into care.

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