Legalising medical cannabis – a German perspective

Germany legalised medical cannabis in March 2017; more than a year on, why are some patients still going without? Georg Wurth shares his thoughts.

Medical cannabis became legal in Germany in March 2017, but high prices, shortages in supply, and a persistent conservatism among medical staff continue to prevent patients from legally accessing the medicines they need to treat their conditions.

Speaking to Health Europa, lobbyist, activist and managing director of the German Hemp Association (Deutscher Hanfverband) Georg Wurth considers how far the medical cannabis law is fit for purpose, the road ahead to full legalisation, and the importance of research.

How far has the new law been sufficient to ensure that the patients who might benefit from medical cannabis have access to it?

The new law has had a big impact. Prior to its introduction, approximately 1,000 people had special approval from a governmental agency to buy medical cannabis at a pharmacy; we now estimate that figure at 20-30,000.

Nonetheless, a lot of patients are experiencing problems. Namely, they are having difficulties finding a doctor who will prescribe cannabis for their condition. Many doctors still think of cannabis as a harmful drug and its users as drug addicts. Doctors must also jump over several bureaucratic hurdles to prescribe cannabis, especially the first time, and there is a lot they are unsure of. There are almost 20 different strains in the pharmacies, all with different THC (tetrahydrocannabinol) and CBD (cannabidiol) levels, and many doctors have no idea which one to prescribe.

The second problem relates to health insurers. The new law dictates that the doctors decide whether a patient should receive cannabis, but the health insurers decide whether to approve the reimbursement. But health insurers only approve reimbursement at a rate of about 60%, which means that 40% of patients are not reimbursed. This is a big problem for people who can’t afford to pay for cannabis themselves.

This is especially a problem because the price of medical cannabis in German pharmacies is very high. Prior to the law, if pharmacies had only a couple of cannabis patients, they were able to set their prices relatively low – roughly €12.50 for one gram. Now the price is more than €20, which is much higher than it should be and about three times the cost of the same product in the Netherlands. As a result, some patients are having to pay more than €1,000 a month, which not all of them can afford. At the same time, this is also a problem for the health insurers.

Supply shortages are also a problem. Even when a patient does have a prescription, the cannabis won’t necessarily be available to them – or, if it is, it won’t be for another month. Because the patient must buy the exact kind of cannabis they have been prescribed, if it is not available they have to go back to their doctor, get a prescription for a different product, and then just hope that is available.

As more research comes forward into the therapeutic use and benefits of cannabis, might doctors’ attitudes change?

The lack of research is definitely a very big issue and at least one reason why doctors don’t like to prescribe cannabis for their patients. In order to bring a medicine to the European market, the pharma industry usually has to fund a series of very large and expensive studies. Such studies don’t exist for cannabis, except in multiple sclerosis. The use of cannabis to treat other conditions is based on the anecdotal evidence of patients and doctors, because the pharma industry must be able to pay for the studies by patenting the new medicine and selling it at a high price. You can’t patent cannabis because it’s a free plant.

The more studies we have and the bigger and better those studies are, the more we will be able to convince German doctors of the medical benefit of cannabis. The new law makes reference to research, but that has to do with the doctors feeding back information about the effect of legalisation on their patients’ conditions, which is very unlike the studies we are used to in medicine.

Research is also difficult because there are so many different strains of cannabis, all with different levels of THC, CBD, other cannabinoids, and terpenes, etc. All of these compounds have different effects and produce different medical outcomes. On one hand, this is one of the big advantages of cannabis because it helps to treat the symptoms of so many different conditions, but, on the other hand, it also makes carrying out studies all the more complicated because, in theory, according to the usual standards of studying medicine, you have to test every single strain for every single condition you want to treat – and that costs millions, if not billions. It is almost not possible.

In order to overcome these problems, the public sector needs to start carrying out and funding more medical studies.

How can the supply of medical cannabis more successfully keep pace with demand? Is domestic growth the only solution?

Worldwide the medical cannabis market is growing, and more and more countries – like Jamaica, Australia, Greece – have announced that they are preparing to export cannabis.

Why should Germany not do the same? Germany has already lost out on a lot of opportunities in fast-growing businesses like solar and photovoltaics. If we are in the biggest market in the world right now for the legal supply of medical cannabis, why shouldn’t we also be a player in that market?

At the same time, home production would help with supply shortages. We currently rely solely on imports, so if ever the exporting countries were to run into some kind of capacity issue, our supply would dry out entirely. It would be good to have German production and to be able to serve our patients ourselves.

Another option would be to let patients produce their own cannabis, as they already can in countries like the USA and Canada. I don’t see what speaks against that happening in Germany. This would widen the variety of cannabis products patients can choose from, allow them to choose precisely which strain they need, and lower costs enormously for both health insurers and patients.

How far should the medical cannabis law be viewed as a stepping stone towards full legalisation?

The legalisation of recreational cannabis in Germany is not inevitable. Drugs such as amphetamines and opioids can be used to treat medical conditions but are not legal for recreational use, for instance.

Progress is, however, being made. We are still some way away from having the majority we need in the Bundestag to legalise recreational cannabis, but opinion is shifting. There are now three parties in parliament who support full legalisation, and together they make up roughly 30%. The Social Democrats are split on the issue, so we are perhaps approaching somewhere closer to 40% – that’s not too far short.

Public support is also growing – in part thanks to the legalisation of medical cannabis, which has shown that cannabis need not be a bad or ‘gateway’ drug and can in fact help people. According to the polls, between 35% and 40% of the German population are now in favour of legalising cannabis for recreational use, which is a much larger share than it was maybe ten years ago.

Full legalisation will of course also depend on what happens internationally. Germany is unlikely to go it alone and become the sole country in Europe to legalise, but if the Netherlands and Switzerland make moves to, then perhaps Germany will follow suit in the not-too-distant future.

Things will eventually move quickly. Nobody thought the Berlin Wall would come down, until all of a sudden it fell. The same will one day be true of cannabis, but I fear that day will not be tomorrow.

Georg Wurth
Managing Director
German Hemp Association
https://hanfverband.de/

This article will appear in issue 5 of Health Europa Quarterly, which will be published in May.