‘Parallel economy’: Psychiatrists, AMA and pharmacists sound alarm on cannabis scripts

Australia’s health regulator is moving to rein in the booming online medicinal cannabis industry, amid calls from doctors and pharmacists for Health Minister Mark Butler to tackle “largely unregulated” prescribing and dispensing.

Amid growing concern from psychiatrists that telehealth operators are putting people with serious mental illness at risk, the Australian Health Practitioner Regulation Agency last week issued new national guidance tightening standards for telehealth, targeting the burgeoning number of online-only clinics.

The agency’s chief executive, Justin Untersteiner, warned that while telehealth had made access to care far easier for many, this must not come before patient safety.

“We just want to make sure that convenience doesn’t come at the cost of safety or quality,” he said.

The reforms follow an explosion in telehealth-only clinics offering single treatments. That lucrative market, now worth hundreds of millions annually, is particularly prevalent in medicinal cannabis, which is dominated by companies such as Montu, as well as cosmetic injectables and drugs for weight loss, hair loss, menopause and erectile dysfunction.

Large telehealth platforms have risen to prominence in the past five years allowing patients to bypass traditional medical gatekeepers.

These companies aggressively market same-day prescriptions. Since cannabis was legalised in 2016, more than 1.5 million prescriptions have been approved. The market’s rapid growth has prompted the federal Therapeutic Goods Administration to launch a review of the sector’s regulations.

On Tuesday, the Australian Medical Association and the Pharmacy Guild of Australia will call on Butler to act on what the two groups say are “poorly regulated prescribing practices” and the proliferation of clinics operating outside typical care models.

“We are seeing a system that is being exploited – with prescriptions issued without proper clinical oversight and patients bypassing their regular GP and pharmacist,” Pharmacy Guild president Trent Twomey said in a statement.

AMA president Danielle McMullen said urgent action was needed to ensure medicinal cannabis was “prescribed, dispensed and regulated in the same manner as other registered drugs of dependence”.

The Penington Institute, which campaigns for drug law reform, warned it would be dangerous to make the drug more difficult to get than was possible via the medicinal cannabis regime. “The last thing we want is for medicinal cannabis to be so difficult to access that people simply switch to easily available illicit cannabis,” the institute’s research director, Jake Dizard, said.

A spokeswoman for Health Minister Mark Butler said the statements from the AMA, pharmacists, Penington and others had been made as part of the Therapeutic Goods Administration’s review of laws around medicinal cannabis. She said that review would “ensure that regulatory settings remain fit for purpose and responsive to emerging risks”.

This masthead revealed in July that one telehealth doctor had churned out 72,000 prescriptions to 10,000 patients in just two years.

AHPRA’s new guidelines make clear doctors are personally responsible for safe prescribing decisions, even when they are employed by telehealth companies.

The agency said it was especially concerned about services that focused narrowly on a single treatment or drug and offered no pathway to in-person consultation.

Psychiatrist Professor Danny Sullivan, a consultant forensic and adult psychiatrist at Forensicare, which runs Melbourne’s Thomas Embling Hospital, a high-security forensic mental health facility, said the growth of online cannabis prescribing in particular had created a “parallel economy” of medicine operating outside normal safeguards.

“The medicinal cannabis industry functions like a sort of parallel economy that doesn’t seem bound by the same good medical practice guidelines that other areas are,” Sullivan said. “People are being prescribed cannabis without any effort by the prescriber to contact their treating clinicians.”

Sullivan said his team regularly encountered patients with psychotic illnesses who were still receiving online prescriptions for cannabis – often without their psychiatrist’s knowledge. In some cases, the lack of communication between prescribers created direct clinical risk.

“If you have a serious mental illness, cannabis is strongly contraindicated,” he said. “It’s highly associated with psychotic symptoms, and for people with schizophrenia, it’s a toxic drug that can cause deterioration in mental state.”

Sullivan said cannabis prescribing was treated differently to other areas of medicine. “If a patient is being treated for schizophrenia or bipolar disorder and they get a cannabis script through telehealth, the prescriber almost never writes to the treating psychiatrist or GP,” he said. “That’s a breach of basic continuity of care.”

Too often, Sullivan said, he could not contact the doctors prescribing cannabis to his patients “to tell them these people have psychotic illnesses. But we often don’t even know who [the doctors] are – they haven’t written to us, they haven’t sought us out, and the patient often won’t say.”

He said that secrecy – the absence of shared information between prescribers – was at the heart of the problem. “You end up with a fragmented system where no one’s accountable,” he said. “It’s a model built for convenience, not continuity of care.”

Veronica Casey, chair of the Nursing and Midwifery Board, said the reforms were aimed at restoring accountability. “As a health practitioner, your duty of care always comes first,” she said. “That responsibility sits with you, not your employer.”

The new guidance urges practitioners to avoid prescribing without a face-to-face consultation, and prohibits the use of chatbots or artificial intelligence to simulate medical advice without disclosure.

Consumer advocate Michael Fraser, of Operation Redress, has followed the rise of telehealth closely and said AHPRA’s updated guidance went nowhere near the required decisive intervention.

“AHPRA’s function is to protect the public. This guidance doesn’t do that,” he said. “The public deserves better than press releases from the regulator that remind practitioners of their basic obligations.

“The large telehealth companies’ business models are designed to be a ‘subscription to a prescription’, signed by doctors you may never meet – vertical integration and increased sales are the goal, not patient safety. Yet regulatory responses seem futile or non-existent.”

A spokesman for Montu said doctors at its Alternaleaf clinics made clinical assessments based on patient need and could prescribe products from other companies.

“We make no apologies for keeping consults affordable and timely for patients, or for paying doctors fair rates,” he said in a statement.

State MP David Ettershank, of Legalise Cannabis Victoria, said harms from cannabis needed to be put in perspective.

“People get very excited about cannabis, but what are we doing about opioids, benzos, alcohol or tobacco?” he said. “They are all way above cannabis for hospital admissions or damage, and all of these things are literally an order of magnitude greater in terms of any clinical risk.”

Royal Australian College of General Practitioners president Dr Michael Wright said commercial interests should not win out over the wellbeing of patients.

“A model of care with only one treatment can only provide that one treatment and may not provide the care that you need,” he said.

“This is a problem built into profit-driven, vertically integrated single-treatment businesses like many of those selling medicinal cannabis. Medicinal cannabis is not a first line treatment, and is something you should discuss with your usual GP, rather than a company with a business model based on prescribing cannabis.”

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