The Medical Board of Australia has declared its commitment to supporting both the medicinal cannabis industry and individual practitioners, while making clear that it will continue pursuing those who disregard proper patient care.
With the Australian Health Practitioner Regulation Agency (AHPRA) releasing updated prescribing guidance for medicinal cannabis, medical board chair Dr Susan O'Dwyer said the board's goal is to be "proactive and supportive" of medical practitioners, nurses, and pharmacists who may have "lost their way".
Dr O'Dwyer said both AHPRA and the medical board hoped the guidance would prompt prescribers to revisit their duty of care and "reflect" on how they are operating.
She declined, however, to specify what broader regulatory steps might follow if poor practices persist without improvement.
"Regulation in relation to the medicinal cannabis industry is bigger than just the medical board," she said. "There are state and territory legislations, the Therapeutic Goods Administration, us. If we aren't able to get [practitioners] to reform I think we need to do a diagnostic review as to what is the root cause of the issue…and what is the correct regulatory solution.
"That may be a solution for the medical board and AHPRA but it may be a solution elsewhere for the state and territory governments, the TGA or the commonwealth."
Dr O'Dwyer did push back against the idea of an outright "ban" — such as removing category 5 medicinal cannabis from the Special Access Scheme, a measure previously floated by the Australian Medical Association.
"I think it's a very blunt tool to deal with the few people who are causing issues from the manner in which they're behaving and prescribing and engaging in this sector," she said.
"As much as possible, we should be trying to work with the sector to get the parameters correct for prescribing, not moving to wholesale bans. I don't know that bans have ever served anybody particularly well."
Dr O'Dwyer confirmed that action has already been taken against 57 medical practitioners, pharmacists, and nurses over their medicinal cannabis practices, with a further 60 currently under active investigation.
She added that the total number of notifications, or complaints, lodged against practitioners is likely to exceed those figures.
"From a medical board point of view, we are trying to do this from a supporting practice position. We are trying not to invoke, unless absolutely necessary, our ability to restrict practitioners from practising, but we will do if we have to protect patients from harm.
"We want to be proactive and supportive to practitioners in this space and the guidance hopefully demonstrates this. We are saying this is the way to practice professionally and consistently with good medical practice standards."
Expanding on what that supportive approach looks like in practice, Dr O'Dwyer said: "We are inviting people who have popped up as having aberrant numbers of prescriptions for a conversation about that practice. What are the reasons for that aberrant number?
"We're looking for people to reflect on their practice if there is something that isn't consistent with good medical care, and to reform those ways. That's what we really want to see. That's the whole premise on which we're built and why we produce all of this guidance and our CPD (continuous professional development) framework."
Poor practices identified in the document include:
Practitioners issuing more than 10,000 prescriptions in a six-month period
Consultations which last between a few seconds and a few minutes, making a proper assessment impossible
Prescribing without a legitimate indication, including cases where the patient requested
Failing to fully assess a patient's mental health and/or history of substance abuse
Prescribing excessive quantities of medicinal cannabis
Providing multiple products so a patient can see 'which one suits them'
Failing to co-ordinate with another treating practitioner
Self prescribing or prescribing for family members
Having a conflict of interest by only prescribing the product supplied by the company the practitioner is associated with.
When it was put to her that the guidance covers ground most practitioners should already understand, Dr O'Dwyer said: "Yes, it does seem like this is stock standard that everybody should be aware of, but there is no harm in reminding people what good practice looks like.
"And there are various levels of understanding of what good practice is. We also have junior practitioners and people who are just entering their careers…who may not be experienced in dealing with people seeking schedule 8 medications, so it's really important to draw their attention to that."
Dr O'Dwyer said she is confident that practitioners can and do course-correct their behaviour.
"Doing the right thing professionally by patients is very important to practitioners. They want to provide safe and high-quality care," she said.
"We've seen it repeatedly. When we get a notification they really do appreciate having a case-based discussion with someone in AHPRA.
"For some it's a real eye-opener. They may have fallen into bad habits or they've lost their way. But they do reflect on their practice and ask what could I do better?
"People do change their ways and on the whole they are trying to do the right thing. If we thought people who were doing the wrong thing were irremediable we wouldn't go to so much effort in terms of trying to be supportive and providing guidance."
Dr O'Dwyer acknowledged that industry stakeholders are understandably frustrated when the misconduct of a small number of practitioners leads to blanket criticism of the entire sector.
"It's similar to the frustration for all the folk who work in the cosmetic surgical industry," she said. "There have been some widespread bad practices which has caused us to produce guidance and protocols and ways in which we want people to practice in relation to that industry as well.
"What we're really saying with this guidance is if you want to work in this field and engage as a prescriber for people who need medicinal cannabis for their clinical situation, this is the best way to do it, this is how you should go about it.
"I'm optimistic that this guidance is going to assist practitioners and help them to do the best they can and provide care that is consistent with good medical practice."
In an earlier statement issued by AHPRA Dr O'Dwyer said: "We don't prescribe opioids to every patient who asks for them and medicinal cannabis is no different. Patient demand is no indicator of clinical need."
Beyond over-prescribing, AHPRA chief executive Justin Untersteiner flagged the conflict of interest that arises when practitioners operate within settings that prescribe and dispense only a single medicine.
He also pointed to online questionnaires designed to "coach patients to say the right thing to justify prescribing medicinal cannabis".
"This raises the very real concern that some practitioners may be putting profits over patient welfare," he said.
Dr David Gunn, who heads Cannabis Clinicians Australia, described the guidance issued by AHPRA and the medical board as "quite reasonable".
"We have been trying for the past few years to put in signposts and a clear direction as to what good practice is," he said. "For whatever reason some people have got off track and put cannabis prescribing in a different box."
Part of the problem, he noted, is that some committed pro-cannabis prescribers reject the designation of cannabis as a schedule 8 drug and prescribe accordingly, as though it were not tightly regulated.
"But that's a completely different debate," he said. "The bottom line is that cannabis [with THC] is a schedule 8 medication. Giving someone multiple types of flower based on preferences with lots of repeats is just not something that's ever done with other schedule 8s.
"I mostly work in a harm-reduction framework and, medically, there's a big difference if we compare the potential physical and mental harms between opioids and cannabinoids, but that's a different conversation. They are still both schedule 8 medications."
Dr Teresa Nicoletti, chair of the Australian Medicinal Cannabis Association (AMCA), called the guidance "common sense" and said it mirrors what was delivered to practitioners at the UIC symposium compliance day in February.
"If health practitioners don't know that content, and it's been reiterated to them a few times now, then they will be subject to regulatory action," she said.
She suggested that the action already taken by AHPRA against nearly 60 practitioners — with a comparable number under investigation — may be what finally prompts non-compliant prescribers to reconsider their approach.
"If there are tribunal decisions…that place restrictions on them or even suspend or cancel their registrations then that is helpful information for us to put out there to warn practitioners that this is what will happen to you if you don't follow guidance," Dr Nicoletti said.
Cannabis Council Australia chief executive Lisa Penlington called the guidance a "necessary step" in protecting patients and ensuring the industry "continues to mature in the right direction".
"We acknowledge the concerns raised by AHPRA and the national boards around inappropriate prescribing," she said. "These practices are deeply concerning and undermine the trust that patients place in both their clinicians and the broader system.
"Cannabis Council Australia supports AHPRA's move to reinforce that medicinal cannabis should be treated with the same rigour as any other controlled medicine. That includes proper use of real-time prescription monitoring, full consideration of a patient's concurrent medications, and prescribing only clinically appropriate quantities with safeguards in place to prevent early repeats."