As the first Medical Cannabis World Forum in Malta came to an end amid much hype just over three weeks ago, many patients are still lamenting what is being perceived as a widespread lack of information within the local medical industry, together with unrealistic financial burdens that are being placed on those who obtain a prescription.
Angela Agius*, 44, is one such patient. Afflicted by fibromyalgia, the woman has for years lived with the constant pain that characterises the condition.
“I was on several medications, but the pain persisted and there were also other side effects. Sleeping was difficult and the condition was also affecting my mental state,” she says.
Then, a few months ago, Angela learnt that new legislation allowed her to seek a prescription for medical cannabis. “The online research seemed very promising. I found countless fibromyalgia patients who attested to how medicinal cannabis had turned their lives around. For the first time, I was excited and hopeful.”
Although Angela had never considered the option before – she adds that she comes from a background where cannabis “is a dirty word” – now that it was a legal alternative she was ready to try anything.
However, little did she know that before even being given a prescription she would be expected to fork out €50 for a medical consultation.
“My usual family doctor didn’t seem to be keen on it, even though I had tried several other medications through the years and nothing really worked. He came across as very unsure about what the whole thing involved. I asked around a bit and was referred to another practitioner who, I was told, was more informed. But then I was told that I would be charged €50 for a simple consultation. I can’t really afford that kind of money just to visit a general practitioner, so I cancelled the appointment,” she explains.
Angela continued asking around until, finally, she managed to find a practitioner who was knowledgeable and who answered her questions confidently and in a way that she could easily understand. Just as importantly, he charged modest consultation fees.
“He was very helpful and I had no problem getting the prescription. But why did I need to go through hoops to get the medicine that I need?” she asks.
Meantime, Angela’s problems are far from solved as she faces the regular expense of purchasing the drug.
“I need monthly prescriptions. The drug doesn’t cure the condition, it merely alleviates the symptoms. And to do that, I need to continue using it.”
But, at €17 a gram, she is worried that she will not be able to keep purchasing it in the long-term.
“I have part-time clerical employment but I am far from being a high-earner. Fibromyalgia limits your career path considerably. I get anxious just thinking that I may soon not be able to afford it, knowing that I will go back to constant pain and to feeling like everything is hopeless.”
She adds that, now she has experienced the “unbelievable relief” the drug offers when compared to her previous medicine, she has even tried to buy it cheaper on the black market.
“I do have some contacts through friends of friends, and I recently bought some for €12 a gram. I haven’t used it yet, though. I don’t know exactly what it is in it. What if it disagrees with me or leads to complications? What will I tell my doctor then? Would I be reported to the police?”
Angela looks distressed even just talking about the possibility. It is a distress shared by other patients who have been prescribed the drug but are facing the same difficulties.
Thirty-year-old Antonella* is another such patient. Diagnosed with relapse-remitting multiple sclerosis (RRMS) in 2009, she bluntly says that she first realised that cannabis offered effective relief after she started using it recreationally.
“I would use it when I started to experience MS symptoms and found that it offered immense relief. Cannabis eases my pain and relaxes my muscles,” she says.
Antonella’s condition comes with symptoms like fatigue, distorted vision and muscle spasticity (the continuous contraction of muscles, interfering with normal movement, speech and gait).
The most disheartening part was the lack of information about cannabis among health care professionals
“The RR part means that I can experience long periods of remission, where nothing out of the ordinary is happening and I feel quite well. Other times, however, the MS flares up and I experience various symptoms. This is known as a relapse and is (seemingly) not caused by anything,” she explains.
The condition can make it difficult for Antonella to carry out relatively simple physical activities, such as going up the stairs. She says that it has also made it hard to be as spontaneous as she would like.
“I have often thought about travelling but needing access to specialised doctors and medication trumps everything. Mentally, MS is associated with depression and overall mood change. It is a disease that alters every aspect of life,” she says.
Asked why she finds cannabis more effective than other medications, she explains that the ‘traditional’ pharmaceutical drugs available for MS usually have side effects associated with them.
“These range in severity from a simple head cold, like sniffles, fever and headaches, to vertigo – all the way to death by infection. Often, the medication is administered intravenously,” she explains.
With cannabis, none of these issues arise.
“It is 100 per cent natural, and it treats many MS symptoms without any side effects. I also find it more comforting to turn to nature for relief, when my life already consists of specialists, MRI scans and hospital appointments.”
Antonella points out that, given all the above, she does not understand why people still question why she prefers to use medical cannabis instead of other drugs to keep her condition under control.
“Obtaining a prescription was such a long process that I almost gave up a few times. The most disheartening part was the lack of information about cannabis among health care professionals.”
Given that the legislative change is still very new, Antonella admits that it comes as no surprise that doctors are sceptical and feel uncomfortable talking openly about cannabis.
“Unfortunately, for someone with an illness, this means that even those in positions of authority, with whom you trust your health, do not know enough about this option, or worse, are sceptical of it,” she says.
She explains how, after a series of failed attempts to obtain a prescription through conventional channels, she took to the internet in the hope of finding someone who had already been through it.
“Specifically, I posted about my situation on Facebook. From here, I established contact with a doctor willing to prescribe cannabis and a pharmacy willing to stock it. This prescription, along with a Control Card, which is granted by the Minister for Public Health through an application procedure, is what I now use to acquire medicinal cannabis at the pharmacy.”
She laments the difficulties that a patient in need of the drug has to go through in order to secure a prescription, saying that the old perception that the drug is something to be feared and not spoken about still prevails.
“This makes it difficult to have a frank conversation, and is resulting in a lack of knowledge. The system would be vastly improved if doctors and pharmacists were educated about the medicine they are now legally entitled to prescribe and dispense.”
Antonella also believes that, now that medical cannabis is to all intents and purposes part of the Maltese system, this need for education goes beyond the medical profession.
“The perception of the public needs to be updated. Were there more information and frank discussions about cannabis, many could benefit,” she insists.
Once Antonella managed to obtain her prescription, the rest was relatively plain sailing, in that she now has legal access to a high-quality, medical product that weighs exactly what it says on the tin.
“My prescription is for a dose of five grams, which costs €80. I do not receive any subsidies for this, which makes it a very expensive medication. I am hoping that the price will level once there is more competition on the local market, especially as there are plans to produce it at the Ħal Far industrial estate,” she says.
And, although she has never had any problems getting her prescription honoured, she puts this down to her relationship with a specific pharmacy.
“I have never taken a prescription to a different pharmacy, so I don’t know what reaction I would get. I am very thankful that, at least now, I can obtain cannabis legally. Having said that, it bothers me that people who are currently suffering cannot access this plant because the law somehow excludes them,” she concludes.
*names have been changed
Medical profession ‘in limbo’
Figures show that, up to November 22, 96 patients had been prescribed medical cannabis. Godfrey Farrugia, the medical doctor and MP, was the first to propose the introduction of medicinal cannabis in Parliament in 2014.
Since his proposal “it has taken three years of fits and starts and five ministers to get the legislation right,” he says.
In the meantime, no patient education campaign was started and the medical profession was left “in limbo”.
“Uncertainty has prevailed. To complicate matters, legislation was approved so that cannabis could be cultivated in Malta, and the concept of introducing its leisure use was aired. Political debate confused issue and public opinion,” he says.
He emphasises that continuing medical education programmes for doctors and pharmacists on the risks and benefits of Cannabis Therapeutic Practice (CTP) are necessary to ensure that patients receive the best quality care and advice.
“No such effective campaigns were started. One cannot ignore the long history of cannabis as an illegal drug of abuse in Malta. The understandable fear of stigmatisation is a strong deterrent for many healthcare providers. Any uncertainty in its legal status will also cause healthcare practitioners to avoid advising their patients towards its use for fear of breaking the law,” he says.
And, while many were dazzled by the high-profile image portrayed by the Medical Cannabis Forum, Dr Farrugia does not believe that it has helped achieve any clarity within the medical profession. “The forum did not have, as its main objective, outreach to the local medical profession. An invite was sent for an evening closing session whose presentation, in my opinion, was poor,” he says.
Asked whether the Superintendence for Public Health planned to address these concerns in the short term, a spokesperson for the Health Ministry said that the Medicines Authority and the Superintendence have conducted information sessions for professionals and support training by the professional associations. No further details were provided.
Questions about whether the ministry planned to address the issue of expense and whether the drug would be included on the free medical formulary remained unanswered.