The strange evolution of the cannabis industry traveled down a road unique in modern medicine. To this day, medical cannabis is available in dozens of countries and the majority of US states. But in most countries, the therapeutic use of the plant lingers in a parallel system. That is, in every country but Germany. German methodology places cannabis firmly in the realm of science, research, and conventional pharmaceutical systems.
The strangeness of the medicinal cannabis structure is apparent in many countries with well established medical cannabis ecosystems. For example, in the legalized US states, physicians do not prescribe cannabis; instead, they ‘recommend’ it.
In Canada, the herb isn’t dispensed through pharmacies by pharmacists; it’s sold through dispensaries by (predominantly untrained) budtenders. This is also true in the US. While the US is perhaps the most obvious example of how cannabis has grown up outside of the traditional structure of modern medicine, it is hardly the only country grappling with a 2-tier system.
In countries which support the medical use of the plant, there is typically the conventional medical system, and then there is the medical cannabis system. Each system operates under its own set of rules and regulations. That is, everywhere but in Germany, where the story is unfolding much differently. In many ways, the German system a more logical, consistent, and medically sound model.
Medical Cannabis in Germany, A Slow Start
On January 19, 2017, German legislators ruled on ‘cannabis as medicine,’ and the German market is now expected to be the most substantial medical cannabis market in the EU. Two years post-legalization, the country is still working through the kinks, but have chosen to tackle the plant through a much different approach than their international predecessors.
To access cannabis for therapeutic purposes, Germans must seek medical advice from their healthcare provider. If approved, a prescription follows. Doctors in Germany may only prescribe cannabis flower as a last resort (they remain hesitant about largely unstudied medicines), but over the last few years, sales of cannabis flower have doubled in the country. Most importantly, German prescriptions are dispensed through pharmacies, and not through a cannabis-only dispensary by budtenders.
Most Germans can find insurance coverage for a cannabis prescription. Health insurance in Germany is mandatory for almost all citizens. The statutory insurance covers roughly 90 percent of all citizens, and they are free to shop around between plans. Many plans now include medical cannabis, making it within reach for most of the country’s inhabitants.
As per a statement following legalization, Federal Health Minister Hermann Gröhe said, “Critically ill people must be cared for in the best possible way. Costs of using cannabis for medicinal purposes will be met by the health insurance companies of the critically ill, if no other form of treatment is effective.”
While insurance companies may not approve all prescriptions for reimbursement, the german model helps significantly reduce the cost of medical cannabis for its citizens. The current price of the herb is an expensive 20 euros per gram. Without comprehensive health insurance, it would surely be out range for many patients.
As per a report from Marijuana Business Daily, German health insurance agency GKV-Spitzenverband paid out for approximately 73.7 million euros worth of medical cannabis products in 2018. Although, this number includes both the unprocessed flower, as well as medicinal preparations of the plant (ex: Sativex).
The German government is taking painstaking precautions to roll out a fair and well-regulated program to manage medical cannabis. The full scope of the program is only now taking shape two years later. Despite the delays and problems with supply, the demand is rising.
Drive for Scientific Study, Not Commercial Experience
The policymakers behind the slowly evolving medical cannabis system in the country care less about commercial success than they do about clinical research. Providers in the country have long relied on the various pharmaceutical preparations of cannabis, much more so than their international counterparts.
The sentiment today is that physicians are comfortable with the pharmaceutical options, but uncomfortable with the unprocessed plant. German physicians see the value in the clinical study which went into these lab-produced cannabinoids medicines but find the lack of robust research into the raw flower unnerving.
The German model, which puts the plant into the established medical system, could be a powerful driving force to achieving the high-level clinical study the plant so desperately needs. The government looks as if it’s favoring scientific support over commercial success when vetting international cannabis imports.
Foreign companies, like the big players in Canada (Aphria, Canopy, and Aurora), vying for space in Germany should take note and adopt more focus on the scientific study of the plant into their business models.
In an interview for Marijuana Business Daily, Franjo Grotenhermen, a physician and managing director of the International Association for Cannabinoid Medicines stated, “If companies wait too long, we may see synthetic modulators of the endocannabinoid system – FAAH inhibitors, MAGL inhibitors, selective CB2 receptor agonists – for which clinical studies have started, introduced and established as a standard first-option therapy (before marijuana) for conditions for which we may use cannabis today.”
Not everyone in Germany is eager to see cannabis into the conventional medical system. Doctors across all sectors of medicine have recently pushed for better reporting, more science, and general caution in policymaking. The German Association of Palliative Medicine, German Association for Psychiatry and Psychotherapy, German Neurological Society and German Pain Society have all banded together to issue a statement calling for a pause while clinical trials catch up with standard use.
Is the German Model Better?
Placing cannabis firmly within the conventional medical system is, in theory, a more effective way of bringing it into the fold of modern medicine. In other countries, Canada and the US as only the most significant examples, there is a 2-tiered system. One system dispensing conventional medications, the other dispensing cannabis medicine. Merging these two systems into one helps legitimize cannabis in medicine, and at the end of the day, provide better medicine to the patient.
Despite the supply setbacks facing Germany in 2019, putting doctors, pharmacies, and pharmacists firmly in charge of cannabis, improves the plant’s effectiveness. It can help reduce the risk of the adverse reaction, boost the accuracy of dose, and help supply data on the plant’s benefits to the medical community at large. Still, for the German system to work, the science of medical cannabis has a long way to go. Globally there could be hundreds of thousands of patients relying on cannabis as medicine, yet there are few clinical trials available.