The UK and Europe are facing down a whole new market with the arrival and increasing popularization of medical cannabis, but there are many forms therapeutic cannabis can take (pills, capsules, and sprays, oh my!) and experts do not all agree on which will take over the market. One thing is clear however the flower alone will not retain dominance in the medical cannabis market forever.
As Europe embraces medical cannabis, it is important to note that the landscape of medical cannabis prescriptions on the Old Continent has different characteristics than that in the United States.
After picking up their prescription from a medical professional, U.S. medical cannabis consumers visit their local dispensary to discuss with the vendor the best flowers and cannabinoid combinations to treat their condition.
In the UK and the rest of Europe, the environment is more medical. In particular, it is up to the prescriber to determine which products are best suited to the patient’s needs.
Many UK patients who use medical cannabis privately still inhale their medical cannabis, smoking a joint or vaporizing flowers. However, as “inexperienced” patients discover the benefits of this once-banned medicine, the picture is changing and becoming more pharmaceutical.
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Flowers might lose their dominant position in Eu
Avihu Tamir, founder and CEO of Kanabo, a medical cannabis company listed on the London Stock Exchange, is actively involved in this change.
“I think over the next couple of years, flowers will still be a significant part of the market. It won’t be 80 percent like it is today, but it will be over 50 percent.”
“You will also see a movement from flowers to alternative products. And that depends on when there are more medical products on the market to replace flowers. That’s in the near to medium future.”
“Other methods of consumption that will become important are obviously vaping and I think that’s our strongest bet. Vaping, when it’s available, will become the most important category.”
Capsules, liquids and oral sprays for pharmaceutical cannabis?
While Avihu Tamir has high hopes for vape, other formats are beginning to emerge, including capsules, liquids and oral sprays.
Prohibition Partners’ recent extraction report highlighted a growing trend toward selling extract-based products to pharmacies rather than flower-based products, which skips the magisterial step.
In addition, many emerging markets in Europe are expected to see an exponential increase in sales of extract-based products, with sales expected to reach €1.5 billion by 2024, again according to Prohibition Partners.
Avihu Tamir continues, “The reasons behind the shift to extract-based products in medicinal cannabis are obvious; they are simply more ‘pharmaceutical’ than flower, and more and more countries in the region are legalizing its use.”
“Dosage is easier to control, cannabinoid concentrations are more precise, products are more standardized and product formats are more familiar to physicians and patients.”
Jonathan Nadler, chief executive of the Lyphe Group, foresees a world where the number of UK patients will grow to more than 10,000 by the end of this year, then to 30,000 by 2022 and finally to 300,000 by 2025.
About the changing delivery patterns, he said, “When we first started, a lot of oils were prescribed, but that’s only because the early indications for us were primarily neurological-type conditions that were most amenable to oils.”
“But suddenly there was an influx of patients for whom flowers were more useful, for example to treat acute pain or certain sleep disorders, so the flower market is currently very unbalanced in the UK.”
“And of the patients who are using flowers, it’s actually a combination of balanced flowers and high THC flowers that are vaporized.”
“The oil market is still very large and we are encouraging the prescription of oils.”
“We want Europe’s cannabis market to become more medical.”
Lyphe recently adopted the NOIDECS distillate spray cartridge, which delivers a metered oil cartridge that fits into a medical device, eliminating the need to pick up a flower and grind it before consumption.
“We think this will have a major impact on the market, which is very flower-dominated. We want the market to become more medical. We want there to be more options like we’ve had for the last 60 years in pharmaceuticals.”
“What has prevented that from happening is the efficacy of these applications. Unfortunately, nothing has come close to the efficacy of the flower, and we hope this distillate vape will be the first to do so. We also hope that science will look at other applications that will give us much more effective products than the flower in the future.”
Professor Mike Barnes, president of the Medical Cannabis Clinicians Society, says the growing number of private patients and physicians – he has trained some 200 – is changing the profile of prescribers.
The UK’s 7,000 or so private patients are served by around 100 floral products from nearly two dozen suppliers, he says.
He continues: “We will see the development of other related products and different ways of taking them, such as patches, mouth sprays and actual tablets, as if a doctor told you to take this three times a day. We’ll see different and improved ways of delivering the drug, and that will develop quite rapidly over the next few months.”
A recognizable pharmaceutical product will reassure Europe’s patients
Do people expect to use something that is recognizable as a pharmaceutical product?
“For a lot of people, I think it is, and a lot of doctors would feel more comfortable prescribing cannabis in gel or tablet form.
“Those who are experienced users, and therefore illegal right now, would say the best way to take the medicine is flower or vaping. A lot of experienced users who come to the clinic now say, ‘I’ve tried that, but I’d rather take a flower to vaper.’ I totally accept what they have to say, but I also think that those who are not experienced users, and many physicians, would prefer a more medical approach.”
“About 60 percent of prescriptions right now are for the dried flower and 40 percent for the oil. This is mainly because there are more experienced users to begin with than naive and inexperienced users.”
“I think the balance is probably going to shift a little bit and we’ll see a little bit less flower prescribed over time. I would say that the ratio will probably reverse over the next six months to a year and we’ll probably see 60% oil and 40% flower, or let’s say 60% non-flower, because the other modes of administration, like patches and sprays, will also come in.”
However, he said, “It would be a great shame if the flower was left out, because it’s very beneficial for many people, especially with acute pain.”
“Vaping will give you relief in a minute whereas oils, taken orally, will take an hour to two hours. So there are very big medical benefits to vaping flowers – and we’re talking about vaping here, not burning.”
“There are many different flowers coming on the market, as well as many different oils and various modes of administration other than the flower, so I think the flower will continue, but it will decline modestly. It’s not going to die out. I hope it won’t.”
No cannabis flowers in the UK or Europe for Columbia Care
Hari Guliani, head of European operations for U.S.-based Columbia Care, also recognizes the benefits of flowers in providing quick relief to pain sufferers.
Although it does not supply flowers in the UK, the company does supply spray cartridges that can be used “as an alternative when patients need quick relief.”
Earlier this year, it introduced a line of capsules that are slower-acting but also longer-lasting, which can be helpful if patients are looking for sustained relief, overnight, for example.
He adds, “Other factors to consider are whether the medications are used in a nursing home, where familiarity with the capsules is helpful, or at work, where discretion is preferred.”
Columbia Care International developed the Columbia Care IMPACTTM registry, which allows it to understand how hundreds of thousands of patients have used their medical cannabis, from their first visit to its dispensaries to the most recent.
Dose-specific cannabis sprays for asthma
Hari Guliani explains, “The main thing that stands out is that there is no single formulation that dominates. We find that patients combine different formulations to get the desired result. For example, a patient may use formulations that are low in THC during the day, but higher in THC at night. They may combine one formulation for pain control, then another when needed.”
In Germany, Sanity Group, through its Belfry Medical brand, is developing a new device for the next generation of cannabis use that will use an extract taken through the lungs, much like an asthma spray.
Founder and CEO Finn Hänsel said, “You pump it into the lungs and the cannabis acts through them just like when you smoke it or vaporize it. However, because it’s an extract, we know exactly what the dosage is, and through our digital health platform, the doctor can track the success of the therapy. This, we believe, will become dominant over the flower.”
However, Pierre Van-Weperen, managing director of Grow Group UK, believes that experienced users, those who may have moved from the illicit market to private prescriptions, will likely continue to use flower.
Patient and prescribers in Europe may be more comfortable with ‘more medical’ cannabis
Pierre Van-Weperen does note that more “cannabis-naive” patients are using medical cannabis, which is due to greater awareness and more doctors willing to prescribe.
There is also a reluctance among some, particularly psychiatrists, who are not happy to prescribe flowers, as some research links cannabis to mental health problems in youth.
He says we are seeing the transition, with a 60% to 40% split in favor of flower likely to change over the next few years.
He says that solutions like Columbia Care capsules – which look like a standard medicine – are proving “very attractive to cannabis-naive patients.”
“There are those who may have dexterity issues-it’s going to be difficult and messy to roll a joint or use a vaporizer-and then those who have caregivers to administer for them, or those who struggle to keep extracts or oils in their mouths.”
He says the capsule allows for a more precise dose, and for doctors, it’s more akin to “the normal medication they prescribe.”
Socially acceptable cannabis products for UK and Europe
“Over the next two years, we will see growth in inhalers, capsules, patches, liquids and pen sprays.”
“As we move to tens of thousands of patients, many of whom will never have had experience with flowers, they will find these products more socially acceptable, and they will eventually dominate the market.”
“And, as doctors and patients become more comfortable, the drug will become personal. It will become a high-quality product tailored to the specific terpene and cannabinoid profiles of patients’ needs.”
“We will see the development of disease- or symptom-specific strains based on patients’ conditions and experiences,” he added.
Some 36 U.S. states now allow the use of medical cannabis, and 8 of them have at one point attempted to create what would look to Europeans like a purely pharmaceutical market.
However, 6 have backed down, and only 2 of the 3 dozen states now require the prescription of cannabis in pills, oils and other products.
On this side of the Atlantic, the European continent is expected to move in the opposite – pharmaceutical – direction to the United States.
Case Study for Europe’s Cannabis – The German Market
Germany has seen an increase in medical cannabis extract products sold directly to pharmacies in the past year, says Pia Marten of wholesaler Cannovum.
She says that while the main method of consumption is inhalation, orally applied cannabis medicines such as Dronabinol or extracts are more likely to be reimbursed than cannabis flowers.
She continues: “Looking at the data of reimbursed cannabis medicines, we can indeed see a trend towards extracts. Data from Prohibition Partners’ sixth European Cannabis Report shows steady growth in the market, with nearly 40 percent of all reimbursed cannabis medicines in extract form by 2020.
“Extracts are more likely to be reimbursed than flowers, which often leaves patients with the only option of obtaining a private prescription and paying for it themselves.
“Another reason for the higher demand for extracts could be the oral mode of application. This mode of consumption is more familiar to physicians and patients, the dosage is easier to control and the products are more standardized.
“Cannabis extracts are close to traditional pharmaceuticals, which means physicians are more likely to use them as a starting point for cannabis-based therapies. The oral mode of application provides another therapeutic option and allows physicians to reach a wider range of patients.”
The main flower alternative prescribed in Germany is Dronabinol because of its long-standing practical use; Dronabinol was first prescribed in 1998 in Germany.
She continues: “We see a trend towards personalized medicine and mixed prescriptions based on the patient’s needs. Different modes of application also mean different durations of effect.”
“Let’s take the example of a patient with chronic pain. To treat sudden bouts of pain, a prescription for cannabis flowers might help him manage his pain. Within minutes of inhalation, the therapeutic effect of the cannabis flower kicks in, with a lasting effect of up to four hours.
“If the patient suffers from prolonged pain, which can for example disrupt sleep, prescribing an extract may be a good additional choice. The effect of the extracts occurs about 30 to 90 minutes after application and lasts up to eight hours. We believe that the individual approach is the future of patient management, as each patient deserves the best therapy.”
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