Telehealth providers have been in the limelight a lot lately – for the wrong reasons. Direct-to-consumer business models have been linked with rising patient safety concerns, including a reported surge in mental health issues related to medicinal cannabis use that prompted the TGA to launch a public consultation this month.
This follows government concerns over “unscrupulous and possibly unsafe behaviour by some telehealth providers,” reported in the Australian Financial Review in May, with Mark Butler asking the regulator to investigate.
In a Healthed poll this month, 89% of over 1500 GPs said they were very or moderately concerned about the impact of direct-to-consumer telehealth cannabis services, while 8% were slightly concerned.
They cited various problems including over-prescribing, lack of follow up, and failure to tell patients they cannot drive after using products that contain THC. Several GPs said neither patients nor the prescriber had told them cannabis had been prescribed, with potentially serious consequences.
“I had no knowledge the patient was using medicinal cannabis; my referral to a surgeon did not have this relevant information. The only person that found out was the anaesthetist on the operating table. This was of relevance to his approach to the anaesthetics and post operative orders for pain relief,” one wrote.
In a June survey, at least 90% of GPs said they thought prescriptions obtained via commercial telehealth providers for erectile dysfunction, weight loss drugs and nicotine vaping products—as well as medicinal cannabis—posed greater risks than those obtained during a face-to-face consult with a patient’s regular GP.
Telehealth can be profitable, generating $US 5,094.4 million in revenue in Australia last year—which is forecast to almost triple by 2030, according to Grand View Research.
In some business models, the same company produces, prescribes and dispenses the product—and can profit off every step. These ‘vertically integrated’ businesses are common in the medicinal cannabis industry.
“Some online clinics are owned by the cannabis company, the doctor works for the cannabis company, the pharmacy is owned by the cannabis company, and the medications being prescribed are owned by the cannabis company,” explains Dr Bryce Joynson, a Gold Coast GP, clinical educator on neurodiversity and endocannabinoid medicine, and experienced adult and paediatric medicinal cannabis prescriber.
“They can make money off the consult fee, the dispensing fee, and the product itself. Some online clinics are trying to get as many patients through the door as they can and prescribe them as many products as possible to maximise the amount of money they can make per patient.”
Doctors can even own a cannabis company, have their own cannabis line, prescribe and dispense their own products during a consultation, Dr Joynson adds.
“It’s such a grey area. Are these patients receiving appropriate evidence based medical care or are they being profited from by these vertically integrated clinics that are just churning out prescriptions?”
Patients who may benefit from medicinal cannabis are often the most vulnerable to exploitation by unscrupulous providers, Dr Joynson points out.
“A huge proportion of these patients are suffering from mental health conditions or chronic pain. They are very vulnerable populations to begin with, and they actually need the most support and care from their practitioners,” he says.
“These are the patients that can get taken advantage of quite easily by vertically integrated clinics. That’s why AHPRA and the TGA are saying we need to make sure doctors are prescribing this medication appropriately. Doctors wouldn’t be allowed to do this with benzodiazepines, they wouldn’t be allowed to do this with opiates, but they can do this with cannabis.”
AHPRA notes some clinics “appear to use aggressive and sometimes misleading advertising that targets vulnerable people,” and are even using online questionnaires that “coach patients to say ‘the right thing’ to justify prescribing medicinal cannabis.”
Under current guidelines, medicinal cannabis should only be considered if first-line therapies have failed—and only after a thorough assessment, development of a suitable management plan, and consultation with the patient’s usual practitioners.
Cannabis can be a very effective adjunctive treatment, Dr Joynson stresses, but it’s not a replacement for mainstream therapies.
But vertically integrated clinics don’t always follow this guidance, he says.
“Patients can ring up and say, ‘Hey, I’ve got some anxiety.’ And they go, okay. You fit the criteria. Let me write you a script for THC flower.”
If patients must meet specific criteria, how are so many accessing products inappropriately?
There are loopholes in the system. Lack of fact checking is a key problem, Dr Joynson says, noting nurses sometimes do the online intakes—and patients may never speak to a doctor.
“A doctor can have a clinic or a nurse sending out scripts under their prescriber number without ever actually seeing the patient. Some clinics have a one- or two-minute consultation with the doctor.”
“It would be very hard to take an adequate history for a complex and chronic condition in that time. There would not be enough time to go through all of the appropriate treatment options, risk vs. benefits and make sure the patient is appropriately consented.”
“The clinics run more like, ‘what would you like? You want a CBD product? Well, why don’t you try a THC flower as well? And next month we can get you trying this one. We’ll give you some gummies now as well’.”
“This can be a likened to upselling because the more prescriptions patients purchase, the more money everyone makes.”
“That’s where you’re seeing one doctor prescribing 17,000 scripts in six months.”
The lack of checks and balances has also generated demand, Dr Joynson says, with some patients seeking cannabis for what may be recreational rather than actual medicinal use.
And they know where to get it, he says.
“Patients are smart. They know which clinics they can get around these loopholes. They prefer to use clinics who they know are not going to fact check — they’re going to just prescribe me whatever I ask for. Often in much larger quantities than could ever be considered ‘appropriate medical treatment.’”
“I have seen a 19-year-old patient be prescribed over 20g of high dose THC flower per day to treat ‘mild insomnia.’”
He stresses most practitioners do follow the guidelines, but we need more doctors with education, training and experience in medicinal cannabis therapy.
“If we can upskill more GPs and train medical students in the endocannabinoid system, then we’re going to see less of these vertically integrated clinics; we’ll see less inappropriate prescribing and we’ll see better outcomes for patients.”
Working for a business that only prescribes one type of medication creates a conflict of interest for doctors and nurse practitioners, the Medical and Nursing and Midwifery Boards of Australia say.
AHPRA has serious concerns about practitioners who may be putting profits before patient welfare, says its CEO Justin Untertsiener.
“We will investigate practitioners with high rates of prescribing any scheduled medicine, including medicinal cannabis, even if we have not received a complaint.”
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