Research letter
The Prescribing of Cannabis Drugs to Self-Payers
An Evaluation of Prescriptions Presented to Pharmacies
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In March 2017, the permissible indications for prescribing cannabis medicines were expanded in Germany, with the aim of improving medical care for patients whose illnesses or symptoms cannot be adequately treated with any other available drugs. Regulations on the reimbursement of treatment costs for patients in the German statutory health insurance system are laid down in §31, Paragraph 6 of the German Social Law Code, Book V.
The number of prescriptions for cannabis drugs within the statutory health insurance system rose by less than 10% from 2020 to 2021 (from 340 165 to 372 071 prescriptions) (1); over the same period, the quantity of cannabis flowers dispensed by pharmacies for patient care rose by more than 43%, from 6297 kg to 9007 kg (2). This suggests an increase in the prescribing of cannabis drugs, and particularly cannabis flowers, on a private basis outside the statutory health insurance system. To assess the extent of such prescribing and to detect potential undesirable developments in health care, the German Federal Institute for Drugs and Medical Devices carried out an analysis of prescriptions for cannabis drugs that were issued in 2021 under the provisions of §12, Paragraph 4, Sentence 1 of the the Narcotics Prescription Ordinance (Betäubungsmittel-Verschreibungsverordnung).
Methods
We evaluated prescriptions for cannabis drugs that were filled by the ten German pharmacies that bought the largest quantities of cannabis flowers—45% of the nationwide total—for medical purposes in 2021. First, data were collected on at least 500 consecutive prescriptions for cannabis drugs that were filled from 1 January 2021 onward in each pharmacy. Documentation included the patient’s age and sex, the specialty or professional title of the prescribing doctor, the drug prescribed and its quantity, and the dosage and mode of administration, if this information was available.
Further data were collected from each pharmacy on 200 prescriptions filled from 1 November 2001 onward. The data from the two time periods did not differ significantly in any of the examined parameters and were, therefore, combined for the overall analysis.
Results
Of the 7075 prescriptions evaluated, 6812 (96.3%) were for cannabis flowers. More than two-thirds (70.6 %) of the prescriptions were private, as opposed to payable by statutory health insurance, and 83.2% were for men. The patients’ average age was 39 years; 24% were aged 14 to 30 (Figure 1). Most prescriptions were issued by general practitioners (Figure 2).
Among the 4994 private prescriptions, 87.7% were for men, with an average age of 36 years. 30.6% of these men were 30 years old or younger.
The average prescribed amount of a cannabis flower variety in private prescriptions was 17 grams; in prescriptions covered by statutory health insurance, it was 39 grams.
Discussion
In 2021, the ten pharmacies from which data were evaluated bought more than 45% of all cannabis flowers that were acquired by pharmacies in Germany. These pharmacies were, clearly, specialized in the provision of cannabis flowers. Approximately two-thirds of the total quantity of cannabis flowers for medical use in Germany in 2021 was purchased by only approximately 100 of the nearly 18,000 pharmacies in the country.
The sample is characterized by a very high percentage of men (83.2%) and a predominance of private prescriptions. At 39 years, the average age of patients for whom cannabis drugs were prescribed is markedly lower than the 57 years determined in the accompanying survey (3). In the survey, 54% of prescriptions for all cannabis medicines were for women, but two-thirds of prescriptions for cannabis flowers were for men.
Only 10.5% of the German population is privately insured; most of the private prescriptions in the sample were presumably for persons covered only by statutory health insurance (4), i.e., persons who are ineligible or have not applied for reimbursement of the cost of these drugs from the statutory health insurance carriers.
In cases where a patient has not applied for reimbursement of the cost of the prescription drug, the question arises why the prescription was issued. The aim of the 2017 Cannabis Act was to ensure care for all seriously ill patients who cannot be treated adequately with other available drugs and who might benefit from treatment with cannabis-containing drugs. Only patients of this kind are eligible for reimbursement of the cost of cannabis drugs, but prescribing these drugs for other reasons is permitted if medically justified, as provided in §13 of the Narcotics Act.
Private prescriptions were mainly for men (87.7%), and the men receiving them were generally young (average age, 36 years). These figures suggest that cannabis flowers are being supplied to the public in ways that the legislature did not intend. It is apparently the case, either that many of the patients receiving cannabis drugs ought to be reimbursed for them as provided in §31 (6) SGB V, but are, in fact, not reimbursed because there is not enough scientific evidence supporting the treatment of their underlying (e.g. mental) illness with cannabis; or else that many of the patients receiving cannabis drugs are actually not among the intended recipients, according the special regulations that concern these drugs.
The fact that private prescriptions are generally for a smaller quantity of drug than prescriptions reimbursable by statutory health insurance may simply reflect minimization of the cost to the patient, but it may also reflect a tendency not to apply for reimbursement when only a small quantity is needed for treatment.
Cannabis drugs cost 8–15 euros per gram for self-payers, but much more for health insurance companies (5).
Limitations
Pharmacies were selected on the basis of purchases of cannabis flowers. Other cannabis drugs may be underrepresented in pharmacies specializing in flowers. The data may also be distorted by price discounts offered by specialized pharmacies.
Peter Cremer-Schaeffer and Solveig Langer
Federal Institute for Drugs and Medical Devices, Federal Opium Agency, Bonn (Cremer-Schaeffer, Langer) Peter.Cremer-Schaeffer@bfarm.de
Conflict of interest statement
The authors declare that they have no conflict of interest.
Manuscript received on 21 September 2023, revised version accepted on 31 January 2024.
Translated from the original German by Ethan Taub, M.D.
Cite this as:
Cremer-Schaeffer P, Langer S: The prescribing of cannabis drugs to self-payers—an evaluation of prescriptions presented to pharmacies. Dtsch Arztebl Int 2024; 121: 338–9. DOI: 10.3238/arztebl.m2024.0026
