Medical and clinical report excerpts
There follows an excerpt from the Medical and Clinical section of Discrimination by Design briefing document. You can view/download the whole briefing document at the link at the bottom of the page.
4.0 Clinical and scientific context
Using the clinical lens, this section shows why route of administration matters and why smoking is uniquely necessary for some patients.
4.1 Clinical indications and access reality
CBPMs are prescribed for a range of conditions, including but not limited to refractory epilepsy, breakthrough pain, severe nausea, spasticity, and neurological disorders. NHS prescribing remains extremely rare; most patients obtain access through private clinics.
For many patients, slower routes such as oils or vaporisation are clinically useful and effective for maintenance or episodic symptom control. But for those experiencing sudden, acute episodes — where treatment must act within seconds — these routes are not sufficient. In such cases, the absence of a lawful smoking option denies access to the only route that can deliver relief immediately, often from the first puff, preventing escalation before symptoms peak.
4.2 Pharmacokinetics, titration, and clinical need
Different routes deliver different speeds of onset, durations of effect, and degrees of titration control. Equally important is whether a patient can physically self-administer during crisis.
Oils/capsules: onset 30–90 minutes; duration 4–8 hours. Titration is imprecise, and, once ingested cannot be adjusted. Useful for maintenance, not sudden escalation.
Vaporisation: onset 5–15 minutes; duration 2–4 hours. Some titration possible, but requires a functioning device, preparation, and dexterity — often difficult for patients with tremor, reduced coordination, or sudden attacks. Relief may arrive only after symptoms have peaked.
Smoking: onset within seconds, often from the first puff; duration up to 2 hours. Allows immediate titration — patients can stop after one or two inhalations once relief is achieved. Minimal dexterity is required, making it viable during acute neurological episodes or breakthrough pain.
4.3 Comparative risk and proportionality
Other substances with higher or comparable risk profiles are lawfully available without route-specific prohibitions. The singling out of cannabis smoking is therefore disproportionate:
Tobacco: lawfully sold despite no medical benefit and overwhelming health harms.
Alcohol: lawfully sold despite no therapeutic benefit, high addiction risk, and major social and health harms.
Opioids, benzodiazepines, ketamine: prescribed despite high risks of dependency, overdose, and misuse; no route-specific bans are imposed.
Cannabis (smoked): carries risks of respiratory irritation and exposure to combustion toxins, but these are not uniquely high. However, published harm ranking studies consistently placed cannabis below alcohol and tobacco in overall harm. (e.g. Nutt et al., Lancet, 2010 – See Annex A 1) Such risks are manageable through clinical guidance, regulation, and patient education.
Cannabis smoking sits lower on the risk spectrum than tobacco and alcohol, and comparable to or below other high-risk medicines, yet it is the only route categorically prohibited in law.
4.4 NICE, MHRA and professional guidance
NICE (2019): NICE recommended restricted prescribing based on limited evidence, but made no recommendation on route of administration, nor did it propose prohibition.
MHRA: Regulates medicines for safety/quality; has never imposed a route ban.
Royal Colleges: Urged caution, but without evidence for an absolute prohibition.
International comparators: Canada, Germany, Israel, and many US states regulate medical smoking instead of banning it.
4.5 Vaping vs smoking – clinical limitations
Vaping is sometimes presented as a substitute, but for acute conditions:
Onset mismatch: 5–15 minutes (vaping is simply too slow for crises that escalate in seconds).
Overshoot risk: patients inhale more than they need whilst waiting, causing sedation, nausea, dizziness.
Dexterity barrier: loading/operating a vape device can be impossible during seizures, tremors, or sudden neurological onset.
Smoking advantage: relief within seconds, minimal dexterity, and controllable titration/dosage (a puff or two may suffice).
Briefing document download
A lawful medicine should not operate outside the rule of law. Discrimination by Design examines how this anomaly arose — and how it can be remedied. Click the button below to view and/or download our Discrimination by Design briefing document.