The United Kingdom medical cannabis market first opened up in 2010 exclusively with the sale of Sativex, a cannabis-derived pharmaceutical oral spray which is used to treat spasticity due to multiple sclerosis. However, it took another eight years before the legalization of the medical cannabis market would become formalized. Even after legalization, access to medical cannabis remains extremely limited as cannabis can only be prescribed by specialist doctors to patients who have exhausted all other available treatments but still have "unmet clinical needs". There are various other logistical barriers to access as well.

Although cannabis products can theoretically be sold across the UK in pharmacies, until March 2020, specialist importers were not permitted to order a stock of medical cannabis preparations to have on-hand. Instead, they were required to go through an onerous import process for each order, creating treatment delays and interruptions. Today, they may import and hold somewhat larger quantities of cannabis (up to 25 individual doses, or that required for 25 courses of treatment of no more than 3 months) for future use by patients with prescriptions – though an improvement, this system remains far from ideal.

Furthermore, only three cannabis-based medicines (Sativex, Epidyolex and nabilone) are available as licensed medicinal products in the UK. Each is expensive and can only be prescribed for highly limited conditions. Nabilone, for example, is licensed to treat chemotherapy-induced nausea and vomiting when other treatments are ineffective. All other cannabis medicines in the UK are currently unlicensed, including flower, oils and capsules, which must still be produced to pharmaceutical standards – and currently the UK’s National Health Service (NHS) only prescribes unlicensed cannabis medicines in exceptional circumstances.

Given the difficulties involved in attaining medical cannabis product through the NHS, as an alternative, a number of private clinics have been formed in the UK where specialist consultants with a strong understanding of medical cannabis can prescribe a range of products to patients in their area of expertise. These, too, carry a high cost (due to steep clinical fees, a regulatory requirement that requires monthly renewals, and prescription costs), though the clinics make access significantly easier. Though COVID-19 was expected to dampen growth due to patients’ newly limited access to the specialists required to receive new prescriptions, the opposite has in fact taken place, with several clinics now prescribing cannabis via video consultations and, in fact, driving more traffic than was being seen pre-pandemic.

Regardless, due to restrictive NHS prescription criteria and the costs associated with obtaining products through private clinics, patients often defer to the significantly cheaper and easier-to-access consumer CBD market (now flourishing), or the illicit market for higher-THC cannabis. Because of these easy alternatives, logistical hurdles and restrictive regulations are causing the UK cannabis market to grow extremely slowly.

Despite the slow ramp-up of its medical market, the UK is the leading country in Europe in one sense: the nation has the most completed clinical trials and continues investing into completing ongoing research. As the number of completed studies continues to rise and encouraging results are gathered, it is expected that legislators will take steps to loosen restrictive regulatory frameworks, such as allowing general practitioners to prescribe cannabis (rather than specialists alone) for longer periods of use, as well as permitting for domestic cultivation, driving a more open, affordable and normalized medical cannabis market. This will lead to vast relative growth, putting the UK medical cannabis market on track to reach nearly £300 million by 2025. Given that the United Kingdom has historically been a conservative country regarding cannabis use, adult-use legalization is not expected to take place within the five-year forecast period.

After a long and protracted delay in implementing a more accessible medical cannabis policy, the UK finally heard the concerns of parents with children suffering from conditions as serious as severe epilepsy. During the summer of 2018, Home Secretary Sajid Javid called for an urgent review regarding cannabis-based medicinal products and sought recommendations for changes to the contemporary system from the Advisory Council on the Misuse of Drugs (ACMD) and the UK’s Chief Medical Adviser.

As a result, a new law passed on November 1, 2018 allowing physicians to prescribe medicinal cannabis to patients without the approval of an expert panel. However, only specialist doctors in the field relevant to the patient’s condition who are listed on the General Medical Council’s specialist register (i.e. not a general practitioner) are permitted to prescribe medical cannabis. Medicinal cannabis products can be prescribed on a case-by-case basis for patients who have a special clinical need that is not being met by licensed alternatives.

Medical cannabis legalization also found support from the Royal Pharmaceutical Society, which stated that it believed the program would provide safe relief for patients with serious health conditions and that it would work side-by-side with the NHS to support specialists in their prescription decisions. Companies that wish to possess, supply, produce, manufacture, or import and export cannabis-based products for medicinal use in humans must obtain a Home Office Controlled Drug license in order to lawfully undertake these activities.

The National Institute for Health and Care Excellence (NICE) was commissioned with developing detailed guidelines for clinicians to provide guidance regarding the prescription of cannabis. These guidelines were published in November and December 2019 and suggest that cannabis-based medicinal products may be effective for people with intractable nausea and vomiting, chronic pain, spasticity, and severe treatment-resistant epilepsy. In addition, they recommend the use of cannabidiol (Epidyolex) with clobazam for seizures associated with Lennox-Gastaut and Dravet syndromes in patients aged 2 years and older. While the December recommendations primarily cover Epidyolex, the November guidelines were more broad, covering:

• Cannabis-based products for medicinal use as set out by the UK Government in its 2018 Regulations
• The licensed products THC combined with CBD (Sativex) and nabilone
• Plant-derived cannabinoids such as pure CBD
• Synthetic compounds which are identical in structure to naturally occurring cannabinoids such as THC, for example, dronabinol.

In addition, NICE recommended that public insurance (through the National Health Service - NHS) cover some licensed medications - namely Sativex, Epidyolex and nabilone - for qualified patients. Only a small handful of patients have qualified to have their costs covered by the NHS thus far.

Prior to early 2020, all medical cannabis products were imported from other nations on an individual basis, which required a long authorization process that often caused patients to turn to the illicit market for their cannabis medicines. For instance, the license authorization process for import from Canada would take up to eight weeks, and this process would have to be repeated for each patient whenever they needed a prescription, which may have expired by the time the product arrived. In March 2020, the UK government loosened these restrictions, allowing for licensed wholesalers to import larger quantities of medicinal cannabis products, which has already increased ease of access to cannabis-based medicines.

Based on patterns seen thus far in the UK, the factor expected to most heavily drive sales on the medical market over the forecast period is slow, incremental adjustments on the part of regulators to allow for organic market growth. For example, the possibilities that regulators will allow wholesalers to stock more product, patients to have less-frequent consultations with clinicians, general practitioners (GPs) to prescribe instead of only specialists, or licensing for legal, local supply chain growth. Each of these policies could drive down costs and augment ease-of-access in a market where there is certainly unmet demand, making for a substantially more robust medical cannabis market.

Despite the potential of medical cannabis, the Home Secretary has made it clear that the loosening of medical restrictions does not pave the way towards adult-use legalization and penalties for unauthorized supply and possession will remain unchanged. In July 2019, a group of Members of Parliament (MPs) visited Canada on a fact-finding trip that was organized by a UK-based cannabis campaign group, Volteface, and was partially sponsored by the North American cannabis company MPX. While the MPs predicted that the UK would fully legalize cannabis for adult use within five to ten years, a spokesman from the Home Office stated: “The legalization of these substances would not eliminate the crime committed by the illicit trade, nor would it address the harms associated with drug dependence and the misery they can cause to families and society”. This indicates that, though some government officials would like to institute sweeping cannabis reforms, the Government has no intention of changing the law when it comes to adult-use legalization in the near future. That said, a change in the governing party of the UK could increase the chance of adult-use legalization being considered.

Given the minuscule size of the market and the current regulatory restrictions on accessing medical cannabis, the competitive landscape for licensed products in the UK is limited to very few players.

European Producers:

Sativex and Epidyolex (GW Pharmaceuticals)

UK-based GW Pharmaceuticals is currently the only company licensed for cannabis cultivation in the United Kingdom, and has cultivated approximately 20 tons of cannabis annually since 2011. The company has been extremely successful with its approach towards developing cannabis-based pharmaceutical items, is one of the largest exporters of medicinal cannabis drugs to the European market - and up until 2018 (when UK reform allowed for the prescription of a wider range of cannabis medicines) held 100% of the market for plant-based cannabis in the UK. It has made huge strides across the globe with its two products: Sativex for MS and Epidiolex for seizures (referred to as Epidyolex in Europe). Sativex alone reportedly made GW, and by proxy the UK, the world’s largest exporter of medical cannabis products in 2016. GW is well-positioned to expand further, with Epidyolex having launched in Germany in Q4 2019 and the UK in 2020.

Cesamet (Mylan)

Nearly one-third of prescriptions for licensed cannabis medicines in the UK are for nabilone, a cannabis formulation typically used to treat nausea and vomiting, which can be sold as either generic or under the brand name Cesamet. Cesamet capsules are manufactured by Mylan, a company with more than 7,500 generic, brand-name and over-the-counter medications sold around the globe.

In addition, a local initiative called Project Twenty21 is aiming to generate a large medical cannabis patient registry in the UK, to ultimately improve access to cannabis. As part of this endeavor, it has partnered with several licensed producers to subsidize the cost of private prescriptions for cannabis-based medicines to significantly lower rates than are typically available (capped at £150 per product per month). Global and local participating producers supplying this product include Khiron Life Sciences, Bod Australia Ltd., Cellen Therapeutics, Senzer Pharmaceuticals and soon, Jamaican Medical Cannabis Corporation, with more pending. Though the project is just getting off the ground, these players are expected to see a strong uptick in traffic and medical cannabis revenues in 2021, though likely significantly less than that seen among licensed pharmaceutical producers.

Access to medical cannabis in the UK is extremely limited – only 7,100 prescriptions were processed by National Health Service (NHS) community and hospital pharmacies in 2019, while private clinics processed fewer than 300. However, the latter figure requires self-reporting and is significantly underrepresenting the full scope of prescriptions and sales taking place through the legal medical market.

Numbers have picked up slowly in part because the process to obtain product is extremely cumbersome. After meeting with a general practitioner to obtain a referral for a specialist or obtain their medical records, patients then need to meet with and receive a prescription from their specialist; however, until recently that prescription would not be filled until each patient’s individual cannabis-based medicine – produced in either the Netherlands or Canada – was imported into the UK. This process routinely took 8-10 weeks from when a patient was prescribed a medicinal cannabis product to when the product to make its way into their medicine cabinet. A March 2020 change allowed specialist importers (wholesalers) to purchase and import larger quantities of cannabis-derived medicines either in anticipation of patient needs or for existing patients’ future requirements. While imports are still limited, the change has allowed patients to access their medicines with shorter turnarounds and fewer disruptions from one of the 12,000+ pharmacies across the United Kingdom, making product more accessible for patients.

If NHS prescriptions are inaccessible , patients can seek medicinal cannabis through a specialized private clinic, which is becoming an increasingly popular alternative as more clinics are launched and costs are noticeably falling. For example, European Cannabis Holdings (ECH), a London-based firm with operations across Europe, runs a network of these specialist facilities called Medical Cannabis Clinics to help bridge the gap between supply and demand – its costs have dropped nearly in half for an initial consultation (now £150). Project Twenty21 has also encouraged the growth of private medical prescriptions by partnering with and supporting clinicians through the process of treating patients with medical cannabis, as well as pushing for more competitive and reasonable pricing, which now ranges from £99-150 for initial visits, and £45-90 per follow-up among clinics in their network.

As patients must renew prescriptions monthly, private clinic costs for cannabis access remain steep in the UK, though their decline is promising and expected to continue. Further factors driving price drops and increased prescriptions are the allowance of prescribing by general practitioners, expected in the near-term, as well as domestic cultivation, which will lift the heavy fees associated with importing, though this may not take place until the medium-term after political pressure to create a domestic cannabis economy mounts following any potential fallout related to Brexit and COVID impacts.

As of November 2018, the UK government began allowing for medicinal cannabis products beyond finished pharmaceuticals (deemed Unlicensed Medical Cannabis Prescriptions or U-CBMPs) to circulate on the market, including a variety of formats such as flower and extracts such as oils and capsules. These unlicensed products are typically only prescribed through private specialist clinics due to very limited U-CBMP prescribing through the NHS. Despite the fact that the regulatory change permitting them on the market took place over two years ago, U-CBMPs - which have not undergone clinical trials in the same fashion as finished, licensed pharmaceuticals - continue to make up a relatively small fraction of the legal medical market, both because of these products’ lower price points relative to licensed pharmaceuticals, and because they are less accessible - the vast majority being prescribed by expensive private clinics.  

As access to cannabis through the NHS has remained highly restrictive and product variety extremely limited, more accessible and increasingly price-competitive private clinics have begun – and are expected to continue – supplanting the NHS as the major driver of medical cannabis sales growth. As a result, the costly finished pharmaceuticals favored by the NHS will become a less and less significant component of the market during the forecast period, making up only 15% of sales in 2025, while products more readily prescribed by private clinicians (U-CBMPs) will be purchased by more patients as well as in greater volumes.