Here’s the introduction to the article outlining the issue and how and why people are doing it
Article Written by Pharmacist Michael Thorp
Integrating medical cannabis into the Australian landscape continues to present a range of legal, logistical, and therapeutic challenges nearly a decade into legalisation. Amongst these challenges, script substitution is an emerging concern for prescribers, pharmacists, and patients – even if they are yet to realise it.
Here, we explore the issues this author has witnessed surrounding script substitution in the context of medical cannabis in Australia, examining its implications for the healthcare industry and proposing potential options for how prescribers and pharmacists might navigate these complexities to improve patient outcomes.
Script Substitution: A Legal and Ethical Gray Area
At its core, script substitution is a pragmatic response to a still nascent industry and supply shortages. As a naturally grown product, medicinal cannabis is subject to more frequent supply issues than conventional pharmaceuticals. Supply fluctuations aren’t uncommon, whether due to regulatory delays, logistical issues, or unpredictable spikes in demand.
In Australia, pharmacists may substitute a product if the prescribed product is not available with an alternative in consultation with the prescribing doctor. However, the legal and ethical boundaries of this practice are murky.
Historically, the ambiguity of state legislation has resulted in varied interpretations of what constitutes “unavailability” and what level of “consultation” is required between pharmacists and prescribers. I have observed instances where the definition of “unavailable” has been stretched to include products that were simply out of stock in a particular pharmacy yet still available to order from a supplier.
The Evolution of Substitution Practices
The ambiguity surrounding script-swapping or substitution has forced the industry to develop informal practices to manage the issue. Initially, the status quo involved pharmacists making time-consuming phone calls to prescribers. Often, this was nigh on impossible, resulting in protracted periods where patients were unable to access their medication, leading to distressed patients and pharmacy staff.
Over time, a more streamlined approach developed, where doctors would implicitly allow substitutions by failing to mark the “substitutions not permitted” box on the script. Other prescribers might include notations like “substitutions allowed +/- 2% THC” or would specify one or more products that they saw as acceptable substitutions.
Some would even list multiple products directly on the script, indicating that any of the listed items could be dispensed. This practice provided pharmacists with a degree of autonomy while ensuring that the prescriber’s intent was respected.
As these practices evolved, so too did the risks. This landscape relies heavily on mutual trust between doctors and pharmacists. Yet the reality is that some pharmacies have taken certain liberties with the process and potentially taking other less altruistic factors into account in their dispensing (such as profitability or affording patients the ‘service’ of being able to choose whatever they wanted).
In other examples, patients would specifically request scripts for products that were known to be out of stock at the time of prescribing. With full knowledge of the system, individuals have been able to select their own products at the time of dispensing – a situation that just defeats the entire purpose of the prescriber/patient relationship.
While such behaviour is not widespread, it does underscore the need for clearer guidelines and stricter enforcement.
Changes in Queensland and New South Wales
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