'Enough with bureaucracy': Has Israel's month old cannabis reform failed?

In early April, the Health Ministry announced the beginning of a new era for Israel’s cannabis reform, with the message being, “Enough with bureaucracy.”

At the heart of the plan was the move from licenses to prescriptions. Instead of having to renew licenses and wait for the decision by the Medical Cannabis Unit, cannabis prescriptions would be given to patients to be used in the nearest pharmacy, just like a prescription drug.

The intentions were good, but according to Walla's examination and many testimonies of cannabis patients, the actual reality is less idyllic.

The reform was built in stages. The plan reportedly began in July 2013, with additional stages being added gradually, such as a "medical release" of the plant for certain patients - in accordance with the government's decision to regulate the Israeli cannabis market.

In addition, a committee headed by Dr. Boaz Lev prepared the current move from license to prescription in an attempt to reduce bureaucracy while maintaining the safety of the public, the products, and an appropriate medical framework.

The members of the committee decided that giving prescriptions would preserve the uniformity and professionalism of the medical treatment by cannabis, as is the case with the vast majority of drugs and medical treatment, so that treatment by cannabis could become an integral part of the medical treatment from the patient's medical file to the Health Maintenance Organization. 

Furthermore, the committee argued that such a move would enable the documentation, monitoring, and control required for this unique type of treatment. As such, the coordination of treatment between all the medical services provided to the patient would greatly improve as well.

Shortage of doctors and opting for private markets 

Just when it seemed that the long-awaited solution had been found and after October 7, there would be maximum understanding for this population, as of today, the appropriate answer has not yet been found - neither for post-traumatic sufferers nor for the majority of people suffering from chronic pain. 

To receive the long-awaited cannabis license, patients suffering from post-trauma will have to attach to the application a special appendix from a psychiatrist who will fill in the details of their request. A specialist doctor would then have to recommend the administration of cannabis to the patient, and finally the Cannabis Medical Unit would examine the application for a fee of NIS 360 per year.

However, as in other fields, the queues for specialist doctors are very long in the public health system, and the shortage of doctors in Israel also affects cannabis patients. 

According to a list provided by the ministry, only 65 specialist doctors can fill in the details for such prescriptions. The ministry claims that more than 400 doctors have been trained in the public service to answer cannabis patients' questions, but the doctors' choice of whether to engage in this field or another is up to them.

In March, about 135,000 cannabis consumers were registered in Israel. In addition, according to the monthly Medical Cannabis Unit report, as of March, there were 16,767 people consuming cannabis under the PTSD (post-trauma) label and 74,374 with chronic pain. This shows a decrease of almost 6,000 patients who lost or did not have their license reconfirmed prior to the introduction of the reform in April.

Officials in the field blame the bureaucracy and the lack of certified doctors. Others blame the private and illegal "booming" "Telegrass" market and its counterparts. Although they are much more expensive and despite the inherent dangers of using cannabis through social media, they are apparently accessible and fast. Some also talk about the many payments for the purpose of receiving the cannabis, when according to the majority opinion, the coming months will be critical for the continuation of the reform and its examination.

However, it should be noted that there are licenses in which more than one label is listed in the patients' files so that a patient can fit a wide variety of labels. In addition, according to the report, most of the patients consume cannabis through the usual smoking methods or vaporization rather than through an extraction process, and only a very few use inhalers. The current procedure offers relief for many patients with the following labels: Oncology patients during chemotherapy or radiation treatments, patients with inflammatory bowel disease, multiple sclerosis patients, Parkinson's patients, Tourette's syndrome, AIDS patients, epilepsy, those on the autistic spectrum, dementia, and terminally ill patients. For them, the new procedure will significantly facilitate the renewal of prescriptions through the health funds and the various institutes at a discounted cost of NIS 180 per year compared to issuing a license, NIS 360 per year.

Cannabis brought me back to life 

"Why should a person with post-traumatic stress disorder have to experiment with harsh psychiatric medications just to get permission to consume medical cannabis that can benefit them," wonders Noy (pseudonym), a medical cannabis patient following post-trauma from an incident of domestic violence she experienced. For her and her friends, the guidelines have not changed. "We were left behind in the reform; it doesn't speak to us. The post-traumatic stress disorder broke out for me after 20 years. I was officially diagnosed only in the last two years, and I had to take drugs that hurt me mentally. Drugs that didn't suit me and affected everything in my life. Nothing helped me like cannabis; it brought me back to life. Why do patients have to suffer so much? I reduced the use of the plant significantly to a few grams, and that's only thanks to the cannabis. I also tried to contact the doctors on the list of the Health Ministry."

Just before the introduction of the reform, Noy paid a private psychiatrist NIS 1,200 for the license and hundreds of shekels a week for the purchase of cannabis, an amount that adds up to thousands of shekels a month. 

"I have a lot of criticism for the Health Ministry. They need to understand that cannabis can suit one person at a certain dose and another person at a different dose. It doesn't work like a pill, and the whole attempt to medicalize and limit categories, components, and levels of THC and CBD is destined to fail," assures Noy. "What's more, the ministry promised to remove the CBD (a component of cannabis) from the Dangerous Drugs Ordinance and release it to patients. In practice, this did not happen."

The feeling of missing out on the reform is also experienced by Orit Dubin, a pain patient treated with cannabis who joined the claims concerning the expensive prices. According to her, before the reform she would buy 80 grams for NIS 470 per month, and today, it is already NIS 2,000 per month. "I was injured in a car accident on the way to work," she says. "I have an orthopedic nerve injury with neurological pain, and I also developed fibromyalgia and post-trauma. After years of pain and pregnancies, my condition worsened, and today I am treated with medical cannabis, and this is my only way to relieve the pain."

According to her, the various reforms only complicated the process. "Life was much better without it," she states. "I also know many people who tried to renew their licenses and encountered difficulties with the health insurance funds. I also tried my luck, and in the end, I gave up and went the old and familiar way. I don't know how patients will manage. Unfortunately, fibromyalgia is considered half an invention; that's how I feel. No one understands what I pass through my body."

Dubin is also aware of the concern arising among cannabis patients following the reform, and she remembers that in the past, they did not renew her license and constantly asked for administrative extensions, which led to a delay of six months. 

"This is an abuse of a sick person. Now I have a prescription until the end of the year, but there aren't enough doctors in the health insurance funds, and it's a complete mess," she explains. "Therefore, I will have to look for appointments with specialist doctors 3-4 months in advance in the hope that I will have a doctor to see me until my current authorization expires. Everything goes through the funds; it is a lot of paperwork, the doctors, in my opinion, feel at a loss, and the solutions provided by the various institutes of the funds, according to my experience, are not working."

Dr. Silvio Brill, director of the pain management institute at the Ichilov Hospital in Tel Aviv, described the reform as an experiment and even used the professional term "pilot" at the expense of cannabis patients in Israel. "It is about trial and error. The reform is supposed to make it easier, but as far as the patients are concerned, I'm not sure it's any easier for them," explained Dr. Brill. "I don't know if it will be successful in six months. They will still need a specialist doctor and most of the HMOs don't really have any, so most people will still have to go to the hospitals, so it doesn't really make it easier."

"Until today, patients would receive a cannabis license at Ichilov, for example. The same patient would get a license and go and buy the cannabis, but now that person will still have to come to Ichilov and then get a letter of recommendation, go to the HMOs who are supposed to take care of it and start a procedure with them.

"I don't know if all the funds know how to do this. Brill continues. “I understand the difficulty of turning more than 100,000 patients into prescriptions overnight. That's why they decided on a small amount. The idea is not bad. Will it work? I don't know. Ultimately, the patients will be under HMOs instead of being treated under the Health Ministry. Cannabis is an auxiliary means, another treatment, and part of the overall treatment basket against disease, but it is not the main thing."

"A person who is dealing with mental health has to go through seven sections of hell to get a cannabis license," says a member of the Knesset Health Committee, Yesh Atid MK Yoran Levi. "Last December, the Health Ministry presented an official figure of 110 specialist doctors who are approved to issue medical cannabis and are responsible for treating about 140,000 patients a year, when in practice, according to the cannabis report booklet, there are only 63 managing doctors in total and there are also reports of less from this number.”

In addition, MK Levi claimed that the Health Ministry denied doctors the possibility of issuing prescriptions for medical cannabis if they issued too many permits to their patients.

Just last February, more than 3,000 patients, according to him, could not renew their licenses because there simply weren’t enough doctors. "On this issue, I submitted a request for discussion while recruiting more than a third of the health committee members. For an unknown reason, the committee refuses to convene on the issue. I believe that the bureaucracy should be eased for the victims of the battle, for the consumers of medical cannabis, and for every person who needs this medicine. In the coming months, the issue of mental health will reach many homes in the State of Israel; we must prepare for it in advance and make it easier from today; we must not wait," he warns.

Health Ministry responds 

The Health Ministry said in response, "The reform in the field of cannabis that came into effect on April 1 is an important and significant step in easing the life of medical cannabis patients and improving the quality of their medical care. The introduction of the reform did not change the way of obtaining prescriptions or licenses for cannabis, which are only given under public medicine. At the same time, after the reform comes into effect, it will be possible to receive a recommendation from a private doctor to be examined by the relevant authorities in the HMOs. Regarding the claim of post-trauma, as part of the implementation of the recommendations of the Boaz Lev Committee, the professional committee that examined the issue, and in light of the complexity of the transition from licenses to prescriptions, the full transition to prescriptions will be done in two stages After the full implementation of the current phase, the completion of the procedure will be examined in the labeling rule."

Regarding the rates, the ministry said: "Within the framework of the regulations, fixed rates have been set for deductibles that the HMOs may collect from patients, where the amount of the deductible for the issuance of a license for medical cannabis will be NIS 360 per year from the date the license is issued, as well as NIS 180 per year from the date the prescription for medical cannabis is given on the labels established in the regulations. 

These rates are significantly lower in comparison to private medicine, where, as mentioned, only a recommendation can be obtained and not a license. The Medical Cannabis Unit in the Health Ministry is in constant contact with the HMOs to identify whether there are barriers to implementing the reform and to ensure a quick and efficient transition of the patients to medical cannabis in the labels approved by the regulations.”

As for the low number of doctors, the Health Ministry said that "so far, the Medical Cannabis Unit” and others “have trained more than 400 doctors in the public service so that they can, within the framework of public medicine, issue a license for cannabis to patients who need it according to their medical condition. Naturally, the choice is up to the doctor whether to practice in this field or another. The Medical Cannabis Unit continues to work to train more doctors in this matter. Regarding the number of patients, it should be noted that the number of medical cannabis patients in the State of Israel in relation to the population is one of the highest in the world."