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Cannabis Regulation in Germany – Opportunities and Side Effects for Switzerland

Cannabis Regulation in Germany – Opportunities and Side Effects for Switzerland

Interview with Peter Steger, President of IG MedCan and Member of the Board of the Swiss Society for Cannabis in Medicine (SGCM), on the impact of the new regulation of medical cannabis in Germany on the Swiss market.

1. Since August 1, 2022, patients in Switzerland have had access to medical cannabis as soon as the treating physician deems it necessary, without the need for an exemption from the Federal Office of Public Health (FOPH). How has the medical cannabis market in Switzerland developed over the past two years?

This opening of the market was initially linked to the hope that doctors would now be able to issue cannabis narcotics prescriptions more easily. In practice, however, it has become apparent that many doctors are still hesitant to issue such prescriptions. In particular, there are still extraordinary hurdles when prescribing cannabis medicines compared to other prescriptions:

A) the patient wants a therapy (with cannabis medicine) about which the doctor usually has little knowledge.

B) He/she must issue a magistral prescription. A process that is rather foreign to the medical profession and is accompanied by additional uncertainty.

C) The medical profession must keep an entry in the Narcotics Register regarding the dispensing and provide the Federal Office of Public Health with data in each individual case.

D) The medical profession must also take care of the reimbursement by the health insurance company, as the patient cannot do this alone.

E) Since cannabis medicinal products are rarely finished medicinal products that doctors could sell themselves, they also miss out on the opportunity to generate revenue through the sale of the product, after all the effort shown above. 

Overall, the medical cannabis market in Switzerland remains in a transitional phase in which the potential has not yet been fully exploited, in particular due to the ongoing reluctance of doctors to prescribe. The ongoing reluctance of doctors, triggered by the reasons outlined above, meant that the abolition of the exemption permit alone had no significant impact on the number of prescriptions in Switzerland. The Swiss domestic market for medical cannabis was hardly able to record any significant gains during this phase. Sales remained low and expectations regarding price developments were not fulfilled to the extent hoped for.

2. In Germany, the prescription of medical cannabis has been established since 2017. As of April 1, 2024, a narcotic prescription will no longer be required to prescribe cannabis in Germany and medical cannabis will no longer be regulated by the Narcotics Act. Instead, cannabis for medical purposes falls under the newly created MedCanG. What is your opinion on this new legal classification of cannabis? Has Germany taken on a global leadership role with the new regulation?

Yes and no. Germany has certainly taken on a leading role, but this should not necessarily serve as a model for Switzerland. There are too many unanswered questions. Switzerland can do better. The cultivation clubs and the controls on the personal possession of cannabis are not clearly regulated and this brings risks on many levels. We are in a transition phase in Germany. At the moment this is temporarily helping the medical sector, but that could soon turn 180 degrees. Basically, little has been done in Germany to meaningfully differentiate the medical market from the recreational market in terms of product. Only the currently quite high reimbursement rate through health insurance companies is a positive sign for patients, although this is precisely what can of course be exploited by recreational users, with a boomerang effect for patients in the end. 

Due to the new legal structure, there is currently some strange confusion in cross-border traffic. For example, we cannot currently have hemp seed oil (food) analyzed in Germany because it has somehow been linked to the Medical Cannabis Act. The exact reasons are unclear. 

3. In a current one decision The Federal Joint Committee (DE) stated that certain groups of doctors can now prescribe cannabis without the need for approval from the health insurance company. How do you classify this decision?

The circle of doctors who can prescribe without a permit has been drawn quite broadly. That is positive. In addition, there is a lot of trust in family doctors. It is also astonishing how this was pushed through by the strong opposing lobbies. The German Medical Association and the National Association of Statutory Health Insurance Physicians were against it. You also have to know the German system. Telemedicine practitioners are not contracted doctors and therefore cannot simply prescribe on the health insurance system. But it is very astonishing that drugs for which there are no specific clinical studies are reimbursed so easily by the health insurance companies. The health insurance company can still refuse in individual cases, even after the G-BA decision, but this is still a fairly revolutionary step for the medical cannabis industry. Unfortunately, this is hardly imaginable in our health insurance system in Switzerland.

However, doctors in Germany are generally afraid of claims for reimbursement from health insurance companies (something we fortunately do not have in Switzerland). The reimbursement system in Germany is a sharp sword. Basic training for doctors on the subject of cannabis would be a good option to give doctors a head start in terms of knowledge, which could take away their fear of reimbursement. 

The Czech Republic has introduced a short special training course for prescribing cannabis and only doctors who have completed the training can prescribe it through health insurance. There, the reimbursement rate is over 90%.

4. Since medical cannabis can be prescribed on a private prescription in Germany, the Sales increased significantlyIn addition, the prices for medical cannabis have fallen sharply in recent years and are now at the same level as the prices of black market cannabis and sometimes even darunterWhen will medicinal flowers be available in Switzerland for less than 10 francs per gram? 

Today, a few thousand patients have a product that is prescribed to them. If this changes and there are significantly more prescriptions, the tipping point will quickly be reached where prices will fall. The processes of the GMP producers are getting better and better and the long supply chains and the middlemen are currently having an impact on the high prices. Prices are already falling and will continue to fall. 

5. Are Swiss products competitive?

Thanks to high production standards, innovative strength, growing expertise and strategic location, we are absolutely competitive internationally and will become even more competitive in the future through further optimization.

6. The media reports that certain companies are apparently abusing the new liberal regulation and aggressively marketing medical cannabis. The focus of the debate is primarily on telemedical prescription of cannabis and prescription via email prescription (Süddeutsche / TAZ / n-tv). Is access to medical cannabis in Germany too low-threshold? 

Telemedicine in connection with the prescription of what is known in Switzerland as formula medicines (this category basically includes all cannabis medicines except Sativex and Epidyolex) is tricky. In general, the tendency to not see a doctor or pharmacist in person and to start treatment on this basis is tricky. The fact that formula medicines are being distributed on a large scale in this way is disturbing the pharmaceutical industry. It is watching this with a keen eye. Normally you can assume that “the empire strikes back” - such scams have a limited lifespan. It is not necessarily politics that will change the laws again if too many abuses occur. The pharmaceutical industry will make its presence felt here and become active with its lobby. So the system should not be overstretched. Unfortunately, I see clear tendencies in this regard in Germany.

In Switzerland, the interaction between mail order and telemedicine is fortunately not yet so well established. There are various reasons for this and the SGCM is happy that this is the case. If there is no personal contact between doctor and patient, the prescription of cannabis carries a significant risk of abuse and the success of the therapy is at risk. Any therapy is only as good as the timing of taking the right dose. This recognized scientific fact is all the more important for cannabis therapy.

7. The Endlich campaign by Four20 Pharma has caused quite a stir. What do you think about the accusation of hidden drug advertising (see article by FAZ)? 

The radical view is as follows: In Switzerland there is a Landmark judgment on the subject of migraines and “triptans”, which had classified a similar approach as indirect advertising. Product-related advertising for prescription drugs is illegal. This is where the campaign is pushing the boundaries. However, certain statements in the campaign are cleverly chosen and, in my opinion, work.

8. Do reputable providers of medical cannabis ultimately lose out because they abide by the rules?   

Yes, from my point of view you can see it that way. On the other hand, the reputable providers who have done their milk book calculations correctly will also have more staying power. So you don't have to look at it so critically.

9. The licensing process for producers was made much easier with the introduction of the Medical Cannabis Act. Licenses were issued for a «unlimited production» What chances do Swiss producers of medical cannabis have on the German market?

That's difficult to say. My impression is that there are now many growers and manufacturers. So can a Swiss producer keep up on the German market due to its quality and reliability? In principle, I think so. Especially if it does its "calculations" correctly. Many manufacturers were very optimistic about the first boom, and it will be difficult for them. Anyone who calculates realistically and has a lot of perseverance will definitely have a chance on the German market too.

10. What needs to be improved in Switzerland to ensure that patients have adequate access to cannabis therapy?

The hurdles for doctors described in question 1 must be removed. In addition, we need to work with health insurance companies to come up with a system that will allow soft factors such as general well-being and "tolerability" of the patient for their relatives, as well as possible reductions in other medications with side effects and financial relief from the health insurance companies in this regard, to be taken into account even more, or how such factors can override the lack of clinical trials. This is one of my main tasks in connection with my work at the SGCM and the IG MedCann. If we can make it easier for patients to get reimbursement, then we will also have the leverage to separate the medical market from a future leisure market and have enough motivating factors so that patients remain under the care of the doctor and obtain the appropriate quality medication from the pharmacy.

Peter Steger is a member of the board of the Swiss Society for Cannabis in Medicine (SGCM), where he is heavily involved in politics and advocates for the interests of patients and the implementation of standards in the research, production and use of medical cannabis. He is also president of IG MedCan, which was founded in 2018 by Swiss manufacturers of cannabis medicines and is committed to a safe and sustainable market for medical cannabis in Switzerland.

Media reports on the topic of medical cannabis:

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