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Consultant psychiatrist Dr Derek Proudlove works with patients whose mental health histories can make prescribing decisions complex. He reflects on his route into cannabis-based medicine, his growing enthusiasm for the field and the tensions between patient choice and professional caution.

Dr Proudlove’s interest in cannabis-based medicine began by listening to patients. Hearing their experiences, then observing medical cannabis consultations, turned curiosity into a commitment to the field.

Today, he works full time in a medical cannabis clinic covering the Isle of Man, Jersey and Guernsey. A consultant psychiatrist whose experience covers the whole range of psychiatry, he has worked extensively with adolescents and has longstanding interests in trauma, dissociation and talking therapies.

Dr Proudlove is specifically interested in the issue of prescribing safely for patients with complex mental health histories, who may be considered high risk; and how we can balance the needs of the patient with the possible risks to the clinician.

From listening to patients to observing clinics

Dr Proudlove’s early awareness of cannabis came through his work with young people. “As a child and adolescent psychiatrist, I was aware that some of my older adolescent patients found cannabis beneficial. I thought that medicinal cannabis would be something interesting to investigate.”

A change in his professional circumstances gave him the opportunity to investigate further. In 2021, he resigned from the health service and began private practice.

“Sitting in clinics as an observer to begin with, I realised how effective cannabis is and saw the life-changing impact that it was having for many patients. This was very exciting.”

Those observations helped move cannabis-based medicine from an area of curiosity to a full-time focus for his work.

Initial concerns and a changing perspective

Dr Proudlove’s enthusiasm developed alongside stubborn questions shaped by his professional background and education in the field.  “I had concerns that cannabis might cause psychosis or schizophrenia, which is a widely held belief amongst mental health professionals.”

Reflecting on his experience since then, he says: “I have been surprised that side-effects are uncommon. I am getting used to seeing it changing lives for the better. I have become a strong advocate for medical cannabis and it is rewarding to see patients’ lives being transformed.”

Dr Proudlove has strong views about the combinations of conventional medicines some patients receive. Polypharmacy – the use of multiple medicines – is one of the issues he highlights when reflecting on the wider treatment experiences of patients entering cannabis clinics.

“In terms of conventional treatments and polypharmacy it is shocking to see the cocktails of antidepressants, antipsychotics, benzodiazepines, pregabalin etc, that patients end up on. This is similar for chronic pain patients.”

For some patients, improvements in symptoms may offer an opportunity to review and reduce other medicines under clinical supervision.

Learning from difficult professional encounters

Not all colleagues have welcomed Dr Proudlove’s involvement in the field.

Dr Proudlove describes encountering hostility in discussions, though he sees them positively. “These, sometimes unpleasant, interactions are good learning experiences and are reminders to be very clear about the rationale for prescribing and the risks. It also gives me things to reflect on in a peer group and for my appraisal.”

For Dr Proudlove, these encounters are part of the wider challenge of working in a field that he wants to see become more accepted and respected within medicine.

Dr Proudlove’s underlying views about patient care and patient choice have not changed. However, he believes cannabis-based medicine raises controversial questions about how those principles are applied, and he places particular value on the experience and knowledge patients bring to consultations.

“There is a strong emphasis on defensive practice, in this new field, which can prevent doctors from allowing patient choice. We must remember that there is more patient expertise here than in other areas of medicine, so patients should have more say in their own treatment, not less.”

Dr Proudlove also favours an individual approach to prescribing for people with complex mental health histories, taking account of their current circumstances as well as their past experiences. His interest lies in how clinicians can carefully assess risk while giving patients a meaningful voice in treatment decisions.

However, he identifies dependence and patterns of use as challenges. “Managing dependence on cannabis, overuse or misuse is a challenge. Especially while trying to give the patient choice and control over their own treatment.” This balance between managing cannabis use and supporting patient autonomy is one of the central challenges of his work.

Evidence, professional acceptance and listening

For Dr Proudlove, a major challenge is how cannabis-based medicine can become accepted and respected by the medical profession. He identifies the lack of randomised controlled trials (RCTs) as a barrier to doctors engaging with the field.

“The lack of RCTs is a barrier for doctors. How can we help them to understand the reasons for the lack of RCTs and the importance of real-world evidence?”

Dr Proudlove has also found it challenging when professional bodies take a position on cannabis-based medicine that he feels is unsupportive of its potential role in patient care. “I would suggest to doctors that they listen to their patients who are on medicinal cannabis.”

Dr Proudlove’s ambitions for the field include wider access through the NHS. His optimism also reflects his interest in cannabinoid receptors and their role in homeostasis, the regulation of the body’s internal balance.

“I am hopeful knowing that cannabinoid receptors are so abundant in the brain and body; and understanding the role they have in homeostasis, means that this will be a very important medicine in the future.”

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Dr Sheila Popert BDS Hons LRCP MRCS has been a Consultant in Palliative Medicine for more than 35 years, with a longstanding commitment to holistic, patient-centred care. Throughout her career, she has witnessed both the strengths and limitations of conventional treatments, as well as the unmet needs of people living with complex pain, psychological distress and reduced quality of life.

Today, she is Medical Director of Indra Clinic and Specialist Consultant at Emerald Health, and prescribes cannabis-based medicinal products (CBMPs) but her interest in cannabinoid medicines began several decades ago.

Early experiences in oncology and palliative care

Dr Popert was first introduced to cannabinoid medicines in the late 1980s while working as a lecturer in oncology at the Royal London Hospital. Some patients experiencing severe nausea and vomiting from cancer treatment were prescribed nabilone when conventional antiemetics had failed.

“What struck me was that, for certain patients, it worked remarkably well. Their vomiting improved sufficiently for them to continue cancer treatment that they might otherwise have had to stop.It certainly didn’t work for everyone, but when it did, the difference could be dramatic.”

More than a decade later, while working as a Consultant in Palliative Medicine and running a joint clinic with a neurologist, she saw some patients with multiple sclerosis and severe neuropathic pain respond extremely well to Sativex. In both settings, the medicines were not universally effective, but for some patients the improvement in symptoms and quality of life was significant.

“That was what initially interested me in the potential of cannabis-based medicines: not as a panacea, but as another potentially valuable therapeutic option when more conventional approaches have not provided sufficient relief.”

The prescription that became a turning point

The experience that prompted Dr Popert to investigate the field more seriously came during a home visit to a patient with advanced cancer. “We had been struggling to control the pain caused by a pancreatic tumour, and during the visit he told me that he had received a prescription for medical cannabis from a private clinic.”
Until then, Dr Popert had not appreciated that CBMPs could be prescribed in the UK beyond the medicines with which she was already familiar. “I asked to see his prescription and have to confess that, at the time, it looked like complete gobbledegook to me. I could make neither head nor tail of the different cannabinoids, concentrations and formulations. That was a real turning point. I thought that if my patients were being prescribed these medicines, I needed to understand them properly.”

She began researching the field in earnest, and the more she learned, the more interested she became.

From scepticism to understanding

Dr Popert is open about her initial reservations. The breadth of claims being made about cannabis caused her to wonder whether some of it was simply “snake oil”. She was also concerned about misuse, adverse effects and the risk of psychosis associated with THC. She decided to investigate the evidence, reading widely and completing courses from organisations in countries where medical cannabis had been prescribed for longer.

A further turning point came when she undertook the MCCS course led by Professor Mike Barnes and began to understand the endocannabinoid system and its role throughout the body. “That didn’t mean accepting every claim made for medical cannabis. I remain a clinician who wants to see good evidence, but it shifted my perspective considerably. What I had initially regarded with considerable scepticism became a fascinating and credible area of medicine that I felt deserved much greater attention.”

She was also conscious of the stigma surrounding cannabis and initially worried about what colleagues, friends and family might think. “I was slightly embarrassed to admit that this was an area of medicine I was seriously considering becoming involved in. For quite some time, I didn’t tell anyone that I was exploring it.” As her knowledge grew, she became more confident discussing CBMPs as a legitimate therapeutic option.

A complex and highly individualised treatment

One of Dr Popert’s biggest surprises has been the complexity of cannabis-based medicine. Before becoming involved, she had imagined that prescribing would be relatively straightforward and largely centred on THC and CBD.

“I now appreciate that THC and CBD are just two of the many phytocannabinoids found within the cannabis plant, and that the wider cannabinoid profile, together with terpenes and flavonoids, may also influence the effects of different preparations. Add to that the importance of formulation, route of administration, individual sensitivity, drug interactions and, above all, careful titration and monitoring, and it becomes a remarkably nuanced area of medicine.”

She has also been surprised by the difference treatment can make for some patients who have experienced persistent symptoms despite trying numerous conventional options. “It certainly does not work for everyone, and I remain cautious about overstating the evidence. But when it does work, the improvement can sometimes extend beyond a single symptom. A patient may sleep better, experience less pain or anxiety, and consequently function better and regain some quality of life.”

This reflects the holistic principles that have guided Dr Popert throughout her career: listening carefully to patients, understanding what matters to them and considering whether a treatment is helping them achieve meaningful outcomes. She has also long been concerned about polypharmacy. For some patients, improvements across symptoms such as pain, sleep and anxiety may create an opportunity to carefully review other medications. “I don’t see CBMPs as an alternative to conventional medicine, but as another potential tool within a broader therapeutic approach.”

Responsible prescribing and clinical curiosity

The most rewarding part of Dr Popert’s work has been seeing patients find relief from distressing symptoms, particularly when numerous conventional treatments have not provided sufficient benefit. “Seeing someone sleep better, experience less pain or anxiety, or simply regain some of their day-to-day quality of life is enormously rewarding.”

At the same time, responsible prescribing requires careful titration, monitoring and an individualised approach. “With CBMPs, as with any medicine, the aim is not simply to prescribe a product, but to find the lowest effective dose that provides meaningful benefit while minimising unwanted effects.”

Dr Popert believes that a basic understanding of CBMPs is becoming increasingly important across all clinical specialties. Even clinicians who do not intend to prescribe are increasingly likely to care for patients who use them. “So, I’d tell fellow clinicians – remain cautious, but be curious. You don’t have to become an advocate for medical cannabis – just learn enough to make an informed judgement for yourself.”

Moving towards mainstream medicine

Dr Popert is encouraged that more clinicians are approaching cannabis-based medicine with curiosity rather than immediately dismissing it. For her, education will be central to further progress. “I would love to see the endocannabinoid system and cannabis-based medicines incorporated into the undergraduate curriculum for doctors, nurses, pharmacists and other healthcare professionals.”

She also believes that medical cannabis must continue moving away from its recreational associations. One practical step would be to reconsider the names given to some medicinal cannabis products. “I can completely understand why a GP with little knowledge of CBMPs might raise an eyebrow on discovering that their patient has been prescribed something called ‘Wedding Pop Triangle’ or ‘Zookies’. Whatever the quality or therapeutic value of the product, the name immediately sounds recreational rather than medicinal.”

Looking ahead, Dr Popert believes greater education, better research and increasingly professional standards will help reduce stigma and build confidence. “My hope is that, in time, cannabis-based medicines will be judged in the same way as any other treatment: on the quality of the evidence, their safety and, most importantly, whether they provide meaningful benefit for the individual patient.”

Interested in learning more?

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Long before Dr Jennifer Forbes could prescribe medical cannabis, her patients were already teaching her about it.

While working in community addiction services, she began asking people more closely about their cannabis use. Many described using it to manage the physical and psychological effects of withdrawal, prompting her to consider its possible therapeutic role.

“Many reported it helped withdrawal symptoms such as muscle pains and sleep,” she says. “This interested me particularly as a possible aid to opiate reduction and an alternative to benzodiazepines.”

From general practice to addiction medicine

Dr Forbes did not set out to work in addiction medicine. After qualifying from the University of Dundee, she began training in anaesthetics before realising that general practice was a better fit. She also spent a year with a community mental health team in Melbourne, Australia.

Back in the UK, while working as a locum and raising her family, she took on some sessions at the Edinburgh Homeless Practice. She initially found the prospect daunting, but soon discovered how much she enjoyed the work. The experience changed the direction of her career, leading to 17 years in community addiction services, including time as a Clinical Lead.

Her work brought her into contact with people experiencing complex combinations of mental ill health, chronic pain, substance dependence and social disadvantage. It also gave her a perspective on cannabis that differs from that of many clinicians entering the field.

The change in the law prompted her to make medical cannabis part of her professional development plan. She began reading about the subject and asking patients more detailed questions about their experiences. “Many of my patients used cannabis, but I hadn’t thought of it as a possible treatment option until it became legal to prescribe in 2018,” she explains.

Her interest increased after she attended an educational event where experienced consultants shared their own prescribing experiences and the positive outcomes they had seen in patients. Their stories, together with what she learned about the safety profile of medical cannabis, convinced her that this was a credible area of medicine worth exploring further.

Balancing therapeutic potential with possible harm

Dr Forbes’ experience has made her acutely aware of the complexity surrounding cannabis use. From the outset, she had reservations. “I was concerned about prescribing cannabis flower and potentially promoting vaping, particularly given the issues for the younger population and my background and experience in addictions,” she says.

As an active prescriber, that concern now sits alongside the positive outcomes she hears from patients and informs how she thinks about risk, product choice and appropriate clinical boundaries. “The domination of inhaled products as opposed to oral products, and the recreational names, was certainly surprising,” she says.  “Patients have taught me a lot about different products, and I consider product type and potency as well as quantity for safe effective treatment.”

Her clinical background also helps her recognise situations that may require particularly careful conversations. “Hearing positive feedback from the majority of patients is incredibly rewarding,” she says, “but managing expectations of heavy cannabis users can be difficult, and discussing cannabis use disorder in the private virtual clinic setting can be particularly challenging.”

Finding a route into prescribing

Although Dr Forbes developed an interest in the field soon after the 2018 legal change, entering it professionally was not straightforward. “I was very disappointed to learn that as a GP I wouldn’t be able to initiate treatment and quickly discovered this was a significant barrier to gaining employment in the sector.”

Her experience in addiction-service leadership, together with professional connections in pain medicine, helped her secure a prescribing role in 2022.  Entering the sector also introduced Dr Forbes to the realities of working with fast-developing start-up clinics. Looking back, she says she wishes she had known more about “the financial risks associated with start-ups and the many ‘experts’ I would need to understand and learn from.”

Her early experiences taught her to look closely at a clinic’s culture, clinical governance and approach to risk. Her advice to clinicians interested in entering the sector is practical: “Research the clinics and approach one that aligns with your risk-management and patient-safety ideals.”

Dr Forbes is now a GP prescriber, co-founder of Borders Pain Clinic, Medical Director for an online clinic and an Executive Member of the Medical Cannabis Clinicians Society, bringing experience in addiction, mental health and chronic pain to the developing field.

Encouraging informed caution

Dr Forbes understands why many clinicians remain hesitant, pointing to the limited number of randomised controlled trials, uncertainty about how to assess real-world evidence, and understandable concerns about prescribing unlicensed controlled medicines.

She does not think clinicians should ignore those concerns. Instead, she says “I would encourage any interested clinicians to read around the subject and consider the safety profile of medical cannabis compared with many routine medications.”

Her approach is shaped by what patients tell her, but also by her experience of the risks. She believes it is possible to recognise the benefits of medical cannabis while remaining alert to potential problems, especially when chronic pain, dependence and heavy cannabis use overlap.

Looking ahead

What gives Dr Forbes the most hope is hearing from patients who feel treatment has made a difference. She believes these experiences will help more people understand medical cannabis and consider it as a treatment option. “I feel this would be helped by some form of legalisation and a move to prescribing more oral products that avoid the potential harms of vaping,” she says.

Her preferred direction for the sector reflects the balance that has defined her career: widening access to potentially helpful treatment while taking questions of dependence, delivery method and patient safety seriously.

Away from clinical work Dr Forbes is also an accomplished runner who has represented Scottish Masters athletics. 

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