For specialist clinicians, pharmacists, clinic managers and specialist nurses. This post sets out the clinical contexts in which cannabis-based products for medicinal use (CBPMs) are most frequently considered in UK practice. It is an overview of where CBPMs are considered, not a recommendation to prescribe in any individual case. Prescribing decisions remain the responsibility of the initiating specialist, who must be on the GMC Specialist Register, and must follow the framework set out in the Misuse of Drugs Regulations 2001 (as amended 1 November 2018).
The two-track reality of UK CBPM prescribing
Since CBPMs were rescheduled to Schedule 2 in 2018, two distinct prescribing environments have emerged. The first is the NHS pathway, which is narrow, cautious and shaped by NICE NG144. The second is the private specialist pathway, which has grown rapidly and which generates the large majority of UK CBPM prescriptions. Clinicians weighing referral or initiation need to understand both, because the indications, the evidence base and the patient expectations differ between them.
NHS England has been explicit that unlicensed CBPMs should be considered only where there is published evidence of benefit, the patient has a special clinical need that cannot be met by a licensed medicine, and the prescription is initiated by a specialist on the GMC Specialist Register. The bar is high, deliberately so. For the broader pathway context, see our earlier overview of prescribing CBPMs on the UK specialist pathway.
The four NICE-recognised areas under NG144
NICE NG144, published in November 2019 and last updated in March 2021, addresses four clinical areas. The guideline does not endorse routine CBPM prescribing across all four; in several it actively declines to recommend.
Intractable chemotherapy-induced nausea and vomiting (CINV)
NG144 recommends consideration of nabilone as an add-on treatment for adults with chemotherapy-induced nausea and vomiting that has not been adequately controlled by optimised conventional antiemetics. The product is a licensed synthetic cannabinoid rather than a plant-derived CBPM, which keeps this recommendation inside familiar medicines-governance territory. The Royal College of Physicians position statement (PS05/19) similarly notes there is reasonable evidence in CINV but flags the side-effect profile and the availability of more efficacious modern antiemetics, recommending cannabinoids only where standard therapies have failed.
Spasticity in multiple sclerosis
NG144 recommends a four-week trial of THC:CBD spray (nabiximols, Sativex) for adults with moderate to severe spasticity from multiple sclerosis where other pharmacological treatments have not provided adequate benefit. Sativex is a licensed product, prescribed by neurology or rehabilitation specialists, and is the most commonly used cannabinoid in NHS practice. It is the clearest example of where the licensed-medicine route and the CBPM framework intersect.
Severe treatment-resistant epilepsy
For Dravet syndrome and Lennox-Gastaut syndrome, plant-derived purified cannabidiol (Epidyolex) as add-on therapy to clobazam has a NICE technology appraisal and is available on the NHS in specialist paediatric and adult epilepsy centres. NG144 makes no positive recommendation for whole-plant CBPMs in epilepsy outside that pathway, citing limited high-quality evidence.
The picture is shifting. Two national NHS-funded clinical trials investigating CBD-only and CBD-plus-THC formulations in drug-resistant epilepsy in adults and children launched through 2025 under NIHR funding and University College London sponsorship, following long-standing campaigning by paediatric neurology and patient groups. Specialists in this area should expect the evidence base to mature meaningfully over the next two to three years.
Chronic pain
NG144 does not recommend offering CBPMs to manage chronic pain in adults outside a clinical trial. The economic and clinical case in the guideline was that benefits appeared small, costs high, and the evidence base inadequate. The British Pain Society position statement aligns with this view: it supports prescribing only within clinical trials or a national registry, and requires a multidisciplinary biopsychosocial assessment before any therapeutic trial is considered. Despite this, chronic pain is by some margin the most common reason patients are referred to private CBPM clinics in the UK, which is the central tension in the current landscape.
Where private specialist practice is most active
Outside the NHS pathway, CBPMs are prescribed under the unlicensed-special framework by GMC-registered specialists across a wider range of indications. The composition of this caseload has been documented by Drug Science’s Project Twenty21 (T21), which ran from August 2020 to the end of 2024 and was the UK’s largest non-profit CBPM patient registry. Published T21 data from over 2,800 enrolled patients showed the most prevalent primary conditions were chronic pain (around 52%), anxiety disorders (around 32%), and post-traumatic stress disorder (around 6%), with the remainder spread across sleep disorders, fibromyalgia, ADHD, autism-related symptoms, palliative care and others.
These figures describe where private prescribing is most active. They do not constitute clinical endorsement of CBPMs for any of those conditions. The T21 outputs published in peer-reviewed journals report observational, registry-grade signals — for example, statistically significant improvements in self-reported health on the EQ-5D-5L at three months and reductions in opioid use among chronic pain patients — not the randomised controlled evidence that NICE or the British Pain Society are seeking.
Chronic pain (private pathway)
The largest indication by volume. Typical referrals are patients with neuropathic, mixed, fibromyalgia-type or post-surgical chronic pain who have failed multiple lines of conventional analgesia, including weak and strong opioids, gabapentinoids, tricyclic and SNRI antidepressants, and interventional approaches. Specialists undertaking these consultations are generally pain medicine, anaesthetics or palliative care consultants.
Anxiety and PTSD
The second-largest registry indication. Referrals are typically driven by partial or non-response to SSRIs/SNRIs, intolerance of benzodiazepines, or PTSD that has not responded adequately to trauma-focused psychological therapies. Initiating specialists are general adult psychiatrists or specialists in trauma and addictions psychiatry. Clinicians considering this referral should weigh the cautions in the Royal College of Psychiatrists position statement, particularly regarding personal or family history of psychotic illness and the importance of mental-health monitoring.
Sleep disorders
Often co-morbid with chronic pain or anxiety, sleep complaints make up a meaningful share of the private caseload. Evidence is largely observational, and the boundary between primary indication and symptomatic benefit from a CBPM prescribed for another reason is frequently blurred.
Palliative care
A smaller but clinically coherent group. Palliative-care specialists may consider CBPMs where conventional approaches to pain, appetite, nausea, anxiety and sleep have been combined and exhausted. The evidence is mostly extrapolated from CINV and chronic-pain literature rather than palliative-specific RCTs.
Less common but documented indications
Endometriosis-associated pain, treatment-resistant Tourette syndrome, autism-related sensory and behavioural symptoms in selected paediatric and adult cases, and inflammatory bowel disease symptom-control referrals appear in the published registry data. Specialists working in these areas will recognise these as third- or fourth-line considerations after established pathways.
What the evidence base actually looks like
Across these indications the evidence ranges from moderate (Sativex in MS spasticity, Epidyolex in Dravet and Lennox-Gastaut) to low-quality observational (most chronic pain, anxiety, PTSD, sleep, palliative). Clinicians should be explicit with patients and referring colleagues about which category any given indication falls into.
The British Pain Society’s position remains that there is no positive evidence to support the routine use of cannabinoids in pain management, and that any therapeutic trial should only follow a multidisciplinary biopsychosocial assessment after established treatments have failed.
NICE has signalled it intends to keep NG144 under review as the evidence base develops, particularly through the NHS England registry and the NIHR-funded epilepsy trials. RCP guidance similarly calls for a compulsory, independent, fully funded national database to mature the evidence picture.
Practical implications for specialists weighing referral
- Confirm the failed prior pathway. Whether the destination is the NHS or a private specialist clinic, the case for considering an unlicensed CBPM rests on having exhausted licensed alternatives at appropriate doses and duration.
- Document the rationale clearly. The unlicensed-special framework requires the prescriber to justify the special clinical need. Vague documentation undermines both governance and any future shared-care arrangement.
- Be explicit with patients about the evidence category. A patient referred for MS spasticity is being offered something with a NICE recommendation and a licensed product. A patient referred for chronic pain is not. Both can be legitimate clinical decisions; conflating them is not.
- Map the supply route in advance. The unlicensed-import logistics are non-trivial. See our earlier coverage of CBPM supply chain considerations for the wholesale and continuity issues that shape what is actually available.
- Consider where the patient will be reviewed. Active CBPM management requires structured follow-up; we cover monitoring and titration cadence in a forthcoming piece.
Where this is heading
The likely direction of UK CBPM practice over the next two to three years is convergence rather than expansion. The NHS England long-read on CBPMs, the NIHR epilepsy trials, the closure of T21 and the gradual transition of registry activity onto NHS-aligned infrastructure all point towards a more disciplined evidence environment. For specialists, the practical question shifts from “is this indication on the list?” to “is this individual patient appropriate, and is the clinical and governance documentation strong enough to defend the decision?”.
For the wider European context shaping product availability and regulatory direction, see our piece on the European medical cannabis landscape in 2026.
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