A European survey found striking differences between countries in cannabis medicine availability, approval, and insurance coverage | Research

The takeaway

A survey of 31 European Pain Federation chapters found that THC/CBD oromucosal spray was approved for MS spasticity in 21 countries, but availability of other cannabis-based medicines varied dramatically, with only German and Israeli pain societies recommending them as third-line therapy for chronic pain.

European policymakers and regulators; pain medicine specialists; patients navigating cannabis medicine access across jurisdictions.

THC/CBD spray approved in 21 of 31 European countries, but only 2 pain societies recommend cannabis medicines

What the researchers found

The European Pain Federation (EFIC) surveyed its national chapters on the status of cannabis-based medicines for chronic pain and palliative care.

31 of 37 chapters responded, revealing large disparities:

THC/CBD oromucosal spray (Sativex) was approved for MS spasticity in 21 chapters. Plant-derived THC (dronabinol) was approved for palliative care in only 4 chapters. Synthetic THC (nabilone) was approved for chemo-related nausea in 4 chapters.

8 chapters had exceptional access programs and 6 had expanded access for medical cannabis.

Only the German and Israeli pain societies recommended cannabis-based medicines as third-line therapy for chronic pain. Conversely, the German medical association and Finnish experts did not recommend prescribing medical cannabis, citing insufficient evidence.

Cost coverage by insurance or state systems varied enormously across countries.

Why it matters

Patients with identical conditions receive vastly different access to cannabis-based medicines depending on which European country they live in. This patchwork of policies creates inequity and reflects the tension between patient demand, political pressure, and evidence requirements.

The numbers in context

31 of 37 EFIC chapters responded. THC/CBD spray approved in 21 chapters. Dronabinol approved in 4 chapters. Nabilone approved in 4 chapters. 8 chapters with exceptional access, 6 with expanded access programs.

How the study worked

Survey of European Pain Federation national chapter representatives (31 of 37 responded). Assessed approval status, access programs, cost coverage, and professional society positions on cannabis-based medicines.

What this study cannot tell us

Survey methodology with potential for incomplete or outdated responses. Rapidly evolving regulatory landscape means findings may not reflect current status. Did not assess actual prescribing rates or patient access beyond formal approval.

How to read the evidence

Moderate. Comprehensive survey of official chapter representatives, though subject to the limitations of self-report and rapidly changing policy landscapes.

When this study was published

Published in 2018. European cannabis medicine policy has continued to evolve, with several countries expanding access since this survey.

The bigger picture

The European situation mirrors the global inconsistency in cannabis medicine regulation. Even within a relatively integrated political framework (the EU), countries have taken dramatically different approaches based on differing interpretations of the same evidence base.

Questions still open

Will European countries converge on a common framework for cannabis-based medicines? Does the variation in access affect patient outcomes across borders? Would a common European Medicines Agency position accelerate or hinder access?

Common questions

Why do European countries differ so much on medical cannabis?

Each country has its own regulatory framework, evidence thresholds for drug approval, and political context. Some prioritize precaution and require robust clinical trial evidence, while others have created access pathways based on preliminary evidence and patient demand.

What is a third-line therapy?

Third-line means a treatment used after first-line (standard initial treatment) and second-line (alternative if first-line fails) options have been tried. Recommending cannabis as third-line for chronic pain means it should only be considered after two other treatment approaches have failed.

Read the original research

Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation.

European journal of pain (London, England), 22(3), 440-454

View on PubMed ↗Publisher’s paper ↗

Citation

Krcevski-Skvarc, N; Wells, C; Häuser, W. (2018). Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation.. European journal of pain (London, England), 22(3), 440-454. https://doi.org/10.1002/ejp.1147