Tasmanian woman Jodie Palmer lives with chronic pain she says keeps her awake and crying most nights. For more than a year the single mother, who is also the full-time carer for a daughter with special needs, has been waiting for a specialist appointment in Hobart to treat a slipped disc in her back.
But with no reprise in sight, and after suffering the side effects of pain medication prescribed by her GP, she decided to go down an "alternative" route. For the past 12 months she has been treating her chronic pain with cannabidiol oil she gets through a Cannabis Doctors Australia clinic in Queensland.
CDA is an authorised prescriber of medical cannabis under the Therapeutic Goods Administration, operating medical cannabis access clinics across the country. For Ms Palmer, CBD is not a cure, but it makes a big difference.
"I am constantly in pain, but there is not much I can can do about it," she said.
"Night time is 10-times worse for me. I lay in bed sometimes and I just cry - that is what I feel like doing. Sometimes I feel like I need to ring an ambulance, but I haven't because I know there are people worse off than me.
"When I've had my oil of a night, because I have a lot of anxiety too because of the pain I am in, it relaxes me and it relaxes my mind. I don't think about the pain as much. I am still awake a lot of the night with pain, but being on that oil is so much better than not being on the oil."
Despite the experiences of people like Ms Palmer, there is currently limited scientific evidence that medicinal cannabis is effective in combating chronic pain.
Last week the TGA approved its 100,000th cannabinoid script. However, Australia's peak pain body has hit back with claims there is not enough evidence to support the use of medicinal cannabis products for patients with chronic pain.
The Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists has instead urged GPs not to prescribe available cannabinoid products to treat chronic non-cancer pain, unless it is part of a registered clinical trial.
In a statement, ANZCA Dean Associate Professor Mick Vagg said available medical cannabis products were "not even close" to showing they deserve a place in the management of complex patients experiencing ongoing pain.
"Until there are results from high-quality, unbiased clinical trials which establish the effectiveness and safety of medicinal cannabis in treating chronic pain the Faculty of Pain Medicine does not believe cannabinoid products should be prescribed," Dr Vagg said. "This is a fundamental requirement for any treatment undertaken by our specialists."
Dr Vagg said the most common reason for the use of medicinal cannabis in Australia was to treat chronic pain - something that impacts one in five people. However, he said there was a critical lack of evidence that it provides "a consistent benefit for any type of chronic non-cancer pain, especially compared to the treatments we already strive to provide in pain clinics".
"The research available is either unsupportive of using cannabinoid products in chronic non-cancer pain or is of such low quality that no valid scientific conclusion can be drawn," he said.
"Cannabidiol-only formulations have never been the subject of a published randomised controlled trial for chronic pain treatment, yet they are the most commonly prescribed type of cannabis product."
ANZA's position has been supported by the International Association for the Study of Pain. It is also in line with the latest position statement from the Royal Australian College of General Practitioners, which calls for "further high-quality research into the safety and effectiveness of medicinal cannabis products, as the current evidence is limited and inconclusive".
The medicinal use and supply of cannabis and cannabinoids was decriminalised in Australia in 2016.
However, because medicinal cannabis products are considered unapproved drugs in Australia, they can only be accessed through the TGA's Special Access Scheme or Authorised Prescriber Scheme.
From February 1, Australians have also been legally allowed to access low-dose cannabis oil from pharmacies without a prescription, after the TGA approved its over-the-counter sale. However, while the laws have been changed so you can buy CBD oil pharmacies, there are currently no products approved for sale - something not expected to change for at least a year.
An unregistered product has not been tested by the TGA to meet safety, quality and effectiveness standards. Almost 200 cannabis products are available by prescription via the TGA's special access application scheme.
To date, Tasmania is the only jurisdiction in Australia where GPs can not prescribe medicinal cannabis to patients. Instead, they can only get legal access though a medical specialist - like a neurologist. However, from July 1 this is set to change with the state adopting the national streamlined online application pathway and 48 hour authorisation timeframe - building on the existing Controlled Access Scheme.
In announcing the changes, Health Minister Sarah Courtney said it would increase access and authorise Tasmanian GPs to prescribe medicinal cannabis products. Community pharmacies will also be able to dispense the products - something previously only available through Tasmanian Health Service pharmacies, at a subsidised rate by the state government.
Despite the state government's push to bring Tasmania in line with the rest of Australia when it comes to medicinal cannabis, concerns remain. Mainly, around the associated costs.
As it is medicinal cannabis products are not subsidised under the federal government's Pharmaceutical Benefits Scheme. It means patients will need to fund the cost of treatment themselves, with the amount varying depending on the product prescribed by a doctor.
For Ms Palmer, this equates to $229 for one 30 millimetre bottle of CBD - enough to last her a month, with additional capsules costing a further $149. Quarterly telehealth appointments to continue her prescription also cost $59. But she said this needs to change.
"The cost is what is holding me back from using more - at the moment I scrape by on the bare minimum. But if it is helping people, why shouldn't it be subsidised," she said.
"I have had a lot friends ask me about it, but I think they might be scared to take that step, in case they are judged. I was too to start with, but I don't care now because I'd sooner be on this than the prescription medication. Yes it's expensive and I am struggling to find the money to be on it, but it is helping me."
Associated costs was something examined by a Senate Inquiry into the barriers to patient access to medicinal cannabis in Australia.
The committee recommended that until medicinal cannabis products are subsidised through the PBS, the government should investigate the establishment of a Commonwealth Compassionate Access Subsidy Scheme for medicinal cannabis, as well as encouraging states and territories to expand the provision of their own Compassionate Access Schemes. In its response to the inquiry, released early this month, the government noted but did not accept the recommendation, saying it did not support the establishment of a subsidy scheme for medicinal cannabis.
"The government maintains that the most sustainable approach for potential Commonwealth subsidy of medicinal cannabis products is consideration by the independent Pharmaceutical Benefits Advisory Committee of products that have received regulatory approval by the TGA."
Its said the PBS was not designed for unapproved therapeutic goods, while a new medicine cannot be listed on the PBS unless the PBAC makes a recommendation in favour of listing.
"The PBAC's consideration against its statutory obligations needs to be informed by evidence about the clinical effectiveness and safety of the medicine when compared with alternative available treatments."
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