Systematic Review of the Costs and Benefits of Prescribed Cannabis-Based Medicines for the Management of Chronic Illness: Lessons from Multiple Sclerosis

  • Samuel Herzog
  • Marian Shanahan
  • Peter Grimison
  • Anh Tran
  • Nicole Wong
  • Nicholas Lintzeris
  • John Simes
  • Martin Stockler
  • Rachael L. Morton
Systematic Review



Cannabis-based medicines (CBMs) may offer relief from symptoms of disease; however, their additional cost needs to be considered alongside their effectiveness. We sought to review the economic costs and benefits of prescribed CBMs in any chronic illness, and the frameworks used for their economic evaluation.


A systematic review of eight medical and economic databases, from inception to mid-December 2016, was undertaken. MeSH headings and text words relating to economic costs and benefits, and CBMs were combined. Study quality was assessed using relevant checklists and results were synthesised in narrative form.


Of 2514 identified records, ten studies met the eligibility criteria, all for the management of multiple sclerosis (MS). Six contained economic evaluations, four studies reported utility-based quality of life, and one was a willingness-to-pay study. Four of five industry-sponsored cost–utility analyses for MS spasticity reported nabiximols as being cost-effective from a European health system perspective. Incremental cost-effectiveness ratios per quality-adjusted life-year (QALY) gained for these five studies were £49,257 (UK); £10,891 (Wales); €11,214 (Germany); €4968 (Italy); and dominant (Spain). Nabiximols for the management of MS spasticity was not associated with statistically significant improvements in EQ-5D scores compared with standard care. Study quality was moderate overall, with limited inclusion of both relevant societal costs and discussions of potential bias.


Prescribed CBMs are a potentially cost-effective add-on treatment for MS spasticity; however, this evidence is uncertain. Further investment in randomised trials with in-built economic evaluations is warranted for a wider range of clinical indications.

Systematic review registration

PROSPERO Registration Number: CRD42014006370.

Supplementary material

40273_2017_565_MOESM1_ESM.docx (35 kb)
Supplementary material 1 (DOCX 35 kb)


  1. 1.
    Australian Medical Association. Green light for Medicinal Cannabis but AMA says proceed with caution. Australian Medicine. Accessed 3 Aug 2017.
  2. 2.
    U.S. Food and Drug Administration. Public Health Focus - FDA and Marijuana. Accessed on 3 Aug 2017.
  3. 3.
    Whiting PF, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313(24):2456–73.CrossRefPubMedGoogle Scholar
  4. 4.
    Amar MB. Cannabinoids in medicine: a review of their therapeutic potential. J Ethnopharmacol. 2006;105(1):1–25.CrossRefPubMedGoogle Scholar
  5. 5.
    Shiroiwa T, et al. International survey on willingness-to-pay (WTP) for one additional QALY gained: what is the threshold of cost effectiveness? Health Econ. 2010;19(4):422–37.CrossRefPubMedGoogle Scholar
  6. 6.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ryan M. Discrete choice experiments in health care. BMJ. 2004;328(7436):360–1.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Dolan P. Modeling valuations for EuroQol health states. Med Care. 1997;35(11):1095–108.CrossRefPubMedGoogle Scholar
  9. 9.
    Brazier JE, Usherwood T, Harper R, Thomas K. Deriving a preference-based single index measure for health from the SF-36. J Clin Epidemiol. 1998;51:1115–29.CrossRefPubMedGoogle Scholar
  10. 10.
    Feeny D, Furlong W, Torrance GW, Goldsmith CH, Zhu Z, DePauw S, et al. Multiattribute and single-attribute utility function: the Health utility index Mark 3 system. Med Care. 2002;40:113–28.CrossRefPubMedGoogle Scholar
  11. 11.
    Hawthorne G, Richardson J, Osborne R, McNeil H. The Australian Quality of Life (AQoL) Instrument: Initial Validation. Monash University Working Paper 66, 1997.Google Scholar
  12. 12.
    Torrance GW. Social preferences for health states: an empirical evaluation of three measurement techniques. Socio Econ Plan Sci. 1976;10:129–36.CrossRefGoogle Scholar
  13. 13.
    Torrance G. Measurement of health state utilities for economic appraisal. J Health Econ. 1986;5:1–30.CrossRefPubMedGoogle Scholar
  14. 14.
    Ofman JJ, Sullivan SD, Neumann PJ, Chiou CF, Henning JM, Wade SW, Hay JW. Examining the value and quality of health economic analyses: implications of utilizing the QHES. J Manag Care Pharm. 2003;9(1):53–61.PubMedGoogle Scholar
  15. 15.
    Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, Augustovski F, Briggs AH, Mauskopf J, Loder E. Consolidated health economic evaluation reporting standards (CHEERS)—explanation and elaboration: a report of the ISPOR health economic evaluation publication guidelines good reporting practices task force. Value Health. 2013;16(2):231–50.CrossRefPubMedGoogle Scholar
  16. 16.
    Slof J, Gras A. Sativex® in multiple sclerosis spasticity: a cost-effectiveness model. Expert Rev Pharmacoecon Outcomes Res. 2012;12(4):439–41.CrossRefPubMedGoogle Scholar
  17. 17.
    Slof J, Ruiz L, Vila C. Cost-effectiveness of Sativex in multiple sclerosis spasticity: new data and application to Italy. Expert Rev Pharmacoecon Outcomes Res. 2015;15(3):379–91.CrossRefPubMedGoogle Scholar
  18. 18.
    Lu L, Pearce H, Roome C, Shearer J, Lang IA, Stein K. Cost effectiveness of oromucosal cannabis-based medicine (Sativex®) for spasticity in multiple sclerosis. Pharmacoeconomics. 2012;30(12):1157–71.CrossRefPubMedGoogle Scholar
  19. 19.
    Gras A, Broughton J. A cost-effectiveness model for the use of a cannabis-derived oromucosal spray for the treatment of spasticity in multiple sclerosis. Expert Rev Pharmacoecon Outcomes Res. 2016;16(6):771–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Ball S, Vickery J, Hobart J, Wright D, Green C, Shearer J, Nunn A, Cano MG, MacManus D, Miller D, et al. The Cannabinoid Use in Progressive Inflammatory brain Disease (CUPID) trial: a randomised double-blind placebo-controlled parallel-group multicentre trial and economic evaluation of cannabinoids to slow progression in multiple sclerosis. Health Technol Assess (Winch, Engl). 2015;19(12):vii.Google Scholar
  21. 21.
    Novotna A, Mares J, Ratcliffe S, Novakova I, Vachova M, Zapletalova O, Gasperini C, Pozzilli C, Cefaro L, Comi G, et al. A randomized, double-blind, placebo-controlled, parallel-group, enriched-design study of nabiximols* (Sativex®), as add-on therapy, in subjects with refractory spasticity caused by multiple sclerosis. Eur J Neurol. 2011;18(9):1122–31.CrossRefPubMedGoogle Scholar
  22. 22.
    Collin C, et al. A double-blind, randomized, placebo-controlled, parallel-group study of Sativex, in subjects with symptoms of spasticity due to multiple sclerosis. Neurol Res. 2010;32(5):451–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Flachenecker P, Henze T, Zettl UK. Nabiximols (THC/CBD oromucosal spray, Sativex®) in clinical practice-results of a multicenter, non-interventional study (MOVE 2) in patients with multiple sclerosis spasticity. Eur Neurol. 2014;71(5–6):271–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Montalbán X, Wright S. Trial period for new symptomatic treatments: lessons learnt from a Sativex in MS spasticity clinical trial. Abstract #131. Mult Scler. 2009;15:S272.Google Scholar
  25. 25.
    Iskedjian M, et al. Willingness to pay for a treatment for pain in multiple sclerosis. Pharmacoeconomics. 2009;27(2):149–58.CrossRefPubMedGoogle Scholar
  26. 26.
    Stevenson V, et al. The high cost of spasticity in multiple sclerosis to individuals and society. Mult Scler J. 2015;21(12):1583–92.CrossRefGoogle Scholar
  27. 27.
    Okoli C, Pawlowski SD. The Delphi method as a research tool: an example, design considerations and applications. Inf Manag. 2004;42(1):15–29.CrossRefGoogle Scholar
  28. 28.
    The EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199–208.CrossRefGoogle Scholar
  29. 29.
    Rog DJ, et al. Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis. Neurology. 2005;65(6):812–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Arroyo R, Vila C, Clissold S. Retrospective observational study of the management of multiple sclerosis patients with resistant spasticity in Spain: the ‘5E’ study. Expert Rev Pharmacoecon Outcomes Res. 2011;11(2):205–13.CrossRefPubMedGoogle Scholar
  31. 31.
    Syed YY, McKeage K, Scott LJ. Delta-9-tetrahydrocannabinol/cannabidiol (Sativex®): a review of its use in patients with moderate to severe spasticity due to multiple sclerosis. Drugs. 2014;74(5):563–78.CrossRefPubMedGoogle Scholar
  32. 32.
    Dakin H. Review of studies mapping from quality of life or clinical measures to EQ-5D: an online database. Health Qual Life Outcomes. 2013;11(1):151.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Coast J, Smith R, Lorgelly P. Should the capability approach be applied in health economics? Health Econ. 2008;17(6):667–70.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Sydney Medical SchoolNHMRC Clinical Trials Centre, The University of SydneyCamperdownAustralia
  2. 2.National Drug and Alcohol Research CentreThe University of New South WalesSydneyAustralia
  3. 3.Chris O’Brien LifehouseCamperdownAustralia
  4. 4.Discipline of Addiction MedicineThe University of SydneyCamperdownAustralia
  5. 5.Drug and Alcohol ServicesSouth East Sydney Local Health DistrictKogarahAustralia
  6. 6.NHMRC Clinical Trials Centre, The University of SydneyCamperdownAustralia

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