Drugs

As Canadian Weed Companies Ramp Up in Germany, Patients Suffer

Germany has the largest medical weed market outside North America. But its regulations are a nightmare for many patients to navigate.

by Manisha Krishnan
Nov 7 2019, 5:03pm

Germany is the largest medical cannabis market outside of North America. John Macdougall/AFP via Getty Images)

Julia Langwieder spent years wanting to die.

She revealed this matter-of-factly sitting barefoot in a meeting room in at Berliner Aids-Hilfe, an HIV outreach organization. On this stormy Friday night in Berlin, however, the space was being used by a group of Germans who are either looking to become medical cannabis patients or are already in the system. It was a chance for them to trade horror stories and give each other advice on things like which doctors are open to cannabis as a treatment, and how to get insurance coverage.

While evidence on the efficacy of cannabis for psychological disorders is scarce, Langwieder, 23, credits weed with saving her life.

Dressed in black fisherman’s pants, a loose green linen shirt, with a choker and two crystals hanging around her neck, she listed the psychiatric conditions she’s been diagnosed with: borderline personality disorder, post-traumatic stress disorder, bipolar disorder. She suspects she also has attention deficit hyperactivity disorder. Her symptoms include severe panic attacks that at times leave her immobilized and suicidal.

“I used to sit on my sofa eating white, untoasted bread because I couldn't get up to do anything else,” she said.

Even after taking numerous pharmaceutical drugs, including anti-psychotics and benzos like Xanax, “I still had the same panic attacks, I still wanted to kill myself almost every day.”

But that all changed when Langwieder started smoking weed regularly after attending a music festival abroad a couple years ago.

“I smoked every day for the first time in my life,” said Langwieder. “I had none of the symptoms, not a single panic attack. I didn’t try to harm myself.”

When she got back to Germany, however, she couldn’t find a doctor to write her a prescription.

Langwieder comes from the town of Traunstein, in Bavaria, where cannabis is scarce and treated like a serious drug by law enforcement. She said her doctor and therapist both dropped her, assuming she was just looking to get high, even though she was demonstrably doing better—her hospital visits and suicide attempts were down and she started working again.

“They wouldn't believe me. They thought I just wanted cannabis as a drug.”

•••

Germany has the largest medical cannabis market outside of North America. And the only weed that can legally be sold there is imported from the Netherlands or Canada.

Because of that, big Canadian weed companies including Aphria, Aurora, Canopy, and Tilray have been ramping up their presence there, through exporting deals, acquisitions of wholesalers and distributors, and the construction of new legal grows. The goal is not only to expand in Germany, but to other European Union countries where weed is legal.

From a business standpoint, it’s being portrayed as a good news story. In May 2017, Aurora acquired European medical weed wholesaler Pedianos. In a press release issued at the time, Patrick Hoffmann, co-founder of Pedanios, said, “Canada and Germany are among the world leaders in medical cannabis, and as trailblazers in our respective countries, Pedanios and Aurora are well positioned to continue to drive innovation, expand our distribution network, and capture significant global market share.”

But on the ground, patients and cannabis advocates told VICE a story of failing public policy. They said that Germany’s medical weed regime is confusing, difficult to access, and that cannabis is still heavily stigmatized, with not enough buy-in or expertise from doctors, and arbitrary coverage denials from insurance companies. Those who have to pay out of pocket said the weed is overpriced and often lacking in quality, if it’s available at all. As a result, some have turned to the black market or illegal growing.

Germany legalized medical cannabis in 2017, with the government acting in response to several Supreme Court decisions. Unlike in other countries, cannabis has been folded into the health insurance program; the country has both private and public health insurance, and most of the 82 million citizens are covered.

However the criteria to get a prescription is strict—the patient must be suffering from a “severe” condition; they need to prove that no other approved medication can treat them; and there needs to be at least a small chance that cannabis can help. It’s a lot of paperwork for doctors, many of whom are already reluctant to prescribe weed because of the lack of research.

“Politicians decided that cannabis is an approved therapy but nobody told the doctors."

The term “severe” isn’t defined. Technically migraines could count, and patients with cancer can be excluded if there are other treatments. Pain patients are required to take opioids before they can hope for a cannabis script.

Langwieder eventually found a doctor who would prescribe her cannabis. But in Germany, where most prescription drugs are covered by insurance, there are exceptional obstacles to getting coverage for medical weed. Even if the conditions warranting a prescription are met, about one-third of patients are rejected by insurers—a practice that doesn’t occur with other drugs.

Julia
Julia Langwieder said her doctor and therapist both dropped her over cannabis. Photo by the author

As a result, Langwieder doesn’t qualify. She has tried paying out of pocket for cannabis from the pharmacy, but the cost is so prohibitive (she would need to spend 450 euros, or $650, a month) that she turned to growing to supply herself.

Nonetheless, the demand for medical weed in Germany is increasing quickly.

There are an estimated 65,000 medical cannabis patients in the country, up from 40,000 in 2018. Prior to medical legalization in 2017, only 1,000 patients were able to get cannabis with a special permit.

Research firm Prohibition Partners expects the patient base to grow to 1 million by 2024, and the medical market to be worth $11 billion by 2028.

The fact that cannabis is covered by insurance, makes Germany particularly appealing to producers. (Canada has more than 330,000 medical cannabis patients, most of whom pay out of pocket.) In order to address the demand, in March the German government allowed three companies to grow cannabis domestically: Canadian licensed producers Aphria and Aurora, and Germany’s Demecann, which is partly owned by Canadian producer Wayland Group.

“Nobody did this before, so we all started from zero,” said Hendrik Knopp, managing director of Aphria Germany, from his Hamburg office, which features walls painted with green and gold weed leaves.

Knopp, whose career has spanned law, telecommunication, online games, and self-driving cars, leads a team of 10 employees at Aphria’s Hamburg office; around 50 people will staff the growing facility.

Both Aphria and Aurora will produce at least 1,000 kg of weed per year. But Knopp acknowledges it’s not enough. Aphria’s German grow, which Knopp describes as a “vault” will have the capacity to produce more than the legal limit, should it increase in the future.

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Hendrik Knopp is managing director of Aphria Germany. Photo supplied

“Already the amount of medical cannabis needed in Germany is much higher than what the tender authority actually was looking for,” he said.

And the price is prohibitive. Under the current system, by the time weed makes its way from Canada or the Netherlands to a German pharmacy, it often costs 20 to 25 euros ($29-$36) per gram—up to seven times more than what Canadian patients pay.

Several patients told VICE the Canadian weed they’ve purchased isn’t worth the price.

Stefan Konikowski, 56, an HIV-positive man who is in the same cannabis peer group as Langwieder, said one particularly bad batch he got from the pharmacy tasted “like cellar.”

“No one can smoke this,” said Konikowski, who has been fighting for insurance coverage but hasn’t heard back in a year. “When I go to a dealer, if I got something like this, I’d kill him.” Another patient, who has turned to illegal growing, said “we are getting the trash which isn’t able to sell on the recreational market in Canada.” Others complained of mislabelled strains, or good ones that never reappeared in stock.

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Stefan Konikowski is HIV positive but can't get insurance coverage for cannabis. Photo by author

Cam Battley, chief corporate officer for Aurora, said he’s heard the opposite about the licensed producer’s weed. “The quality of our product is very high,” he said, noting that other than a brief hiccup, there have been no issues with delivering product on time.

Aphria’s products aren’t sold in German pharmacies right now. In January of this year, the company acquired CC Pharma, a pharmaceutical distributor that supplies more than 13,000 pharmacies in Europe. The move resulted in Aphria posting its first profitable quarter since weed became legal in Canada.

As the company positions itself to become a major player in Germany, Knopp said one of the main challenges is ignorance within the medical community.

“Politicians decided that cannabis is an approved therapy but nobody told the doctors,” he said. “When you talk to the doctors, they don’t even know the difference between THC and CBD.”

By the time weed makes its way from Canada or the Netherlands to a German pharmacy, it costs up to seven times more than what Canadian patients pay.

Prior to joining Aphria as medical director in 2018, Jan Witte specialized in oncology, working in a hospital in Berlin.

Witte had positive results with cancer patients and cannabis early in his career, but for a long time he didn’t follow up with it. He started working at Aphria in part because he wants to improve the medical cannabis system in Germany.

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Aphria's German growing facility is being constructed. Photo supplied

“There is a lot of skepticism from the medical community,” he said from the Berlin WeWork office where he’s based. “Most prescriptions in Germany are done by very few cannabis specialized doctors.”

Langwieder’s friend Lisa Hess has made the 700-kilometre journey from Traunstein to Berlin in search of tips on finding someone to prescribe her cannabis. Hess, 30, who said she has borderline personality disorder as well as a joint condition called arthrosis, regularly drives 200 km round trip with her husband to procure black market weed, at a cost of up to 1,000 euros ($1,450) a month.

“I have talked to so many doctors,” she said, exasperated. “I have talked to my psychiatrist and he said ‘yeah I know it will help you probably, but I’m just not going to prescribe it.’”

Lisa
Lisa Hess regularly drives 200 km round trip for black market weed. Photo by the author

The first time Witte wrote a prescription under the legal regime, it took him an hour to get through the paperwork. He’s had “quite a number of rejections” from insurance companies, which he feels interferes with his rights as a doctor.

But Witte doesn’t judge doctors who are wary of prescribing medical weed. He said the evidence is not there in the same way it should be for medical treatments and that the media is guilty of hyping it up without being critical enough.

For all its faults, Witte said Germany’s medical cannabis regime is a great step forward from the previous system, which required patients to apply for a special permit and pay for the weed.

“If you had a terminally ill patient, the timespan to get this approved for my patients was longer than their lifetime sometimes.”

•••

There’s hope for looser cannabis regulation in Germany.

Recently, the country’s new drug czar, Daniela Ludwig of the Christian Social Union, indicated that the “ideologically-charged black-or-white debates” over cannabis need to end. Her views are in sharp contrast to those of her predecessor Marlene Mortler, who was firmly anti-legalization.

While the current coalition government of the Christian Democratic Union/Christian Social Union, and the Social Democratic Party has no plans to legalize recreational weed, the next government could change that. The Green Party, which is currently polling well, favours legalization, as do the Social Democrats. (The election is slated for 2021, but could be called early.)

And two court cases playing out right now will examine whether or not Germany’s cannabis ban is even constitutional.

According to AOK, one of the country’s main health insurers, the current system of approving coverage for cannabis will likely remain in place for five years. During this time, all doctors are collecting feedback from their cannabis patients.

“Based on the outcome, medical cannabis might become a standard benefit of the public health insurance,” an AOK spokeswoman told VICE. Additionally, changes to pharmacy regulations could bring down the price of weed.

Witte of Aphria said he’s in favour of a patient registry to track results from cannabis therapy. He is also working on designing smaller clinical trials to increase the body of evidence doctors can rely on.

In the meantime, cannabis patients and advocates will continue to navigate the system, or work outside of it, as best as they can.

Langwieder moved to Berlin from Bavaria in September to attend Freie Universität, defying expectations.

“People told me I was going to stay on welfare for my whole life, no chance to even work,” she said.

When she moved, she harvested the last of her weed and gave away all of her growing supplies. She said she’s surviving off her final yield and whatever she can afford to buy.

Langwieder is studying pharmacy. She hopes to change the medical cannabis system from the inside one day.

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