Navigating Medical Cannabis and the Endocannabinoid System

A historical depiction of the cannabis plant, illustrating its long history of use in ancient medicine and agriculture.

The History of Cannabis

In written history, the cultivation and use of the plant dates back at least the third millennium BC and possibly as far back as the Pre-Pottery Neolithic B (8800–6500 BCE). Cannabis was farmed for fibre, food, medicine, and religious/recreational purposes, with evidence from Neolithic times and ancient China/India, used by Scythians and Hindu saints. Its medicinal use grew in the 19th-century West, while later 20th-century global restrictions emerged, only to see recent movements toward decriminalisation, showcasing a long, evolving history. 

Source: Dr. Russo, E.B., “History of Cannabis and Its Preparations in Saga, Science, and Sobriquet,” 2007.

The diagram illustrates the relationships between the use of cannabis and cannabinoids and various health and mental conditions, as well as diseases such as Alzheimer’s, Parkinson’s, multiple sclerosis, epilepsy, diabetes, hepatitis, seizures, tinnitus, pain, osteoarthritis, arthritis, myositis, fibromyalgia, phantom limb pain, spinal injuries, stroke, migraine, cramps, insomnia, headaches, muscular dystrophy, cancer, HIV/AIDS, glaucoma, fatigue, asthma, ADD/ADHD, lupus, hypertension, Crohn’s disease, cachexia, loss of appetite, nausea, gastrointestinal disorders, anorexia, anxiety, depression, stress, PTSD, multiple sclerosis, Alzheimer's, Parkinson's, tinnitus, animal cruelty, pain, arthritis, inflammation, spasms, phantom limbs, spinal injuries, stroke, migraine, insomnia, headaches, muscular dystrophy, cancer, HIV/AIDS, glaucoma, fatigue, asthma, ADD/ADHD, lupus, hypertension, Crohn’s disease, cachexia, loss of appetite, nausea, gastrointestinal disorders, anorexia, anxiety, depression, stress, PTSD, multiple sclerosis, Alzheimer's, Parkinson's, tinnitus, animal cruelty, pain, arthritis, inflammation, spasms, phantom limb pain, spinal injuries, stroke, migraines, insomnia, headaches, muscular dystrophy, cancer, HIV/AIDS, glaucoma, fatigue, asthma, ADD/ADHD, lupus, hypertension, Crohn’s disease, cachexia, loss of appetite, nausea, gastrointestinal disorders, anorexia, anxiety, depression, stress, PTSD, multiple sclerosis, Alzheimer's, Parkinson's, tinnitus, animal cruelty, pain, arthritis, inflammation, spasms, phantom limb pain, spinal injuries, stroke, migraine, insomnia, headaches, muscular dystrophy, cancer, HIV/AIDS, glaucoma, fatigue, asthma, ADD/ADHD, lupus, hypertension, Crohn’s disease, cachexia, loss of appetite, nausea, gastrointestinal disorders, anorexia, anxiety, depression, stress, PTSD, multiple sclerosis, Alzheimer's, Parkinson's, tinnitus, animal cruelty, pain, arthritis, inflammation, spasms, phantom limb pain, spinal injuries, stroke, migraine, insomnia, headaches, muscular dystrophy, cancer, HIV/AIDS.

Known medical uses

Phytocannabinoids act on the body's universal regulatory system (ECS). Consequently, the medical industry has investigated phytocannabinoids potential for a diverse range of conditions. Based on data from the German BfArM Companion Survey (2022) and international scientific reviews, common areas of application have included:

Sources: BfArM,“Final Report on the Accompanying Study,” 2022); Health Canada, “Information for Health Care Professionals,” 2018); NASEM,“The Health Effects of Cannabis and Cannabinoids,” 2017).

When is cannabis prescribed?

Therapeutic goals and potential benefits

Medical cannabis is primarily prescribed as a therapy for severe, chronic conditions where standard treatments have been exhausted or poorly tolerated. Based on the current DGS Practice Guidelines (2024) and data from the BfArM companion survey, the therapy focuses on the following clinical goals:

A shield symbol featuring a nerve structure, surrounded by a green hexagon indicating the modulation of chronic pain.

Modulation of Chronic Pain:

Primarily neuropathic (nerve) pain.

The goal is a relevant reduction in pain intensity ("pain relief") rather than total pain freedom. By modulating pain perception in the central nervous system, patients often report an improved ability to cope with persistent symptoms.

A logo featuring a stylized, linear depiction of spasticity in gold, surrounded by a dark blue hexagonal border.

Relief of Spasticity:

Multiple sclerosis (MS) and other neurological disorders.

In clinical studies cannabinoids have been shown to reduce muscle stiffness and spasms.

A logo featuring a stylized leaf and a yin-yang symbol in shades of green, surrounded by a gold hexagonal border, symbolizing symptom management in palliative care.

Symptom control in palliative care:

Oncology and severe chronic diseases.

Used as a supportive therapy to manage the side effects of severe treatments (e.g., Chemotherapy, Nausea, Appetite).

A stylized sun logo featuring sunbeams, a circle, and wavy lines, in shades of yellow and blue-green.

Improvement of quality of life:

Secondary symptoms of chronic illness.

Chronic illness often disrupts sleep and mental well-being. A key benefit observed is the improvement of sleep quality and general well-being.

Sources:

  • DGS Clinical Practice Guidelines,“Clinical Practice Guideline: Cannabis-Based Medications in Pain Medicine (Version 2.0)” 2024

  • BfArM, “Final Report on the Monitoring Study Conducted Pursuant to Section 31(6) of Book V of the Social Code on the Prescription and Use of Cannabis Medicines,” 2022. (Download Link)

The Endocannabinoid System (ECS)

The endocannabinoid system (ECS) is a widely distributed signalling system in the human body that is involved in the modulation of numerous physiological processes. One of its central roles is the regulation of homeostasis—the dynamic balance of internal processes.

The system consists of three core components:

  1. Endocannabinoids—the body’s own neurotransmitters:
    Lipid-based signalling molecules produced endogenously by the body (AEA and 2-AG).

  2. Receptors (CB1 and CB2):
    G-protein-coupled receptors expressed across the central and peripheral nervous system, immune cells, and various peripheral tissues.

  3. Enzymes: Enzymatic pathways responsible for the synthesis and degradation of endocannabinoids.

The image shows the human brain and central nervous system in relation to cannabinoid receptors, with labels indicating appetite, immune cells, motor skills, and major organs.

CB1 receptors are found throughout the body, but are primarily located in the brain. Their role is to facilitate communication through the nervous system.

Diagram of CB2 receptors in peripheral organs and their location in the human body, including the digestive system, nervous system, and other systems, with a legend for organs, the nervous system, cannabinoid receptors, and the immune system.

CB2 receptors are distributed throughout the body. They specifically regulate communication between the organs and the immune system.

How it works: A helpful way to understand the endocannabinoid system is the lock-and-key analogy. Cannabinoid receptors can be thought of as “locks” on the surface of cells, while endocannabinoids act like “keys” or “encrypted messages” that bind to these receptors and trigger signalling processes allowing the communication to take place.

In situations such as pain, inflammation, or stress, this signalling helps the body adjust and regulate physiological processes. Rather than acting as a simple on/off switch, the endocannabinoid system supports fine-tuning and balance within the body.

Source: Pertwee RG (Ed.). Handbook of Cannabis. Oxford University Press, 2014.

What do cannabinoid receptors (CB1 and CB2) do?

Phytocannabinoids – Nature’s Keys

The cannabis plant produces over 100 bioactive compounds known as phytocannabinoids .
Some of these plant-derived compounds share structural and functional similarities with the body’s own endocannabinoids, enabling them to interact with and modulate the endocannabinoid system (ECS).“

THC (Δ9-tetrahydrocannabinol):

THC is the primary psychoactive phytocannabinoid. In a medical context, it is used for its central nervous system effects, including muscle relaxation, modulation of pain perception, and appetite stimulation.

CBD (cannabidiol):

CBD is a non-psychoactive phytocannabinoid.

It is actively researched for its modulatory effects on inflammatory signalling, stress-related processes, and muscle tone, without producing the characteristic intoxicating effects associated with THC.

The "Entourage Effect" (Phytocomplexity)

Medical cannabis contains more than just THC and CBD. It also includes other compound classes such as terpenes (aroma-active constituents) and flavonoids.

The concept commonly referred to as the “entourage effect”describes the hypothesis that multiple plant compounds may interact to influence overall effects and tolerability. While this concept is still under scientific discussion, it is often used to explain why full-spectrum preparations can differ in their subjective and clinical profiles compared to isolated substances.

A man who is experiencing pain or discomfort in his lower back is holding his waist and has a painful posture.

How is treatment prescribed?

Since April 1, 2024, the legal framework for medical cannabis in Germany has changed. With the removal of medical cannabis from the Narcotics Act (BtMG), it is now prescribed on a standard prescription (Rx) where medically indicated.

This means that a strict “last resort” requirement is no longer a formal prerequisite for issuing a prescription in every case.

However, for statutory health insurance (GKV) reimbursement, specific criteria and a prior approval process may still apply.

Use this 4-step guide to prepare for your consultation.


Phase One: Documentation Preparation

Even though cannabis is no longer prescribed under BtMG rules, your doctor will still need a clear medical rationale. Good documentation supports a well-informed decision.

Compiling the “Treatment History”
Compiling "Therapy History" To documenting your condition clearly, consider the following:

  • Diagnosis List: Relevant medical findings confirming your condition (e.g., chronic pain, MS, migraine).

  • Current status: A short symptom log and how symptoms affect your daily life.

  • Prior Treatments: A list of medications and non-drug therapies you have tried (incl. outcomes and side effects).

Why this is helpful: Even if not strictly required for a private prescription, structured documentation helps your doctor assess whether cannabinoid therapy is appropriate and proportionate for your individual situation.


Phase Two: The Consultation

Finding the right physician is key. Patients do not need a “special cannabis doctor,” but a licensed physician who is willing to consider cannabinoid therapy as part of an individualized treatment approach.

The Doctor-Patient Dialogue

  • Who can prescribe:
    Any licensed physician in Germany (except dentists and veterinarians) may prescribe medical cannabis on a standard prescription, provided a medical indication is present.

    The current legal framework:
    Medical cannabis does not have to be prescribed only after all other options have been exhausted. If your physician considers cannabinoid therapy medically appropriate—for example due to insufficient efficacy or tolerability of other treatments—it may be prescribed directly.

    How to address the topic: You may frame the discussion in a neutral, non-demanding way, for example: “I am interested in treatment options that focus on symptom relief and tolerability. Given the current regulations, could cannabinoid-based therapy be a reasonable option in my case?”

A woman is having a mammogram in an examination room while a patient sits next to her, smiling.

Phase Three: The Reimbursement Application

If you would like statutory health insurance (GKV) to cover the costs of cannabinoid therapy, a formal reimbursement application is still required.

  • The doctor’s role: Your physician prepares the medical justification, outlining the indication, disease severity, and why cannabinoid therapy is considered appropriate.

    The patient’s role: You submit the completed application documents to your statutory health insurer.

    Assessment criteria: For reimbursement approval, the legal framework generally requires that a serious condition is present and that standard therapies are not available, not suitable, or not sufficiently effective in the individual case.

    Timeline: Once a complete application has been submitted, statutory health insurers are legally required to issue a decision within three weeks.


Phase Four: Prescription Fulfilment

Once your prescription has been issued, it can be filled at any pharmacy (Apotheke).

Redeeming Your Prescription

  • Where to fill the prescription: Medical cannabis prescriptions can be redeemed at any german pharmacy. However, not every pharmacy stocks cannabis-based medicines on site, so ordering may be required.

  • Availability and Ordering: If the prescribed product is not immediately available, the pharmacy can usually order it from a licensed distributor. Delivery times may vary depending on product availability and supply logistics.

  • Advice at the pharmacy: Pharmacists provide information on correct use, dosage instructions as prescribed by your physician, and practical aspects such as storage and handling.

A patient is at the doctor's office discussing with her doctor whether medical cannabis is appropriate for her symptoms.
A jar of medical cannabis buds placed on a scale as part of the chemical and microbial testing at the Galaxia Vertical laboratory.

Important Legal Notice for Patients

The content provided on this website is intended for general informational purposes only. It does not constitute medical advice and is not a substitute for consultation with a licensed physician or other qualified healthcare professional.
This website does not promote self-diagnosis or self-medication. Decisions regarding medical treatment, including the prescription of cannabis-based medicines, are made exclusively by licensed healthcare professionals based on individual medical assessment.
Medical cannabis is subject to national regulations and may only be prescribed where medically indicated and in accordance with applicable laws.
While we strive to keep the information on this website accurate and up to date, medical knowledge and legal frameworks may change over time.

For further reading and the sources cited for the information in this website, please refer to our References & Further Reading page.

For further information and the sources used, please see References & Further Reading .