This study aims to present the full chronicles of MC in Israel, from its inception to current times. The current study results showed consistency with prior publication of MC licensure trends for 2013–2018 (Sznitman 2020), but with added value of more granular (monthly rather than annually) data, an extended study period, and additional measurements that were not available previously. Furthermore, the current study displays the changes in MC regulations alongside observed MC licenses trends, to inform future MC regulators and associated parties about the consequences of government decisions on patients.

In practice, the most important metric for MC patients, physicians, regulators and the industry is the number of monthly active MC licenses. This figure allows patients to estimate the likelihood of continuity in their treatment, while physicians treating patients with MC can anticipate workloads related to license or prescription initiation and renewals. In turn, regulators may assess the effects of policy changes, and the industry can plan accordingly. For example, MC growers might forecast future market demands and determine optimal planting strategies to meet patient needs while minimizing resource waste. However, due to the incompleteness of the publicly available data presented in this study, it is currently speculative as many factors that cannot be controlled may affect the future status of the Israeli MC market.

The current study shows that up until a few months prior to the full enactment of the MC reform (Landshaft et al 2019), there was a slow and steady increase in the number of active MC licenses. This trend (~ 151% increase) is similar to that previously reported for the 2013–2018 period (~ 121% increase) (Sznitman 2020). The inflection point was likely one of the reforms, as following its implementation and the publication of protocol #106 (Landshaft et al 2019), the number of active MC licenses increased sharply, despite intermittent stagnation, peaking in January 2024.

From that point onward, a consistent and substantial decline in active MC licenses was observed through March 2025. This reduction is presumably linked to the HMOs prescription reform enacted in April 2024 (Israeli government 2024), which transferred prescription authority for most indications from the IMCU to the HMOs. However, the decline began even before the reform’s official implementation. This may have been triggered by early media reports announcing the proposed reform as early as December 2023 (Cohen 2023; IMOH 2023) and even initial hints in August 2022 (IMOH 2022). While these regulatory changes should have resulted in license replacement and perhaps even an increase by HMO-issued prescriptions, and some transition lag is expected in large-scale bureaucratic processes, the combined dataset from both IMCU and HMO sources, nearly a year post-reform, still shows a noticeable halt in the number of active MC patients.

Another possible explanation for the observed decline and stagnation is the exposure of licensing irregularities during the previous growth period. Reports have suggested that many licenses may have been issued under questionable circumstances (Levi L 2022). In particular, several physicians had their IMCU authorizations revoked after allegedly issuing licenses from private clinics rather than within public healthcare settings, as required. In one prominent case, a single physician was responsible for over 13,000 license approvals (Cannabis magazine (Cannabis 2022)). Consequently, once those licenses expired, many were likely not renewed by other physicians, contributing to the observed decline. Internationally, access models vary: in the UK, most MC products are prescribed in independent (private) clinics under Care Quality Commission (CQC) oversight with only narrow NHS pathways (NICE 2021; NHS 2019; QCQ 2025). Similarly, US federal settings (e.g., Veteran Affairs) clinicians cannot prescribe or certify (US Department of Veterans Affairs 2023), effectively shifting access to private clinics under state programs. Whereas Italy embed prescribing and dispensing in public health systems (Chambers and Partners 2025).

The gender distribution of patients holding an active MC license remained consistently male-dominant (62%) in the current study. This finding is similar to previous reports (68.5%) (Sznitman 2020), although the gender data for this study was available only for 2024–2025, whereas the prior report covered 2013–2018. One explanation for this finding may be the higher rate of MC-related adverse effects among females, as was found in a previous study published by the author of this study (Aviram et al. 2021), which may discouraged women from pursuing or renewing their MC license. Israeli clinical guidance for oil extract and CBD-rich products preference, treatment initiation with lower THC potency, cautious maximum dose and slower titration (i.e., "start-low, go-slow") was published for pain physicians in 2023 (Brill et al 2023). Nonetheless, subsequent years females' lower frequency does not seem to be effective, possibly as this guidance is not gender specific. Thus, there is a need for further sex-stratified safety/effectiveness research. Another reason may be the relatively high proportion of active MC licenses for the indication of PTSD, which in Israel is predominantly combat-related, thus, predominantly male (Solomon 1989). Nonetheless, the most frequent MC indication was found to be CNCP, which in a recent epidemiological survey in Israel, is more frequently female dominated (~ 60%) (Sharon et al. 2022). However, in a study of over 1,000 eligible MC patients for CNCP in Israel from our lab, the sample was predominantly male (~ 57%) (Aviram et al. 2020b). An additional possible explanation is that female-predominant CNCP diagnoses, such as fibromyalgia and endometriosis, are not approved by the IMCU for MC license (Landshaft et al 2024), which may result in rejected applications or prolonged approval timelines (Aviram et al. 2020b). Compared with the United States (US) MC programs, in a recent analysis of publicly available data from seven states, male-to-female ratio was 102.1 (~ 49.8%) (Boehnke et al. 2025). This difference supports the current study hypothesis about the uniqueness of the Israeli MC patient's population. Unfortunately, there is no additional comparisons to be made as the US programs reported on different measures than the Israeli IMCU did, such as continuous age, percentage of minorities and ethnic groups, household income, unemployment, poverty, disability and veteran rates.

During the investigated period, although there were fluctuations in total numbers of active MC licenses and changes in regulatory framework, CNCP, PTSD and the undefined category proportions increased substantially. In contrast, most of the other medical indication proportions decreased substantially up to the time the HMOs MC prescription reform was enacted on April 2024 (Israeli government 2024), and following this reform, almost disappeared, presumably as all medical indications other than CNCP, PTSD and the undefined, were transferred to the authority of the HMOs. The previous trends report demonstrated a ~ 28% and ~ 1044% increase in active MC licenses for CNCP and PTSD, respectively, between 2013–2018 to frequencies of ~ 59% and ~ 10%, in 2018, respectively. Additionally, the previous report showed a ~ 69% decrease in the undefined category to ~ 12% in 2018 (Sznitman 2020). As the current report data on these measurements begin in December 2020, those trends cannot be compared directly, but may serve as an earlier extension and validation of the current report initial data point. As such, CNCP, PTSD and the undefined frequencies in December 2020 were 53%, 14%, and 9%, respectively. Considering the two years gap of information between the reports on this measurement, a ~ 10% and ~ 25% decrease was observed for CNCP and the undefined category, respectively, and a ~ 40% increase for PTSD. The small decrease in CNCP proportions during this gap might be explained by the changes in data structure or emerging clinical guidelines at that time, which advised CNCP specialist physicians to assert caution before prescribing a cannabis-based medicine due to lack of high-quality controlled trials, and to do so only as a third-line treatment and only for chronic neuropathic pain (Häuser et al. 2018). The additional decline in the undefined category proportions may be explained by improved physician education and more accurate form completion (IMOH 2023), or by the full enactment of the MC reform which clarified approved medical indications (Landshaft et al. 2019).

Notably, between 2020 and 2025, the proportion of the undefined category increased, contradicting expectations of continued decline from the previous report (Sznitman 2020). This may be explained by the rapid expansion in active MC license numbers, which may have led to increased data entry inconsistencies due to overload on physicians and IMCU processes. PTSD proportions extended between reports and across the entire current study period, being the only indication that increased both in proportions and sample size, even following the total decline in MC licenses and the HMOs prescription reform. Unfortunately, this is easy to explain. As the only Jewish country in the Middle East, Israel has been subjected to many wars since its inception, and many of its citizens are exposed to continuous traumatic stress, leading to PTSD and depression (Green et al. 2017). A recent projection estimated that 5.3% of the population (> 520,000; CI: 1.64–9%) may develop PTSD due to the ongoing war (Katsoty et al. (Katsoty 2024)). Perhaps the most convincing explanation is economic: As PTSD in Israel is mainly combat-related, many patients are treated under the Department of Rehabilitation of the Ministry of Defense, receiving full reimbursement for MC costs (Israeli department of rehabilitation 2025). Importantly, this increase is not in accordance with clinical guidelines, which strongly recommend against the use of MC for PTSD due to a lack of high-quality studies (Lang et al. 2024). Still, the growing number of PTSD patients receiving MC may have led psychiatrists to gain clinical experience supporting its perceived benefits. Additionally, regulations for MC license approval for PTSD remain stricter and require longer period of conventional treatment exhaustion attempts than for other approved indications (Landshaft et al 2019).

The small observed increase in MC licenses for ASD and dementia is likely driven by recent clinical studies demonstrating potential therapeutic benefits (Hermush et al. 2022; Hacohen et al. 2022; Schnapp et al 2022).

The current study provides a novel analysis of monthly MC amounts permitted under active MC licenses, as this variable was not reported in previous literature. Data were available for the years 2021–2025. According to the MC regulations in this period, the initially approved monthly amount could not exceed 20 gr (Landshaft et al 2019), and therefore, almost all patients were provided with this amount at first (Aviram et al. 2020b). The decrease in the proportion of this initial amount may reflect a lower proportion of newly issued MC licenses compared to renewals. A similar trend of reduction in proportions was found for 30 gr/M. Based on the regulations, for any change in the license, including dose increase or product type change, specific documents must be submitted by the treating physician for approval by the IMCU (Landshaft et al 2019). The reduction in the 30 gr/M category may follow the same logic, as it represents the first approved dose increase.

Trends are different for the category of 40 gr/M, which remained relatively stable between 22%–25% throughout the study period. This stability may be attributed to most patients not requiring more than this monthly amount. It might be explained by the dosing guidelines for MC (Bhaskar et al 2021), calling for a maximum daily dose of 40 mg of ∆−9-tetrahydrocannabinol (THC) by oral oil/extract formulations. Given that many Israeli patients use THC-rich MC (~ 20% potency, or ~ 200 mg/gr), particularly those with CNCP (Bar-Lev Schleider et al. 2022), and that most choose flower products (Aviram et al. 2020b), the theoretical requirement to reach the recommended 1,200 mg/month THC dose would be ~ 6 gr/month of MC. However, considering the significant blood concentration variability (2%–56%), dependent on inhalation technique, device design, lung capacity, and user behavior, and with ~ 30% of THC assumed to be destroyed by pyrolysis (Lucas et al. 2018; Grotenhermen 2003; Huestis 2007), patients may require up to 40 gr/M of raw MC flowers.

Nonetheless, the current study shows a trend for substantial increase in the proportions of 50 gr/M and 60 gr/M categories. This finding is harder to explain given the aforementioned guidelines for MC dosing. Some evidence on CNCP patients, shows that clinical practice may allow for a limit of 60 gr/M, when clinically justified (Robinson et al. 2022). Higher monthly amounts of 70–110 gr/M or more are infrequent and showed a decreasing trend, almost disappearing. This trend may be attributed to an IMCU initiative to reduce licenses exceeding 90 gr/M (Cannabis magazine 2019). Another reason for these relatively high amounts might be their use in producing Rick Simpson Oil (RSO), requiring up to 180 gr for production. Although RSO is largely unstudied clinically, it is perceived by some as an anticancer treatment (Guggisberg et al. 2022). Notably, there may be a risk of secondary gain by diversion of MC to the general public, a risk that may increase with higher monthly allowances. A recent study showed that despite being informed that diversion on their part constitutes drug trafficking, most patients still perceived it as at least moderately moral (Ne’eman-Haviv and Rozmann 2023).

Another novel variable analyzed in this study is the trend in active MC licenses by HMOs affiliation, which has not been previously reported. Although MC expenses are not reimbursed by the HMOs in the majority of cases due to its regulatory definition, since the enactment of the National Health Insurance Law in 1995, all Israeli permanent residents are automatically covered by the public health system (Israeli government 1994). Therefore, every patient holding an MC license is affiliated with one of the four national HMOs.

This information became more important due to the HMOs prescription reform, which delegated prescribing authority for all indications except CNCP and PTSD to HMO-affiliated physicians, starting in April 2024 (Israeli government 2024). A decline began after the reform’s announcement (December 2023) and continued through implementation (April 2024), consistent with both anticipatory behavior and subsequent stricter prescribing as well as purge of irregular licenses and transition frictions. If regulatory control of CNCP and PTSD is also eventually transferred to the HMOs, the data presented here may assist in workload forecasting and resource planning, although the IMCU and the HMOs have not reported that this is in their scope at the time this study was submitted.

This corresponds with Clalit’s position as the largest HMO in Israel, insuring 52% of the population (Sagy et al 2025). In general, the proportion of active MC licenses affiliated with Clalit and Maccabi increased until shortly before the HMOs prescription reform, after which a modest decline was observed. Shifts in HMO shares may reflect member churn, coverage/routing differences and regional mix. Specifically, a reduction in the "Other" category, which likely captured cases with missing HMO information, since no additional HMOs exist in Israel. Conversely, the observed decline in Clalit and Maccabi proportions may be due to a relative increase in Meuhedet and Leumit affiliations during the same period.

Another novel aspect of this study is the analysis of MC product type trends, along with the estimation of monthly flower package and oil bottle volumes based on active MC licenses, and the average number of product units available per patient. The current study results demonstrate that the most prevalent MC product type is MC flowers, which increased over time to reach 94% of all dispensed product allowance. In contrast, the proportion of MC oil products declined to under 5% of the total allowance. These results correspond with what was reported (86%) among CNCP patients during 2018–2020 prospective one-year study, and also show a similar trend of increasing flower use (mostly via smoking) and decreasing oil purchases (Aviram et al. 2020b).

This contradicts medical guidelines, which generally discourage smoking (Häuser et al. 2018). A possible explanation is the higher short-term adverse event rate associated with MC oil (~ 52%) (Pud et al. 2024), compared with smoking (~ 40%) (Aviram et al. 2020b), which may discourage its use.

Inhaler frequency steadily increased to 0.5%. Notably, unlike MC flowers and oil products, the inhaler utilizes a much lower amount of MC flowers, specifically 13.5 ± 0.9 mg per inhalation and 0.81 g per 60-inhalation cartridge (Aviram et al. 2022). Thus, while the inhaler accounts for just 0.5% of total product allowance (in Kgs), it may represent a disproportionately large share of patients. This pattern aligns with broader observations that inhalation remains common among MC patients in a recent European survey (Fortin et al. 2025).

Although data on actual patient purchases are available only for recent months, these figures may shed light on potential discrepancies between licensed and consumed quantities. This gap could suggest overprescription (i.e., allocation of unnecessary monthly amounts), or it may reflect economic barriers, as market prices (Israeli government 2019) ranging from $122 to $1,162 per month depending on the approved amount. This price dispersion likely reflects pharmacy margins, GMP standardization costs, product brand segmentation, and import dynamics under the market-based model. Another possibility is that some patients discontinue treatment but retain an active license without making any purchases.

Allowance data from the IMCU on active MC licenses also enables estimation of market share for MC growers and companies. At its peak in January 2024, the total monthly allowance reached 501,300 flower packages and 41,900 oil bottles. Assuming an average product price of $40–$110 (Israeli government 2019), this equates to a potential market value of approximately $21.7–59.5 million per month (annualized $252–$684 million, under the same assumptions). However, these figures apply only to IMCU-issued licenses and not to HMOs-issued prescriptions, and therefore may not fully reflect post-April 2024 market dynamics (Israeli government 2024). Separately reported import data show that, in December 2024, just before the MC license peak, the estimated value of imported flower products ranged from 17.7$ to 48.9$ million. Given the capped total MC supply, imports likely displaced a portion of the domestic market. Imports were initially approved by the Israeli government in response to rapid demand growth that caused product shortages (Pilot A 2019). By early 2024, however, domestic producers began petitioning the government to address market saturation caused by excessive imports, particularly from Canada (Israeli government 2024). Despite this, 302,268 imported MC flower packages were reported as recently as March 2025.

Throughout the study period, the average number of MC product units (flower packages and oil bottles) per patient steadily increased, reaching 4 units per patient by March 2025. This finding aligns with previous research from our lab indicating that the majority (51%) of male MC patients in Israel, licensed for durations ranging from 1 to 13 years, consumed between 40 and 100 g per month, with a median of 40 gr/M (Aviram et al. 2021).