HEALTH: Medicinal cannabis.
Although medicinal cannabis is now legal in Australia, under tight controls, the science of its risks and benefits is still not settled and doctors are reluctant to prescribe it, writes Sophia Auld.
Tony Hopkins has used cannabis for 40 years but doesn’t consider himself a “stereotypical pothead”. Rather, he uses it therapeutically, as part of a lifestyle that also includes yoga, meditation and healthy eating. Hopkins says cannabis helps him to relax and deal with the pain of osteoarthritis. “I use cannabis for the same reason that someone has a beer,” says the 57-year-old from Esk, Queensland. “You relax with a beer, a glass of wine, relax with a joint – it’s all the same.”
Medicinal cannabis was legalised in Australia in November 2016, albeit with tight restrictions. Australia’s first medicinal cannabis clinical guidelines were released by Queensland Health in March last year, with national guidelines slated for completion in 2018. Nonetheless, medicinal cannabis users are still reporting difficulty legally accessing the drug.
Cannabis has been used medicinally for millennia, but scientists are still exploring its properties and effects. The compounds found in the plant activate the body’s endogenous cannabinoid system. Dubbed endocannabinoids, these compounds and their receptors are located in the brain, organs, connective tissues, glands and immune cells. This helps to explain the varied ways cannabis affects its users, including increased appetite and reduced seizure activity, nausea, muscle spasm and pain.
Hopkins realised he had been using cannabis medicinally when he stopped smoking it recreationally and his pain flared up. After researching cannabis’s medicinal effects, he started experimenting on himself. “To me, it works on a psychological level,” he says. “It took the edge off the pain enough for me to get hungry so I’d eat … and gave me a good night’s sleep.” He also found cannabis had fewer side effects than prescribed painkillers. “You get very stoned on that stuff,” he says. “I prefer to medicate myself in a way that I can actually function and be a productive member of society.”
Medical authorities advise caution. A spokesperson from Queensland Health said that more evidence is needed to conclusively determine how medicinal cannabis works. “These products contain a range of cannabinoids including tetrahydrocannabinol (THC) and cannabidiol (CBD), and both have been found to have therapeutic properties,” they advised. “Researchers are working to find out more about the many other compounds found in the cannabis plant to see if they may be beneficial for human health.”
So far, research has identified medicinal cannabis as a potential treatment for various conditions, including some types of epilepsy with severe seizures, chemotherapy-induced nausea and vomiting, symptoms associated with palliative care (poor appetite, nausea, vomiting and pain), and severe spasms and other symptoms associated with multiple sclerosis.
Pain relief after spinal surgery was the reason
Deb Lynch, president of the Medical Cannabis Users Association of Australia (MCUA), first used cannabis.
She tried it on the suggestion of a friend, when conventional painkillers and anti-inflammatories weren’t working. Lynch found it helped with the pain and spasming, although she got a lot of ridicule from people suspicious of her motives.
Later, when she was diagnosed with posttraumatic stress disorder, Lynch was prescribed a cocktail of anti-anxiety and sedative medications. Paradoxically, they had the effect of leaving her feeling either numb or “so worked up that I couldn’t calm down”. She decided to come off these and replace them with smoking cannabis. “It took a few weeks and the drug fog started to clear, and I thought, ‘Oh my God, that wasn’t even me’,” she says. “I was much calmer, I didn’t have the ups and downs in mood that I had before.” She has since used cannabis oil for the oesophageal spasming and skin ulcers associated with scleroderma – an autoimmune disease – and, she says, to treat a bladder cancer, attributing her recovery to its use.
But while Lynch and Hopkins swear by the healing power of cannabis, the science is still not settled. Based at Sydney University, the Lambert Initiative is working to unlock the potential of cannabis-based medicines in the management of epilepsy, mental health, pain, insomnia and neurodegenerative diseases such as dementia. It was named after the Lamberts, a couple who donated nearly $34 million in 2015, after the miraculous improvement in their granddaughter’s Dravet syndrome – a severe seizure condition – following treatment with cannabis paste. More than 15 projects are under way, with the initiative also playing a role in advocacy and education for clinicians, consumers, health professionals and politicians about the therapeutic potential of cannabinoids.
Queensland Health has commissioned the Lambert Initiative to evaluate results from their clinical trials into medicinal cannabis treatment for children with severe, drug-resistant epilepsy. Under a compassionate access scheme, Children’s Health Queensland is currently using Epidiolex, a liquid form of pure cannabidiol, to treat 30 such children, a Queensland Health spokesperson said.
These children are randomly assigned to receive Epidiolex or a placebo, in addition to their usual treatment, and evaluated over a specific period. These trials are “blinded”, meaning patients, families and physicians do not know which treatment a child is receiving. Results from trials such as these will help to determine whether medicinal cannabis will be approved as a prescribed medicine for these conditions.
Medically prescribed cannabis can vary significantly to illegally sourced products, the Queensland Health spokesperson said. “Illegally produced cannabis products have unknown and variable concentrations of active ingredients, may contain potentially harmful contaminants and are produced in unregulated environments.” The cannabis used in clinical trials must meet stringent standards set by the Therapeutic Goods Administration (TGA). “The product must be high-quality, consistent in cannabinoid dosage and free of heavy metals, pesticides, fungi, moulds and any other contaminants.”
The product may be considered pure, but that doesn’t completely negate risk. The spokesperson said they could not comment on whether there had been any adverse reactions in the clinical trials until all the program information had been reviewed.
They emphasised that medicinal cannabis should be integrated into a patient’s overall treatment plan, supervised by a doctor, and supplied through a pharmacy. “Any cannabis product provided outside of the medicinal cannabis framework remains illegal.”
Currently, legal access to medicinal cannabis is a complicated process. A doctor must either be an “authorised prescriber”, or be prepared to make an application on behalf of their patient through the TGA Special Access Scheme. Both routes require detailed information to be presented on the proposed drug, its composition, formulation, dosage form and known adverse effects. The doctor must also justify why medicinal cannabis is an appropriate treatment for the patient’s illness.
Apparently, few doctors feel confident to make either of these applications. In June 2017, the number of patients receiving medicinal cannabis products under these schemes was about 150 – a minuscule number compared with those thought to be using illicit products.
This has been the problem for Lynch, who makes her own products. “I have a doctor that will prescribe, but … I can’t get my oil tested to see what the ratios are in it [to] get a prescription written,” she explains. She also claims her specialists have been warned off prescribing. “My specialist told me that they had been told by Queensland Health, ‘If you rock a cannabis boat you’ll lose your job’. ”
She says several MCUA members have had similar experiences. “We’ve had members of the MCUA come back and say, ‘My doctor showed me this letter where the AMA [Australian Medical Association] have warned them don’t prescribe cannabis – don’t even try’,” Lynch says. The national AMA vice-president, Dr Tony Bartone, says the federal AMA has never written such a letter.
Doctors are in an awkward position, with the AMA advocating caution on the sale of medicinal cannabis, leaving patients floundering to find a doctor capable of helping them. “The use of cannabis for medicinal purposes is a complex issue that requires careful consideration of research and evidence,” Bartone says. “Decisions must be based on the best available medical advice, rather than political or ideological agendas.”
To complicate matters, many medicinal cannabis products are very expensive and not subsidised under the Pharmaceutical Benefits Scheme. This makes access a pipe dream for many patients with chronic illness, who are frequently on disability pensions and unable to work. This is a diverse group, including young children.
Hopkins argues: “Cannabis is not a bad person’s drug. I’m a homeowner, I’ve paid for my house, I help in the community.”
Lynch says many medicinal cannabis users just need acknowledgement of their situations. “There are tens … if not hundreds of thousands of Australians out there using this product illegally,” she says. “Their doctors won’t interact with them, for the most part, in their treatment. This is wrong. Who is it going to hurt?
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It’s not going to hurt anyone.”