Clearing the smoke

Cannabis is now widely accepted as a medical treatment, but does it have the evidential backing of other medicines? From herbal remedies to clinical therapies, Max Daly investigates the big business of medical cannabis.

After losing his right leg in a road traffic accident as a young man, New Zealander Billy McKee discovered that, for him, smoking cannabis eased the pain more effectively and with fewer side effects than conventional painkillers. He became an activist for the medical use of cannabis, grew some plants to keep him in medication and set up a website, GreenCross, to push for a change in the law.

To Police eager for an easy drug bust, he was the proverbial low-hanging fruit. Aware that a site that promoted medical cannabis could well lead them to the drug itself, Police decided that targeting McKee using an undercover officer could well get them a result. Donnie Brasco it was not.

In 2010, a constable going by the name of Lee Michaels called Billy, via the number advertised on GreenCross, and said he needed some help dealing with acute migraines. McKee recommended legal hemp oil and told him he should see a doctor in case the migraines were something more serious. But Lee Michaels was persistent.

In a string of emails, ‘Lee’ repeatedly asked the 58-year-old amputee for ‘raw medicine’, referring to cannabis. McKee advised him to become a member of GreenCross and to apply, as McKee had successfully done, to obtain an exemption from prosecution, under Section 8 of the Misuse of Drugs Act, via the support of his local GP. After four months of hassling, McKee relented, and over the next year, sold him four small bags of cannabis totalling around $300.

McKee’s home was subsequently raided and 66 cannabis plants were found. Despite a defence that he was growing the cannabis for purely medical use, he was convicted last year of supply and cultivation and sentenced to 12 months home detention.

Picking up the morning papers to read about the case, evidently the result of a fairly spiteful act of low-level entrapment by the Police, New Zealanders may be forgiven for asking why, in their country, medical cannabis sellers were being hunted down by the Police, while in America and Canada, the authorities were helping them fill out their tax forms.

Medical cannabis will soon be allowed in some shape or form across half of America. The medical cannabis juggernaut is on a roll, and the therapeutic powers of cannabis are now a global concern. When Sanjay Gupta, CNN’s chief medical correspondent, completed an abrupt U-turn in August by giving his full backing to medical cannabis, the story went viral. Infused with political agenda, half-baked claims and prejudice, it’s an issue that has left many countries, states and jurisdictions somewhat perplexed. The dilemma was explained succinctly in a paper by Peter J Cohen, a professor specialising in drugs and law at Georgetown University in Washington, DC, who wrote in 2009: “Whether medical marijuana should be accorded the status of a legitimate pharmaceutical agent has long been a contentious issue. Is it a truly effective drug that is arbitrarily stigmatised by many and criminalised by the Federal Government? Or is it without any medical utility, its advocates hiding behind a screen of misplaced (or deliberately misleading) compassion for the ill?”

Indeed, it is fair to ask whether America’s trailblazing medical cannabis industry is merely a thinly veiled stepping stone to full, unadulterated legalisation. Or whether public health is being sacrificed on the altar of entrepreneurialism – and an instant state-sponsored tax bonanza for hard times. Whatever is claimed about the medical properties of cannabis, it’s a plant with a long history of therapeutic use. Based on Chinese oral traditions going back to 2700 BC, Pen-ts’ao ching (‘Big Herbal’) is the world’s oldest pharmacopoeia. It listed cannabis as being useful for treating rheumatic pain, intestinal constipation, disorders of the female reproductive system and malaria.

Records of its medicinal qualities pop up in Indian, Assyrian and Arabic medical literature. In 1464, for example, the scribe Ibn al-Badri reported that the epileptic son of the caliph’s chamberlain was successfully treated with cannabis resin.

During the mid to late 19th century, the world’s biggest laboratories, such as Merck in Germany, Burroughs-Wellcome in England and Parke-Davis in the US, were marketing a myriad of weird and wonderful cannabis extracts and tinctures, available in the high street store, to treat anything from gonorrhea to gout. Even Queen Victoria was prescribed cannabis for period pains. Her personal doctor declared the plant to be “one of the most valuable medicines we possess”.

At the start of the 20th century, cannabis’s quaint appeal was superseded by other medical advances and the fact toxicological testing through clinical trials became mandatory, before being ground into the dust by prohibition. Now, however, cannabis is back. And this time, with a complete makeover.

Research that began in the 1950s and snowballed since the 1980s has, without doubt, established cannabis as a plant with therapeutic potential. The fact that 18 states in America and countries such as Canada, Israel, the Czech Republic and Spain have decriminalised raw cannabis for medical purposes is testimony to that. In many countries, courts go easy on people caught with the drug who can prove they take it on medical grounds.

Studies have shown smoking cannabis and taking pharmaceutical drugs containing synthetic versions of chemicals found in cannabis, such as Marinol and Nabilone, can alleviate pain and combat nausea and loss of appetite among cancer and AIDS patients.

Cannabis-based drugs have been used as anti-inflammatories and to treat hypertension and memory loss, while new research is looking into how it can be used for diabetes, epilepsy, post-traumatic stress disorder (PTSD) and sickle cell disease.

Despite all this, the only thing cannabis is clinically proven to do, in terms of meeting the gold standards of a licensed medicine, is to treat pain and spasticity associated with multiple sclerosis (MS). The medicine that is proven to do this, Sativex, is a mouth spray whose chemical compound is derived from natural extracts of the cannabis plant.

GW Pharmaceuticals, the makers of Sativex, began growing its own crop of cannabis plants in the late 1990s. They obtained a licence from Home Office officials who were, according to GW, “quick to help us because they were eager to put clear blue water between the recreational and medical uses of cannabis”.

To start off their cannabis grow, which now yields 20 tonnes a year from a secret location in the affluent southern English county of Kent, GW imported an entire cannabis seed bank from the Dutch firm Hortapharm. Sativex is now being trialled as an analgesic treatment in adult patients with advanced cancer and for its capacity to treat epilepsy and, ironically, cannabis withdrawal.

There are many claims made about cannabis, says Dr Ben Whalley, who has spent the last 13 years leading research at the University of Reading in England into how components of cannabis (cannabinoids) can help reduce and control seizures in epilepsy. He says the harsh reality is this: “If a drug has not gone through randomised clinical trials, then all you have are anecdotes.”

For Dr Whalley, not enough of the medical cannabis discourse is grounded in real medicine. He recites the well worn Tim Minchin joke: “You know what they call alternative medicine that’s been proved to work? Medicine.”

It may not amount to much within the confines of medical science, but the huge pool of knowledge we now possess on the therapeutic uses of cannabis – insight that has eased the suffering of millions of people around the world – has been hard won. After all, working with a substance viewed by many as the thin end of the narcotic wedge and the symbol of society’s moral decline was never going to be easy.

In 1992, Dr Donald Abrams, a clinical pharmacologist and professor of medicine at the University of California, San Francisco, proposed a study into whether smoking cannabis could ease the symptoms of AIDS wasting and produce gains in body weight. He had heard that hundreds of people infected with HIV in the Bay area were using the drug for this reason.

But Dr Abrams quickly discovered, as many scientists have since, that science and public health are frequently trumped by political agenda. As with many other countries, the US Government classifies cannabis as a substance of no medical value. Therefore, the overwhelming majority of studies into cannabis focus on the plant’s harms, rather than its benefits.

Accordingly, Dr Abrams’s research was delayed for six years, which, in terms of the wasting effects of AIDS, is a long time. The National Institute of Health (NIH), the only domestic source of the drug for scientists, refused to play ball. It said it could not provide cannabis for projects it was not funding. In 1998, after a delay Dr Adams described as “disturbing” and “offensive”, the NIH finally approved his request. Abrams then initiated the first federally funded effort to study the effects of cannabis on patients with AIDS.

As luck would have it, the following year, a $3m budget deficit prompted the state of California to set up the Center for Medicinal Cannabis Research (CMCR). Based at the University of California and headed by Dr Abrams, it completed 14 trials over 11 years. Some of the studies found cannabis to be effective in treating pain in patients with MS and HIV, but the funding dried up. Nevertheless, the findings from CMCR played a big part in the legitimisation of medical cannabis throughout the United States.

Now it is big business. It is a standalone economy with its own lobby groups and energetic start-ups. There are even medical cannabis guided tours in Seattle and in the conveniently nicknamed ‘Mile High City’ of Denver. The industry’s fresh and fertile pastures are being eyed by the men in suits: the accountants, the investors and the bankers.

In Colorado, the state’s 100,000 registered cannabis-receiving patients spent $220 million on cannabis and cannabis-laced products between 2011 and 2012, generating $6 million in taxes for the state. This was immediately earmarked to spruce up the area’s rundown schools. In the first nine months of the 2012/13 financial year, medical cannabis sales had already reached a colossal $225 million.

California’s Board of Equalization estimates that, last year, “total sales of medical marijuana ranged between $700 million and $1.3 billion”. That translates to between $58 million to $105 million in tax revenue for the Sunshine State.

But Kevin Sabet, a former drug-policy adviser within the Obama Administration, is not happy with the way medical cannabis is regulated in the US. He thinks the system is a sham, merely a way of backdoor legalisation. He points to the fact that Colorado and Washington, two of the 18 states that have permitted the use of medical cannabis, will be legalising the drug for recreational users in 2014.

“What, of course, is never talked about is how medical marijuana programmes in states that have gone full steam ahead actually work,” says Sabet. He sees a big disconnect between the people voters thought the new laws would be helping and those who, in reality, are buying most of America’s medically sanctioned cannabis.

“In 1996, when Californians passed Proposition 215 allowing for marijuana to be used for ‘medical’ purposes, voters decided that, if a cancer or AIDS patient should find relief from marijuana, they should not be arrested. Voters also believed that, if the patient was too ill and unable to grow marijuana on his or her own, the patient could buy it from a non-profit group of people growing small amounts for specific users.

“Fast forward 16 years, and most Californians know that “medical” marijuana has become a sad joke. Scantily clad “caregivers” and a few unscrupulous “on-call” doctors line beaches and boulevards promoting marijuana use for everything from back pain to headaches. Today’s dispensaries – really pot shops selling the drug under the guise of medicine – bear little resemblance to voters’ intent.”

Sabet has a point. A study of 1,655 people seeking a physician’s recommendation for medical cannabis in California found very few of those who sought a recommendation had cancer, HIV/AIDS, glaucoma or multiple sclerosis. Meanwhile, another study of 3,000 active medical cannabis users in the same state found that nearly nine in 10 had tried cannabis before the age of 19 and that the average user was a 32-year-old white male. Hardly any had life-threatening illnesses.

“It’s time to get the legalisation lobby out of the business of medical marijuana and instead focus our attention on scientists developing non-smoked marijuana-based medications for the truly ill,” he says. “That would make this issue no longer the sick joke that it is today.”

While the system in these American states may well be open to abuse by people who just want to get stoned, at least those citizens who are in desperate need of medical cannabis can access it without fear of arrest and jail.

When Victoria Davis, an environmental campaigner from Nelson on New Zealand’s South Island, discovered that cannabis was the only cure for the horrific phantom limb pain endured by her double-leg amputee husband John, she did what most other people would do and started growing some cannabis plants.

“We both hated the side effects of prescription painkillers – they just turned us into constipated zombies – and Sativex was too expensive,” she says.

“Luckily, while John was smoking one of his occasional cannabis joints, we found out that it did the trick. I had some old cannabis seeds a friend gave me and planted them. It was amazing how much smoking cannabis improved the quality of John’s life.”

However, the plants were discovered, and Ms Davis was charged with possession and cultivation of cannabis. Last year, after what she described as a “stressful” few months, she was discharged without conviction by Judge Tony Zohrab at the Nelson District Court and instead ordered to pay $300 to a Nelson alcohol and drug clinic.

“Being described as a serious criminal offender by the Police was a shock to me. It was a bad time for us,” says 62-year-old Davis, whose husband died last year.

“But I was overwhelmed with offers of help and the fact that so many people wanted to tell me their stories.

“One suburban housewife from Nelson offered me most of her crop. A man who grew cannabis for his father’s arthritic pain told me he had to make a huge round trip each month to hand deliver it in small batches because his dad was so scared of getting sent to jail if he was caught with a big batch. I had lots of middle-aged and elderly people describing how they secretly grew and smoked pure cannabis joints to help with hip pain as they awaited replacement operations, insomnia, nausea caused by chemotherapy, menstrual pain and depression.”

Ms Davis looks across at what is happening in America and other countries, and it makes her angry.

“Our politicians are gutless, they are all too afraid to reform the law on medical cannabis. It’s criminal that people suffering from cancer should not get the help they need. Why is New Zealand so behind the times?”

The government has so far refused to adopt the Law Commission’s 2011 recommendation to conduct clinical trials into the medical use of leaf cannabis. There is little sign the country will head down the market-led US route, although the courts and the public appear to have some sympathy for those caught using and growing cannabis for health reasons. Meanwhile, because of its remote geographical position, New Zealand has for decades been, by necessity, a cannabis growing country, and the DIY cannabis culture is far more socially acceptable than it is in Europe.

On other areas of drug policy, New Zealand is not so behind the times. The country’s ground-breaking Psychoactive Substances Act, which puts the onus on drug makers to prove their products are safe before putting them on the market, has catapulted the drug conversation into the mainstream and thus created conditions for change. Whether medical cannabis, particularly the synthetic versions, will somehow be dragged into this legislation, remains to be seen.

Dr David Allsop, of the National Cannabis Prevention and Information Centre based at the University of New South Wales, says developments in the US have divided the international medical community.

“Normally, a medicine has to jump through strict regulatory procedures, governed by the Therapeutic Goods Administration in Australia and the Food and Drug Administration in the US. Those procedures include extensive tests of safety and extensive tests of effectiveness for treating the medical problem that the drug is intended for. The process is laborious and extensive and, given the requirement for tightly controlled randomised controlled trials, usually costs a lot of money as well.

“Raw cannabis has not really been through any of those tests. This means that there are no formal guidelines for dosages for particular medical conditions. Can you really call something a medicine if you don’t know what dose you need to make the ailment better? And the fact that it is usually administered by smoking makes it a real difficult issue for the medical profession to accept it as a medicine.”

Dr Allsop, who is currently trialling Sativex for the treatment of cannabis withdrawal, says the future, outside of the US, is more likely to involve Petri dishes than rolling papers.

“Australia and many other jurisdictions are opting to go down the ‘individual cannabinoids’ route – such as with the synthetic cannabinoids like dronabinol and nabilone, and Sativex, for which we have extensive safety data, and the ability to deliver known doses in a safe manner rather than via smoking.”

Dr Allsop admits that this may not be great news for some medical cannabis activists.

“There is some kickback against Sativex from the hardliners and anti-capitalists in the dope-smoking community, who think that the government and big pharma are out to get them – the ‘one rule for you another for me’ sort of thing.

“But at the same time, it seems selfish to put obstacles in the way of delivering useful medical treatments to those who need them. Most people wouldn’t want to smoke, and most people with medical needs probably want a good handle on the dosage they need.”

From a purely scientific point of view, the medical cannabis revolution in North America is pure anarchy. Millions of people taking a potentially toxic substance in the hope that it will cure them of an often undiagnosed illness is not science.

For Dr Whalley, the main barrier to the development of medical cannabis is the fact that so much discussion is based on the psychoactive component of cannabis, THC.

“Hopefully, in 20 years, medical marijuana will be completely separated from recreational use or legalisation. THC is only 1 percent of the discussion. There are 99 percent more cannabinoids in this plant.”

Dr Whalley says that the plant’s notoriety is a double-edged sword in terms of its medical use. The stigma that surrounds cannabis has undoubtedly slowed progress and limited funding, but its consistent presence in the media has, in Sativex is changing the way we will use cannabis as a medicine. turn, stimulated interest from academics and investors.

If there was a straight race into medical cannabis’s future, there can only be one winner in terms of legitimacy and effectiveness.

“Smoking raw marijuana to treat illnesses and pain is about as scientific as chewing on a piece of willow bark if you have a headache,” says Dr Whalley.

“Just because something is historically useful shouldn’t mean you are wedded to it. Why not just take an aspirin if you have a headache? That something is natural does not make it safe: go swim with sharks or roll around in poison ivy.”

But in reality, will it be a straight race between spliffs and science? The reason drugs are so intriguing is that it’s not just about the science, it’s about culture. Drugs have an effect on the human brain, but they are also imbued with deep and varied meanings by individuals and communities. So while scientists and politicians prefer to steer people towards the regulated option, in reality, if someone feels that, by smoking some cannabis, their lives will be improved, then that’s what they will do.

The future, it seems, lies within that much maligned and much worshipped annual herbaceous plant Cannabis sativa itself.

“The cannabis plant has 60–80 cannabinoids and we’ve only looked deeply into 12–14 of them,” says Mark Rogerson of GW Pharmaceuticals.

“Our research shows that the individual differences in cannabinoids have separate roles to play in treating different conditions. There is considerable scope for future treatment. But it’s not just ‘let’s make a better aspirin’, it will be serious conditions we’ll be looking at, such as epilepsy, diabetes and actually treating some forms of cancer. The cannabis plant is a huge, unexplored area.”

And as Dr Allsop says, as long as the naturally occurring benefits of this plant can be used for the good of mankind, then we are doing the right thing.

“All I know for sure is that cannabinoids have medical properties. And where there is an unmet medical need, they should be made available to people.”

Dr David Allsop’s views are his own and do not reflect those of the Australian Government.

Max Daly is a journalist specialising in illegal drugs and author of Narcomania: How Britain Got Hooked on Drugs (Windmill, 2013).