A current medical student discusses the use of cannabis to share her knowledge and dispel some myths.
Israel. Cannabis. Not words you usually hear together.
Medicinal cannabis appears to be a cure-all, or the bane of drug addicts. Its benefits are deeply contested – some believe that medicinal cannabis will lead to the collapse of the integrity of medicine, while others believe it is a challenge to the monopoly of the powerful pharmaceutical companies. But what is there to learn from medicinal cannabis, rather than starting ideological arguments? What has Israel got to do with all of this? And can a millennial like me teach you anything apart from the perfect way to have smashed avocado on toast?
Let’s begin with what medicinal cannabis is and how it differs from recreational cannabis.
Medical cannabis comes from the Cannabis sativa plant. The same plant from which recreational marijuana comes. The plant contains 80-100 cannabinoids, which are substances that can act on the endocannabinoid system in the body. This system influences mood, memory, sleep and appetite and has been shown to be implicated in disease. Tetrahydrocannabinol (THC) is one of these cannabinoids, present at high levels in recreational marijuana and is responsible for the ‘high’ often given when smoked. Other cannabinoids, such as CBD have been shown to relieve symptoms of disease through anti-inflammatory, antioxidant properties. Examples of diseases that have used medical cannabis as treatment include multiple sclerosis (MS), epilepsy, post-traumatic stress disorder (PTSD), chronic pain and nausea amongst others.
In medical cannabis, CBD and other similar cannabinoids tend to be at higher concentrations, while THC tends to be at lower concentrations compared to recreational marijuana. In addition, recreational marijuana tends to be smoked or ingested (often baked in foods), while medical cannabis can be given as an oil, smoked, as a nasal spray or inhaled as vapour. In countries such as Canada, The Netherlands and Israel, strains have been developed with differing levels of THC and CBD to give the best response to different diseases. For example, high THC and CBD has been found to be good for treatment of MS. All of these countries have a National Medical Cannabis Programme.
Israel is a world-leader in medical cannabis research. Now, to some, this might not be overly surprising. Israel is home to many pharmaceutical companies and its research output and spending per capita is one of the highest in the world. Research on medicinal cannabis is funded both by state and private sector. Its technology sector rivals that of Silicon Valley. So why is its medical cannabis industry virtually unknown?
In the 1990s the government moved to legalise its use and production for medical reasons, with oversight by the Health Ministry and has a specific unit dedicated to research, Medical Cannabis Unit (MCU). Money is poured into research and clinical trials – looking at efficacy of different plant strains, effects on pain relief and nausea. Dosing charts have been formulated for each strain of plant, interactions with other drugs have been investigated, pharmacokinetics, or the study of interactions between drugs and the body have been done. Control of farming and formulation of drugs are stringent and overseen by the government. Prescribing measures are strict; different forms of the drug can be given and religious leaders have been consulted.
To gain access to medical cannabis, the individual must have exhausted all forms of conventional treatment if medicinal cannabis is to be used for diseases such chronic neuropathic pain, multiple sclerosis, Parkinson’s disease, terminal cancer and palliative care. A physician who specialises in the disease which the medical cannabis is requested, fills out a form to the MCU following a rigorous assessment of the patient’s circumstances. Finally, a trained nurse at an authorised pharmacy explains how to take the medical cannabis safely.
What sort of companies are researching in Israel?
Tikun Olam is the first and largest medical cannabis company in Israel, operating under licence from the Ministry of Health. It supplies medical cannabis, has a large nursing facility to treat patients and has a research and clinical trials wing. It has a substantial international presence, co-founding many subsidiaries, including Medifarm in Queensland, Australia’s first licenced medical cannabis grower. Tikun Olam has developed a dosing schedule and several strains with specific levels of THC and CBD both in tablet and oil forms aimed at adults and children.
So, what’s stopping us from doing this in Australia?
The Therapeutic Goods Administration (TGA) issued a variety of guidelines about medical cannabis. These were to address tension between patient autonomy and ethical principle of “do no harm” as well as enabling health professionals to support patients who wish to use a therapeutic good that is unapproved.
In treating nausea, medication tends to prevent symptoms or treat the nausea itself. Trials with medical cannabis have found that strains with high THC levels can be effective for nausea but only should be used if other treatments have not worked. The TGA reports that there is no consistent reported beneficial effect of medical cannabis on nausea. Medical cannabis for epilepsy treatment in people under 25 years is recommended by the TGA to be used in addition to anti-epileptic drugs when trying to improve quality of life and reduce frequencies of seizures. Lastly, the TGA recommends a treatment plan should be created with the patient outlining goals and monitoring methods of the treatment.
Medical cannabis research has focused on testing the effectiveness of treatments for a variety of conditions. However, an emerging field includes how medical cannabis can be used to reduce the risks of polypharmacy (use of multiple medications) and act on other aspects of disease or treatments. Medical cannabis also has fewer serious side effects compared to opioids and is better tolerated than opioids. Overdose is incredibly rare, with about 680.40kg needed to be ingested. Medical cannabis can also be used to relieve nausea, increase sleep and reduce anxiety that is associated with many chemotherapy treatments. Despite the research performed, the TGA believes that there is a need for larger, higher quality studies to look at benefits, limitations and safety of medical cannabis.
This shifts the responsibility onto doctors. Doctors, like in any other profession, must keep up to date with research and innovation. Increased education, including integration into medical school curricula and specialty training is required. Communication between industry and research, government authorities, health professionals and patients, and the public is essential. If we want Australia to continue offering effective health services, catering to more complex cases, we need to follow models like Israel, The Netherlands and Canada, and push for innovation to do the best for all those involved.