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CERTAIN patients should be allowed to use cannabinoids for medical reasons but a major stumbling block is the medicolegal liabilities faced by doctors who prescribe cannabis, according to an Australian expert.
Professor Wayne Hall, deputy director of policy at the University of Queensland Centre for Clinical Research, said it was a hurdle that had been underplayed.
“Doctors are understandably reluctant to prescribe a drug that hasn’t been approved, where they may well be liable if patients report any adverse events or experience any harms”, he said.
Professor Hall was commenting on an article published online by the MJA today, which calls for legal reforms to permit medical prescription of cannabis. (1)
“A civilised and compassionate country that supports evidence-based medicine and policy should acknowledge that medicinal cannabis is acceptably effective and safe, and probably also cost-effective”, the authors wrote.
All natural and synthetic forms of cannabis are currently illegal in Australia.
A NSW cross-party parliamentary committee unanimously recommended in May that medicinal cannabis should be made available for selected conditions. (2)
However, the NSW Government recently ruled out the suggestion, rejecting the committee’s recommendation to allow terminally ill and AIDS patients to legally use up to 15 g of cannabis for medical reasons.
The MJA authors said the unauthorised use of cannabis as a medicine in Australia was widespread, suggesting significant demand, but this use was neither supervised nor regulated.
“Like any medication, cannabis will be safest if the smallest dose is prescribed for the shortest period required to gain the desired therapeutic effect, under medical supervision”, they wrote.
Professor Hall said the ideal way to provide medical cannabis would be for the Therapeutic Goods Administration to approve pharmaceutical preparations such as nabiximols, an oromucosal spray which had been approved in the UK, Canada and parts of Europe. This would be preferable to patients smoking cannabis.
Professor Hall, who has advised the WHO on the health effects of cannabis use, said he broadly endorsed the desirability of giving people access to cannabinoids for medical benefit.
There was good evidence to support their use for certain conditions, including for nausea and vomiting in cancer patients undergoing chemotherapy and radiotherapy, and for appetite stimulation, neuropathic pain and multiple sclerosis.
Professor Hall said one option — as recommended by the NSW parliamentary committee — was to allow a defence against criminal prosecution if patients could demonstrate that they had a condition that could benefit from using cannabis.
This could mean doctors would not need to prescribe cannabis but could, for example, simply sign a letter saying the patient had a certain condition such as cancer and their appetite was suppressed. It would then be up to individual patients to buy the drug if they had trialled it and found it of benefit, Professor Hall said.
However, NSW Health Minister Jillian Skinner told MJA InSight that with only limited scientific evidence available on the safe use of cannabis, the government was unable to support decriminalisation of the use of crude cannabis for selected patient groups based on medical approval.
Dr Matthew Large, clinical senior lecturer at the University of NSW’s School of Psychiatry, said he would support the medical use of cannabis for some very limited conditions, using the analogous model of amphetamines, which were taken for recreational use and were illegal, but which could be prescribed for attention deficit hyperactivity disorder.
Dr Large said although there was good evidence for cannabis use in neuropathic pain and more modest evidence for treating chronic spasticity in multiple sclerosis patients and cachexia associated with terminal disease, he did not believe decriminalisation of cannabis was the answer.
“If you decriminalise cannabis use and keep supply illegal, essentially what you are doing is giving a free kick to drug dealers”, he said.
“The alternative is to legalise it and tax it and then at least you could have a proper education campaign, include warnings on packaging, and stop children from using it. We could do what we have done for smoking.
“At the moment, a 14‒19-year-old in Australia is more likely to have smoked cannabis than cigarettes. (3)
If cannabis was used for medicinal reasons, it would be best as an oral preparation, which would be straightforward and easy to regulate, he said.
1. MJA 2013; Online 9 December
2. NSW Parliament, Legislative Council. General Purpose Standing Committee No 4: May 2013
3. National Cannabis Prevention and Information Centre 2009; Young people and cannabis use
I’ve been working in Canada for a few years now. “Medical marijuana” has been legal here for a while. The general public think it’s a great painkiller and very safe with no addictive properties. Most doctors refuse to prescribe it due to lack of clinical trials and known harms. My local town council is considering setting up a large grow-op for profit. There is no other medical therapy which is legislated by government for the sole purpose of garnering votes. The whole issue is ridiculous and a bureaucratic smokescreen for pseudo legalization with doctors being expected to be the gatekeepers instead of government. Either legalise completely like they’re starting to do in the USA, or do proper clinical trials and isolate active ingredients in measured doses without the carcinogens. If you simply want to smoke free pot every day don’t get me involved.
Many people who grow cannabis plants for their own use could contribute to research on quality control to assist the authors , and even inform the authors regarding “how they determine the correct dose ….”. Cannabis users could also assist the authors with information on how the users determine whether their use is “medicinal or recreational”-is this dose or frequency-dependent perhaps?
However, the questions raised regarding driving, operating machinery , while under the influence of cannabis have obviously been studied by certain industries, who choose not to employ persons who test positive for cannabis. Perhaps the authors could seek their input regarding legal and insurance aspects of cannabis use.
There is a long history of the usefulness of plant-based materials in therapeutics. The utility of quinine, digitalis, ipecachuana, morphine, curare, to mention a few, has been well-established, even though some of these agents have since become obsolete. It must be remembered that a new agent of the modern era, artemesia, took years of work and many trials to develop variants which could be considered suitable for routine usage in the treatment of falciparum malaria.
These points need to be considered when discussing the introduction of cannabis into the pharmacopaeia. Not only do the active principles need to be properly characterised, purified, and rendered suitable for an acceptable, quantitatively accurate, and non-injurious mode of administration, but proper trials need to be undertaken to check whether the cannabis derivative is indeed a worthy agent. In the past, such trials have been difficult. How does one ‘blind’ the treatment arm when the subjects are as high as kites? How, also, does one produce the raw product with adequate security? How does one reliably stop the patients (and those who steal the medicine) driving cars and working machinery? Is the prescriber going to be liable in case of disasters?
I feel that much work needs to be done before scripts are written for cannabis. The sceptic in me suspects that enthusiasm for cannabis as a medication still represents a desire for acceptable mind-bending rather than decent science.
We thank Cathy Saunders and readers for their comments. However, we believe that most of the issues raised were addressed in our paper. Primarily, our paper emphasised the importance of differentiating between the medicinal and recreational uses of cannabis. Specifically, we accept the evidence that: the medicinal use of cannabis is consistent with an acceptable benefit:risk ratio; cannabis composition is variable, thus standardised medicinal grade cannabis is required; various modes of administration are possible, but smoking should be considered only when medically and socially expedient; although sufficient research evidence is already available to proceed, future research should include evaluation of any local schemes; a ‘decriminalisation’ use model may fail to achieve sufficient quality regulation, and be unlikely to achieve the openness required in the doctor-patient relationship; we are concerned about the potential cost of finished products such as nabiximols driving patients to seek illegal supplies. Additionally, there is no link to our (quite extensive) knowledge of involvement of tobacco companies; and the evidence is now being questioned for cannabis in schizoprenic mental disorders [1] and of smoked cannabis in lung cancer [2].
We reiterate our position: the evidence is in, and we are staggered that it is dismissed so freely in the NSW Government’s response to the NSW Report.
1. Proal AC, Fleming J, et al. A controlled family study of cannabis users with and without psychosis. Schizophr Res http://dx.doi.org/10.1016/j.schres.2013.11.014
2 Tashkin DP (2013). Effects of marijuana smoking on the lung. Ann Am Thorac Soc 10(3): 239-247
Why should we doctors be responsible for prescribing any drug which is currently illegal in any form in this country? No doubt we then we will blamed for any adverse effects. If cannabis is so safe, why is it illegal?
Surely if cannabis is so useful and so safe the first step would be to decriminalise it rather than trying to make doctors responsible for prescribing it. Cannabis plants grown for personal use only by an adult should not be a crime in my opinion, as there is no evidence that this harms anyone other than the user.
However, selling mouldy contaminated buds which would not be deemed suitable for our livestock , let alone our children and grandchildren at private and other schools, is a harmful flourishing trade, which the governments ignore.
It has been written that in Buddhism, Cannabis is regarded as obstacle to clear awareness-that is certianly my perception of the medical students and doctors whom I have known who were daily users of Cannabis, so I choose to avoid people who use Cannabis.
Cannabis does not have to be smoked, it can be eaten in cookies, so the argument that we have to prescribe it to prevent harm from smoking it is a joke.
So let the governments admit that their legislation is ineffective, make Cannabis grown for personal medical use legal without any prescription, and leave doctors out of their legislative debacle.
I agree wholeheartedly with Dr. Baster’s commentary. Unfortunately, my late daughter would have undoubtedly benefitted from an oral form of cannabis when she was alive, suffering extreme agony from neuropathic hyperanaesthesia due to a persistent viral infection. She required constant hospital inpatient treatment with intravenous Ketamine at considerably greater cost than an oral spray of cannabis supplied by prescription for a few dollars. While we continue to live in a nanny state ruled by politicians who have limited understanding of medical problems the advancement of medicine will progress but slowly.
The whole debate about medical marijuana is a bit like suggesting using smoking opium for pain management rather than using morphine orally or the like. There is now overwhelming evidence for a biological system called the endocannabinoid system that is fundamental to many aspects of physiology including modulating both acute and chronic pain. Indeed this system explains many aspects of pain that have hitherto been a mystery such as allodynia and hyperalgesia. Modulating this system rather than the endorphin/enkephalin system will provide us with the tools to manage those difficult chronic pain cases in the future probably as a combination of nsaids/cox2/paracetamol and a CB1 or CB2 receptor agonist. Any clinician using paracetamol or the nsaid/cox2 drugs are already manipulating the endocannabinoid system via inhibiting the uptake or breakdown of the endogenous cannabinoid anandamide. We should not have any reservation about using this class of drugs but certainly not as an inhaled smoke.
Surely this is a cart before horse issue. What is needed is good clinical research of cannabis derived chemicals (there are multiple different active agenst within cannabis all with differing effects, the proportions of which can vary plant to plant), with this evidence then used to inform clinical practice.
Currently cannabis is a relatively raw plant product with no controls on dose/concentration or impurities. In it’s smoked route of administration, it carries substantial amounts of tar – more than tobacco. It is not currently a substance that can be safely prescribed.
If there were non-smoked pharmaceutical grade formulations of cannabinoids which are proven to be clinically effective, then those particular medications should be made legally available.
I find this discussion quite ridiculous. As doctors, we prescribe substances that are far more dangerous than cannabis – and often with doubtful benefit! – every single day. If there is a chance that cannabis might be helpful for some conditions in some circumstances and it’s risk:benefit ratio comparable or better to the available alternatives (or no available alternatives) than itwould seem preposterous that a legal system would prevent us from using it as medication.
Even if cannabis was fully legal for all, I doubt we would ever see as much harm arise as we see it constantly from the use of tobacco, alcohol, or especially soft drinks.
Conflict of interest: none – I am not interested in Cannabis myself at all, at least not in my current good state of health.
we have managed to reduce smoking of tobacco down to histoically low levels, we dont want to encourage smoking of a more toxic substance, or smoking of anything, its a health hazard as well as a child hazard and it stinks. If cannabinoids are so useful for medicinal purposes then make a pill and conduct a control trial to prove it! I ask my chronic back pain patients if it helps them, they say it doesnt get rid of the pain linke narcotics do, but it stops them worring about it! I understand the tobacco companies are behing the push for medicinal marijuana smoking, they dont want a pil as it costs more to manufacture and the will be less profit. If no one wants to make a pill, then at least keep the ban on smoking the stuff (smoking anything) and do a trial of eating cookies.
I question whether medicial use legislation as might be suggested is safe and relevent in all cases. Under Common Law cannabis use is legal as long as no one is harmed by psychosis. People with schizophrenic spectrum disorders (psychopathic disorder) should not take cannabis whether they are terminally ill or not. Ordinary cannabis is borderline trait/state is generally safe and legal but hybridised forms which do not contain an antipsychotic are not. Not all use in this so called borderline group need be for terminal illness only.This requires not only an understanding od law but also evolution.