In recent years the use of medicinal cannabis has become a subject of much debate with global political powers now looking to re-evaluate their stance on the plant and its molecules. Within the UK, calls for the medicalisation of cannabis has provoked the British government to legislate for access to medical cannabis for UK patients from the 1st of November 2018.
Despite this new legislation, it remains exceedingly difficult for UK patients to access medical cannabis products through the NHS. The governing body that provides national guidance and advice to NHS professionals is the National Institute for Health and CareExcellence (NICE).
Figure1.The National Institute for Health and Care Excellence’s (NICE)recommendations on the use of cannabis-based treatments for chronic pain.Source: NICE.org.uk.
NICE provide a series of evidence based guidelines that outline the best practices for UK medical professionals based on the extensive medical evidence and studies that are available to a committee of clinical experts. Medical professionals in the UK must adhere extremely closely to the NICE guidelines as they protect them from a legal standpoint through almost all aspects of medicine. These guidelines are developed based on evidence built up over years of surgical procedures, clinical trials and experimentation. Given this, Cannabis poses a particularly sticky situation for all involved.
For decades medical research into cannabis was discontinued following a sustained campaign from the American Medical Association in 1945 that forbade exploration of cannabis for medical use. This later resulted in the classification of cannabis as a substance of abuse which stunted wider cannabis research for many years. Though there has been a recent renewal of cannabis research, compared to opiates and opioids, we are some thirty to forty years behind in our understanding of cannabis medicines. This is the key issue currently facing NICE and the NHS. Though the government has technically opened the window to cannabis medicines, NICE currently lacks double-blind placebo-controlled drug testing required to develop medical guidelines for medical cannabis. This has generated a stand still in the accessibility of medical cannabis, ultimately stemming from the historic ban on research. This has meant we are decades behind in our understanding of this exciting branch of reawakened medicine. The current blame game surrounding medical cannabis has generated a cloud of misinformation and chaos for patients across the UK. Despite the lack of costly double-blind drug trials there still exists a wealth of published medical data demonstrating the vast potential of cannabis as a therapy in various diseases.
The aim of this article is to highlight this issue and provide support to those currently caught within this loop of frustration that resembles Penrose’s stairs. The first rational step then would be to initiate research programmes that aim to add clarity to the situation and answer the unknowns that currently inhibit NICE guidance and public access. This raises another issue. To develop a body of evidence this substantial, it would require decades of clinical trials and billions of pounds in research funding. Whilst this research is conducted patients around the UK would still be unable to access the potential of these treatments.
How do we resolve this?
Cannabis constituents are extremely well tolerated by the body. Questions raised about the safety, and efficacy of cannabidiol have been quelled by studies showing prolonged exposure to cannabinoids both in animals and humans noting the absence of adverse effects (Fine and Rosenfeld, 2013).
Based on the historical use and relative safety of cannabis, a slightly less conservative but possibly more rational and logical would be to regulate cannabis as we would any other drug. If we perceive cannabis like we would alcohol, paracetamol or perhaps, tobacco we soon develop a picture of how cannabis, like many other drugs, can be regulated sensibly and distributed to the public.
Doing so would shift the ethical burden of medical cannabis from medical professionals to patients and offer millions of patients the opportunity to explore alternative and a potentially safer treatment strategy than is already being utilised. As in many cases now seen in the media, many patients have explored all conventional therapeutic options to minimal benefit. In these cases, cannabis would justifiably warrant supervised experimental use in the interests of quality of life. This same argument applies to patients of terminal diseases for which there is currently no cure, should they not have the opportunity explore alternative methods to alleviate their suffering. Extreme suffering leads people people to break these legislative barriers in an bid to ease suffering. Compassion and understanding is lacking from our policy.
This debate boils down to several key medical principles of ethics and human rights. This issue was outlined by the 2010 UN general assembly (report attached below). Respect for autonomy, beneficence, non-maleficence, and justice. The current UK cannabis legislature directly infringes and inhibits the fulfilment of these core medical principles. This is not the fault of medical professionals. Doctors have been placed in this difficult and potential career risking position in which they are being asked to provide patients with informed consent without having clear guidance themselves. The current reluctance to prescribe cannabis based medicines on the notion of “do no harm” may in fact be having the opposite of the desired effect. This ability to withhold cannabis treatments due to potential risks compromises the autonomy of the patient who may derive significant benefit. we should be striving to help patients make informed decisions around cannabis rather than placing this burden on doctors. Many of whom have zero training in the field.
Fundamentally this choice of treatment and course of management resides with the patient or guardian and not with the medical professionals or legislators. Desperate patients are being forced into the realms of criminality due to our current cannabis policy. The UN fundamental right of everyone to the enjoyment of the highest attainable standard of physical and mental health is currently being infringed. In light of the significant evidence supporting medical cannabis it is unethical to with hold criminalise such products where there is grounds for its use. Perhaps the most impactful step would be to remove this burden from medical professionals through regulated public access and education. This public access would mean that research professionals can conduct observational research whilst giving patients the opportunity to trial cannabis based medicines alongside current treatment regimes in the absence of the appropriate medical protocols. Based purely on just how safe and well tolerated cannabis is compared to current prescription and recreational drugs, it is more than reasonable to consider the potential of implementing a strictly regulated and accessible cannabis medical system (Sachs, McGlade and Yurgelun-Todd, 2015). A supporting system that addresses and carefully monitors and minimises many of the risks we already know are associated with crude cannabis use. Education of consumers must underpin this. Without informed an informed public we will only further burden the medical system.
As a final note, at no point has the endocannabinoid system been factored into the debate. The physiology of the body has been factored into this conversation which has meant that the debate has been very plant and commodity focused. The endocannabinoid system is a fundamental that underpins this entire field.
This article is an extract from our upcoming handbook which has been compiled to ensure patients are armed with the information they need to understand just exactly what benefits medical cannabis may or may not provide them. This article does not promote cannabis as a treatment for all illnesses but instead aims to highlight that there is more to cannabis the debate than the plant and its potential for abuse. Cannabis has shone a light on a world of exciting medical potential in the form of endocannabinoids and the endocannabinoid system which has untold therapeutic potential across all mammalian health and disease.
Fine, P. G. and Rosenfeld, M. J. (2013) ‘The endocannabinoidsystem, cannabinoids, and pain.’, Rambam Maimonides medical journal.Rambam Health Care Campus, 4(4), p. e0022. doi: 10.5041/RMMJ.10129.
Sachs,J., McGlade, E. and Yurgelun-Todd, D. (2015) ‘Safety and Toxicology of Cannabinoids.’, Neurotherapeutics : the journal of the American Society forExperimental NeuroTherapeutics. Springer, 12(4), pp. 735–46. doi:10.1007/s13311-015-0380-8.