What’s next for UK cannabis?

2021 has seen the cannabis conversation continue to grow.The CBD media frenzy continues. Millions of pounds are being made. Sounds great right? It’s alright for some.  

The London Stock Exchange has also seen its fair share of action with IPO’s being launched regularly. There has been a fair share of commercial success. But, has this translated into patient benefit and access? Despite these great market successes, patients on the frontline have not seen a great deal of change.

The primary issues are education and cost. Most patients inthe UK are used to receiving their prescriptions from the NHS at no charge. In the case of cannabis, the primary access route as of 2021 is via private clinics. Private medicine has been quick to fill the gap left by the 2018 legislation change. Unfortunately, this does come at a cost and so patients that access cannabis are looking at a sizeable cost to their access. The other alternatives are less than reliable over the counter cannabis products that also fetch a premium price. The impact of these costs is such that a financial barrier develops. The impact of this is that many patients and community members are forced out of desperation to grow their own cannabis or interact with the criminal black market.

Social Impact

Patients seeking support and guidance have very few placesto turn. Given the often-desperate situation, these groups are vulnerable to misinformation which remains a prevalent issue in the online patient communities that have developed. Environment, Social, and Governance principles are becoming increasingly popular amongst investors and businesses as a measure of social impact and sustainability. These impact focus principles are needed now more than ever in the cannabis industry which has been built off the back of patients and their advocacy. An example of how companies are failing the community can be seen in the wave of patient charities that have been forced to form as a result of the gaps in our cannabis system. Intractable.org.uk is a charity that is working to help the families of epileptic children pay for their cannabis prescriptions. Formed by the families of the epileptic children whose campaign was responsible for changing the laws, Intractable’s mission is to alleviate the financial stress of families in need. Prescription costs can run into thousands of pounds per month and add a significant financial burden to an already stressful situation. Some families and patients are unable to bear the costs of cannabis prescriptions and so turn to alternate means of cannabis access. The police still officially take a zero-tolerance on unprescribed cannabis and so patients using unofficial cannabis sources are subject to prosecution. In this scenario, there is no separation between organized criminals and patients. In this scenario, there is also no legal support for those who do not wish to plead guilty. Groups such as Seed our Future fill have been working tirelessly to highlight the UN human rights of everyone to the enjoyment of the highest attainable standard of physical and mental health.

A quote from the summary of the UN general assembly 2010:“The primary goal of the international drug control regime, as outlined in the preamble of the Single Convention on Narcotic Drugs (1961), is the “health and welfare of mankind”, but the current approach to controlling drug use and possession works against that aim.”

The full report can be found below.

 

Research & knowledge

Since the launch of the cannabis industry very little data has been gathered. This is a tremendous, missed opportunity given that thereason further cannabis progress can’t be made is due to the lack of data. An incredible amount of cannabis is consumed every year, nearly 255 tonnes per year based on current estimates (Snowdon, 2018). Great tools such as Alta Flora’s Eva app have been created to help capture consumer feedback. At an academic level, research barriers remain high. Much of cannabis research has been left in itspre-clinical infancy. This is in part due to the ethical restriction around researching cannabis in humans and their tissue. The endocannabinoid system is a feature of the cannabis conversation that has been heavily overlooked. Still not taught in medical schools and this disadvantages the next generation of medics. Academic fear is a very real issue in the realms of cannabis researchwhich is why much of it has been privatized. The impact of private research isthat the data isn’t always made public and withheld as intellectual property.Research of this kind can be very product-focused and costly. The UK medical institutions are demanding randomised

NICE definition of a randomised control trial is a study inwhich similar people are randomly assigned to 2 (or more) groups to test aspecific drug, treatment, or other intervention. One group (the experimental group) has the intervention being tested, the other (the comparison or control group) has an alternative intervention, a dummy intervention (placebo), or nointervention at all. The groups are followed up to see how effective the experimental intervention was. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically. This method is also used to reduce bias.

RCT’s are not infallible. A major issue with clinical trials is that they can be influenced by industry. Research exploring financial conflicts of interest in medical studies has shown some worrying trends. Investigators at McGill University in Canada independently extracted data on disclosed study funding, author-industry financial ties, and author employment from each meta-analysis, from RCTs included in each meta-analysis, and on whether meta-analyses reported disclosed COIs of included RCTs. Of 29 meta-analyses reviewed, which included 509 RCTs, only 2 meta-analyses (7%) reported RCT funding sources; and 0 reported RCT author-industry ties or employment by the pharmaceutical industry (Roseman et al., 2011). Of this group of studies that reported funding sources, 69% were industry-funded. Exploring this phenomenon at an institutional level astudy from Bekelman et al in 2003 outlines the wider relationship between research and industry. The study found that approximately one-fourth of investigators have industry affiliations, and roughly two-thirds of academic institutions hold equity in start-ups that sponsor research performed at thesame institutions (Bekelman, Li and Gross, 2003). The results of this investigation showed a statistically significant association between industry sponsorship and pro-industryconclusions. This Industrial sponsorship is associated with restrictions on publication and data sharing which further stifles the filling of these knowledge gaps. This is not limited to medicines, industry-funded trials are more likely to be associated with statistically significant pro-industry findings, both in medical trials and surgical interventions (Bhandari et al., 2004).

This financial ring-fence around data and research isa societal disadvantageous approach that is delaying the building of big a pictureview. The scientific and political conversation around cannabis and wider drugpolicy will broaden slowly as they have done for the last few decades. Without this field, we will be reliant on political ideology and blind guesswork for direction. An understanding of the social and biological context of cannabis will help direct policy, build solutions and improve impact. The UK medical establishment is only just scratching the surface of cannabis medicines and is yet to fully grasp the scale of the endocannabinoid system. Our demand for randomised control trials might be better placed as a tool to develop our public policy around cannabis (Haynes et al., 2012).

 

Wider Drug policy

The community of cannabis advocates across the country has been instrumental in changing public perceptions around cannabis. Much of this community has been criminalised and persecuted for much of their lives due totheir cannabis consumption. Cannabis still carries a heavy stigma and fear which will take many years to dissipate. Education plays a key role in helping the public reperceive cannabis and other commonly consumed drugs. Helping society understand cannabis and other drugs and the reasons why people turn todrugs is fundamental to building a sustainable ecosystem. Some see approaching cannabis as the sole target of reform seems like a more measured approach. Cannabis shares the same stigma as other drugs in society. Based on the current state of drug policy research it seems as though the next logical progression of the conversation is to tackle the morality of drug use by assessing drugpolicy. Bold may though this may seem, there is a great amount of evidence behind this approach.

Cannabis has been just one target of the war on drugs which has been heavily politicised. One of the key weapons used in framing this agenda was the words and language of prohibition. With prohibition, we assess alldrugs through the lens of legal and illegal. Drugs are just inanimate objects or compounds. It is we who give them the label of controlled legal and illegal drugs. This binary approach no longer holds much weight in a world where life exists on a spectrum. The Law is an equation of words that is there to govern behaviour so at to reduce socially harmful outcomes. The facts of the matter demonstrate that the policy is outdated and now in fact causing more harm than reducing it. An inanimate object such as a drug cannot be the subject of war. Merely, it is a war on the user of the drug. We know many of the consumers of drugs are in pain or using drugs for physical or psychological trauma. Drug-related deaths are at an all-time high in the UK so there is a need for some significant reassessment.  

In the last 20 years, our understanding of adverse childhood experiences (ACEs) and their effects on later adult life has been steadily maturing. Such adverse childhood experiences might include exposure to or experience of psychological,physical, or sexual abuse; household dysfunction; or living with house hold members who were substance abusers, mentally ill or suicidal, or ever imprisoned (Hughes et al., 2017; Felitti et al.,2019). People who have experienced four or more adverse childhood experiences are four to twelve times more likely to suffer from alcoholism, drug abuse, depression, or a suicide attempt compared to those with no exposure (Felitti et al., 2019). The damaging effects of ACE’s can even extend to sexual health, mental health, weight, physical exercise, violence, and physical health status.

Another consequence of our penal approach has been a division between communities. This division is a direct result of dehumanizing people who use drugs due to its immorality. Prohibition has had the opposite of the desired effect which has now evolved into a method of controlling people, not the drugs being consumed.  The consequences of criminalising people who use drugs often outweigh the risks they face from drug use, and there is no convincing evidence that this prevents wider drug use or drug-related harm (Holland, 2020).  It is well accepted that drug consumption cannot be eliminated. Maintaining this penal approach to managing drug consumption as a whole is directly damaging society.

In a statement made in 2019 by the High Commissioner for Human Rights Michelle Bachelet, called for a change in focus from the punitive approach to drugs to one thatemphasizes the wellbeing and rights of people who use drugs (full statement below). At a fundamental level, the war on drugs becomes amatter of freedom and liberty. Drugs have contributed to the development ofhumanity and culture long before the existence of government. Rather than just peaking behind the iron curtain of prohibition we have the opportunity to bebold and assess the issue in its entirety. Viewing cannabis through the lens of prohibition is short-sighted and ultimately holds back the next generation ofsocial maturation. Rebuilding communities by showing compassion andunderstanding to people who use drugs.  Groups such as Transform / LEAP and doing great work to raise the case for a wider rethink of the way we perceive drugs. The Prohibitionist paradigm of legal and illegal drugs holds back progress. Compounds such as cannabinoids are a natural part of physiological systems throughout and present across all vertebrates. Drugs are part of our environment and as such our biology inherently can interact with elements ofthis environment and explore it fully. As such I see the cannabis conversation emerging into a wider drug policy conversation.

The UK is still in its infancy, but a post-prohibition paradigm is emerging. The transformation happened with alcohol, one of the most dangerous drugs statistically, is it unimaginable that we treat drugs as a whole on this even playing field?

To understand the business implications of this context start by speaking with the GCS team.

 

References

https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=24529&LangID=E

Bekelman, J., Li, Y. and Gross, C. (2003)‘Scope and impact of financial conflicts of interest in biomedical research: asystematic review’, JAMA. JAMA, 289(4), pp. 454–465. doi:10.1001/JAMA.289.4.454.

Bhandari, M. et al. (2004) ‘Association betweenindustry funding and statistically significant pro-industry findings in medicaland surgical randomized trials’, CMAJ : Canadian Medical Association Journal.Canadian Medical Association, 170(4), p. 477. Available at:/pmc/articles/PMC332713/ (Accessed: 21 September 2021).

Haynes, L. et al. (2012) ‘Test, Learn, Adapt:Developing Public Policy with Randomised Controlled Trials’, SSRN ElectronicJournal. Elsevier BV. doi: 10.2139/SSRN.2131581.

Holland, A. (2020) ‘An ethical analysis of UK drug policy asan example of a criminal justice approach to drugs: a commentary on the shortfilm Putting UK Drug Policy into Focus’, Harm Reduction Journal 2020 17:1.BioMed Central, 17(1), pp. 1–9. doi: 10.1186/S12954-020-00434-8.

M, R. et al. (2011) ‘Reporting of conflicts ofinterest in meta-analyses of trials of pharmacological treatments’, JAMA.JAMA, 305(10), pp. 1008–1017. doi: 10.1001/JAMA.2011.257.

Snowdon, C. (2018) Estimating the Size and Potential ofthe UK Cannabis Market. Available at:http://iea.org.uk/wp-content/uploads/2018/06/DP90_Legalising-cannabis_web-1.pdf(Accessed: 18 June 2019).