The Ministry of Health and BPAC (Best Practise Advisory Group) have together released a draft guide for doctors and other prescribers about medicinal cannabis, and invited feedback on the draft. This is NORML’s advice, prepared by our patient advocate Jonathan Rennie.
NORML NZ: Patient advocate
The National Organisation for the Reform of Marijuana Laws (NORML New Zealand Inc)) is a non-profit membership-based incorporated society that was formed in New Zealand in 1979 (Incorporated 1980), and is affiliated to NORML in the USA. We work to end cannabis prohibition in New Zealand, and bring about progressive drug policies.
NORML’s mission is to move public and bureaucratic opinion sufficiently to legalise the responsible use of cannabis by adults, and to serve as an advocate for consumers to assure they have access to high quality cannabis that is safe, convenient, and affordable. The medical cannabis using community presents an important and vulnerable sub-set of cannabis consumers who deserve special attention. The need for safety, convenience and affordability is even greater for this group; and there is a more urgent moral imperative for government to end barriers to legal access. We acknowledge that the medical cannabis scheme now being implemented in New Zealand represents a reasonably sincere effort by government to meet this obligation.
NORML NZ is responding to this draft document in the capacity of patient advocacy. Every day, we field questions and requests for help in gaining access to legal medicinal cannabis under the MOD Amendment Act 2018. They are ordinary Kiwis looking for the relief that cannabis medicines may offer them. Many are already successfully using illicit cannabis to treat themselves, but it’s medicine to them, not some game – they just want the assurances that come with a legally produced product. Public awareness of medicinal cannabis has grown significantly in the last decade, and we have had conversations with literally thousands of patients. From people suffering from minor ailments to those with very serious conditions, all agree that NZ’s scheme, as it stands, has not served them: with confusion and dismay being the almost universal experience. But together we can change this, and we agree that this draft resource is a step in the right direction. It is vital for patients that doctors get the best possible information about prescribing cannabis medicines, and we hope our insights on this will be helpful.
We strongly support the intention of this document and are grateful for the opportunity to respond. We receive a great deal of anecdotal material from patients about the state of the medical cannabis scheme and how well it works for them. The experience has been disappointing for the majority, and unquestionably, a low level of medical practitioner knowledge and confidence regarding cannabis medicines accounts for much of the problem. A resource like this one is obviously a good first step in addressing this issue. However, we do have some concerns about the weighting given to different kinds of information presented, in terms of how doctors’ decisions on whether to prescribe cannabis will be affected. Chiefly, the current lack of “gold-standard” efficacy data is made very prominent in this document, while the mountains of anecdotal evidence and at least 5000 years of traditional experience are entirely ignored.
Also, we notice that this resource appears to fulfil a dual purpose of both guiding doctors through the prescription process for cannabis medicines, while also advising on recent research on their efficacy for treating various conditions. We are concerned that this may be generating a case of “one who chases two rabbits catches neither”, where-in the brief sketches on the science do not do the topic due service, and possibly detract from the positivity the prescription pathway advice. It might be more prudent to produce a resource that focuses strongly on the prescription pathways, and save the science review for a more thorough presentation than what can be achieved here.
It’s about the patients
This resource, despite its many good points, may inadvertently deter some doctors from prescribing cannabis medicines to those who will benefit. A lot of weight is given to the paucity of high-quality data supporting their efficacy in treating many ailments, but the importance of patient lived experience is given no weight at all. The document itself admits that many people seeking a prescription are already using street cannabis for their illness and know that it works, so patient self-knowledge is very important for doctors considering cannabis prescriptions.
The main reason for the lack of clinical evidence is lack of clinical experience: cannabis medicines have effectively been locked out of the pharmacopeia for three generations, so little quality research has been done – or reliable patient data collected – in this period. There has been an upswing in stronger research in recent years as legislation allowing medical cannabis has been passed in many jurisdictions around the world. As well as opening the doors for more controlled studies, this also creates a population of formal medical cannabis users, generating a new wealth of patient data. However, it’s still early days, so we may reasonably expect the weight of evidence in favour of medical cannabis efficacy to improve over time.
NZ’s new medical cannabis scheme therefor provides an excellent opportunity to collect data immediately, as we will have a growing sample of patients using cannabis medicines in the field. Given the relative low toxicity and good safety profile of cannabis drugs, it is sensible to cast a wide net with subscriptions to obtain maximum patient data. For this reason, the document ought to be worded to be more encouraging for doctors who are interested in prescribing the drug. One way this can be achieved is by offering some discussion on the importance of patients’ own experiences of their illness and how cannabis has helped them. This approach should, in turn, help doctors feel more confident about suggesting cannabis therapies for patients who have not yet tried them, because they will see there is a body of patients already benefitting from this medicine, without experiencing significant side effects.
However, we propose that doctors be especially encouraged to prescribe cannabis medicines to the category of patients who have already experimented with cannabis and found that it works for their condition, or who initiate the conversation about cannabis and are already mentally prepared to try it. In addition to historical legal barriers, an important roadblock to gold standard research into cannabis medicines is the ethical and logistical issues that arise around using a placebo. These respectively relate to: a) patients who require effective relief as soon as possible, and b) a drug with a pronounced psychoactive effect that “gives itself away”. But this needn’t stop us from collecting data. Under this medical cannabis scheme, doctors can treat their cannabis patients as n=1 studies, and set the results against non-cannabis using patients with the same illnesses, to provide head-to-head comparative data between cannabis and other drugs.
The data collected by doctors can then be consolidated to provide research of significant sample size. For example, Dr Gulbransen, who runs a specialist cannabis clinic in West Auckland, has consolidated several his clinic’s own n=1 patient studies into a larger sample (n=400) and published it in the British Journal of General Practice (BJGP Open, V4, Issue 1, 04/20).
Potential for abuse
One possible objection to this approach is the potential for abuse of system by patients looking to acquire cannabis for recreational use. In reality, this is a highly unlikely scenario. Approved products are currently more expensive than illicit herbal cannabis, and although we hope those prices will fall, it is unlikely they will ever be significantly “competitive” with the illicit market. Meanwhile, the doctor/prescription process is intimidating enough for genuine medical users, let alone recreational users “trying it on”. Additionally, the usual dropper, spray, capsule, and tincture forms of medical cannabis are unappealing to most recreational users, who prefer smokable herb, cakes/biscuits and vapourisation of extracts for dose-delivery. Even if it became widely known that it was reasonably easy to secure a cannabis medicine prescription by approaching your doctor, from our long-standing knowledge of the NZ recreational cannabis consumer community, NORML is very confident that this medical scheme will not become a route of acquisition for recreational users. This demographic will always find the recreational market (regardless of legality) easier, cheaper, and more appealing to access.
Because we are seen as allies, people are frank with us. In thousands of conversations with patients inquiring about medical cannabis, we have not heard from a single, solitary person intimating that they were considering it as an alternative route for recreational acquisition. In short: Kiwis who are prepared to get a medical prescription for cannabis do so because of genuine medical need. This point also puts pay to the potential ethical objection of making “guinea pigs” of Kiwi patients. Besides the well-established low toxicity of cannabis, people who need relief from sickness are only too happy to become research subjects. Denying people this opportunity may be the real breach of ethics.
Of course, “feeling high” can be characterised as a “side-effect” of cannabis medicines, but for many conditions it is also one of the intended effects. In the complexities of pain management, for example, distraction from – and increased coping-capacity with – discomfort can be just as valuable as dampening the physical nerve signal. It seems unnecessarily puritanical not take this into account when discussing the use of any drug for pain management. The “stone” of opioids complements its signal-dampening effect by providing additional disassociation and calm. Even the very subtle SSRI amitriptyline, besides whatever change to somatic signaling it may achieve, must also improve the patient’s psychological relationship with their nerve pain because it works by increasing serotonin: it’s literally an antidepressant/antianxiety agent being prescribed for physical pain! The same principle applies to cannabis, although its psychological effect is more pronounced than SSRIs and less pronounced than opioids – and obviously much less dangerous than the latter. This may be exactly the right middle point for many patients. We would like to see some discussion of the potential benefits of the psychoactivity of cannabis, as a useful adjunct to its somatic activity, for a more holistic appreciation of its worth as a medicine.
Cannabis should be widely prescribed
We are uncomfortable with the assertion that cannabis never be offered as a first line of treatment. Research has shown that as doctors’ knowledge of cannabis improves, so does the likelihood of them prescribing it. Those doctors who are experienced with prescribing cannabis, and who have seen the benefits in their patients, do recommend cannabis as a first treatment line for some illnesses. Due to the low level of acute toxicity – for those patients who are not likely to be vulnerable to side effects – cannabis could well be an excellent first treatment approach for a variety of minor ailments. However, we acknowledge that the high cost of unfunded medicines would itself be a barrier to most patients experimenting with cannabis before they have tried more conventional treatment lines.
There are some important categories of disease that are not covered by this article. Most notably missing is the potential for cannabis to be helpful for skin complaints, for which there is an abundance of anecdotal evidence. Balms containing active cannabis have been found to be effective against psoriasis, eczema, general abrasions/lesions, and possibly some skin cancers. We concede that high quality research on this area might still be lacking. However, topical application of a balm or cream is also considerably less risky than consuming a substance through more internally penetrative routes, so some doctors may be more confident with giving cannabis a try for patients with difficult skin conditions. There are currently no topical application cannabis medicines among our approved products, but they are common overseas and NZ doctors can still theoretically prescribe them.
A range of disease types not investigated by this resource are briefly discussed and dismissed as not having “compelling” evidence that cannabis will be effective against them. This is based on a 2019 “review of systematic reviews” which sounds comprehensive, but these “reviews” can be prone to producing unhelpful generalisations. A review can be no better than the studies it is reviewing: so if we acknowledge that there hasn’t been much quality research to date, that returns us to square one. Engaging with patients’ lived experience is a far better way to approach the potential usefulness of cannabis for these ailments. We wonder if it would be better to simply mention the range of illnesses that cannabis is thought to provide relief from, and leave doctors to do their own research, and in consultation with patients, decide for themselves when and how to prescribe it.
However we also agree that increasing doctors’ theoretical knowledge of cannabis medicines is important. It would be wise for a resource that looks deeply into the current state of knowledge on cannabis medicines to be produced for this purpose. Such a document would draw from a wide range of experts, and be prepared to engage with anecdotal evidence in good faith, as well as providing a comprehensive analysis of clinical data to date. With the greatest of respect, we are not satisfied that the authors of this draft are qualified to summarise the current state of knowledge on cannabis medicines, or that a document like this is the correct place to even attempt such a complex and thorny task. We therefor would prefer to see a document that levels up doctors’ theoretical understanding of the current science produced as a sperate, purpose-built project.
Altogether, we believe this resource would function better as primarily a “yes you can / how to / please do” manual for doctors to prescribe cannabis medicines. This draft is attempting to also provide a short review of the current science on their efficacy, which has an inevitably reductive effect. For reasons discussed, it is entirely expected that quality efficacy data will be underrepresented at this point in the history of cannabis medicines. The challenge is to find out how, where, and how much the mass of anecdotal evidence will, with experience, intersect with confirmed medical results. This medical scheme should be used as an opportunity to meet that challenge head-on, and this practitioners’ resource should reflect that. There is no point hand-wringing about using Kiwi patients as “guinea pigs” when so many rodents are lining up for their place in the lab. This medicinal cannabis scheme is an excellent opportunity to progress our knowledge of cannabis medicines, and the NZ public health system should seize it with both hands.