An editorial comment, by Dean Unger
“The prescription opioid crisis was created when we loosened regulations around opioid prescribing,” he remarks; “I hope history doesn’t repeat itself.” Meldon Kahan, Medical Director of the Substance Use Service at Women’s College Hospital.
They can’t patent the plant, they can’t get Nabiximols (Sativex) or Nabilone (Cesamet) to work… How will pharmaceutical companies get in on the act?
The new government regulations to come into effect April 2018, were opposed by many physician groups, including the Federation of Medical Regulatory Authorities of Canada, and the Canadian Medical Association. These organizations insist that the new regulations will put patients at risk, because there’s been no conclusive research, nor is there any standardization of potency of smoked marijuana.
They say there is simply insufficient evidence concerning possible risks and benefits.
Even with strict objectivity and a mindful attitude, often there is much nebulous and obtuse language coming from the Traditional Medicine camp, which insists that marijuana needs to be subjected to the same rigorous testing and approval standards other prescription medications undergo – and then become tightly regulated by the pharmaceutical industry. This, in my opinion, for those who stand to gain, is an important first step in allowing pharmaceutical companies to wedge their foot in the door, to become part of an important and very lucrative discussion from which they’ve been notably absent.
Rocco Gerace, Registrar of the College of Physicians and Surgeons of Ontario is the first one to step up and insist. And understandably so. In 2016, marijuana sales in North America netted $6.7billion dollars. These kinds of figures, where medicine is concerned, don’t often happen too far from the pharmaceutical stables.
Some would say they had their chance, and missed it. To remain competitive with the mainstream marijuana market, various synthetic forms of cannabinoid, were manufactured by Big Pharma – Nabilone and Nabiximols – synthetic drugs that attempt to mimic the effects of natural THC and CBDs. Why create a synthetic form of marijuana? Precisely because they cannot standardize potency and packaging in a strictly manageable, easily regulated form. It is, by all accounts, a natural medicinal substance, that would – in all logic – make more sense on health-food store shelves, than it would in an antiseptic pharmaceutical environ. Ultimately, due to its recreational nature, as well as a vast number of medicinal applications, it will make more sense growing in the direction it has: in specialized dispensaries, that can cater to both.
All of this hasn’t stopped Big Pharma from taking a few swipes at the cat. Largely, these efforts have come under the guise of, first-off, at the front-lines, physicians’ voices who diligently tote the company line and the pedagogical stance of the College of Physicians and Surgeons (COPS), who, by all appearances, seem to be exactly on par with Big-Pharma. Or is it the other way around?
Any case, In the US, the anti-marijuana lobby by industry proponents is pulling out all the stops, including a video ad campaign that amounts to unsubstantiated scare tactics. It’s interesting that they (organized industry voice) think nothing of issuing a call-to-arms like this, yet, when asked specifically about harms of marijuana – proven or otherwise, mums the word. That is because still to this day, it’s never been substantiated. In fact, in comparison to many main-stream pharmaceuticals, marijuana, is virtually innocuous.
Physicians touting the COPS mandate say marijuana is not a first-line therapy for any medical condition. Nor should it be.
In an online article, published in 2014, by Dr. Jeremy Petch, manager of special projects, Li Ka Shing Knowledge Institute of St. Michael’s Hospital; Dr. Jill Konkin, Associate Dean for Community Engagement with the Faculty of Medicine and Dentistry at the University of Alberta; and Mike Tierney, Vice President of Clinical Programs at The Ottawa Hospital and former Director of Pharmacy at The Ottawa Hospital and Vice President of the Common Drug Review at the Canadian Agency for Drugs and Technologies in Health, (I know, right?), say that doctors who are considering prescribing marijuana to patients need to counsel that marijuana is not first-line therapy for any medical condition. “For nausea, Ondasetron is both more potent and longer-lasting than marijuana.” Likewise, “there is a clear consensus among experts that when patients request marijuana for legitimate medical conditions, approved therapies should be tried first, and marijuana can be tried if these first-line agents fail to prove effective.”
The statement that Ondasetron should be pushed over marijuana to treat nausea is questionable – suspect at best. Firstly, the correct spelling of the drug is, Ondansetron aka Zofran. Secondly, the list of potential side-effects include allergic reaction, chest pain, slow heart-beat, numbness and tingling, trouble controlling body movements, seizures, and I quote: “A very bad and sometimes deadly health problem called serotonin syndrome may happen. The risk may be greater if you take this medicine with drugs for depression, migraines, or certain other drugs.”
That doesn’t happen with organic medical marijuana
It’s mildly surprising to learn that the authors who wrote this piece are physicians – well-respected physicians who are active on health boards, and community health organizations etc… What strikes me as odd – there is a situation critical on the street, in the face of the College of Physicians and Surgeons placing a lock-down on addictive prescription Opioid drugs, which is as it should be, but for many thousands of patients – many I’ve known and have talked to myself – MMJ was instrumental in their recovery of many respective debilitating illnesses. I know it works, and I know it is non-invasive: medical marijuana was largely responsible for my own recovery from a life-threatening illness. I’ve seen, personal and up-close, people who suffer debilitating and life-threatening disease, and have visibly seen the relief wash over them as the effects of the MMJ set in.
The paper also states that testing MMJ would be far less expensive and less complex than testing a strictly pharmaceutical drug – so what’s the problem?
When you look at the thing from bird’s eye view, it all seems a little too quaint. Pharmacists may be left running to the curb with suitcase in hand only to watch the bus drive away without them. A pharmacist owner whom I spoke with in fall of 2016, shared that, because of the immense ocean of red-tape, and the many grey areas around measurement, packaging, regulating potency levels etc… it would, in all likelihood, mean that pharmacies will be left out of the equation – and have no seat at the POS (point of sale) table.
Shades of absurdity
I’ve experienced the incredible pain-sating properties of MMJ myself. I’ve spoken with countless “humans” about the why and the wherefore of their respective MMJ use, and the overwhelming success many, many patients have had, many of whom were left out to dry by the medical establishment. I have read and researched, ad-naseum… In short, Kahan’s statement about lumping medical marijuana in with Opioids – an epidemic of death and destruction they may have helped create themselves by loosening prescribing guidelines, is patently absurd and has not a shred of logic to it.
The article continues in its absurdity: “The intoxicating effects that have made marijuana popular as a recreational drug carry a number of known risks. In addition to the risk of dependence, these include impaired learning, memory, alertness, reaction speed and judgment, all of which affect driving and work performance.” It’s as if these statements come right out of a 1960s anti-drug scare campaign. Further, “In young adults, marijuana dependency can result in mild, but potentially permanent impairment of executive functions such as problem solving, and has been associated with a decline in IQ and the risk of psychosis.” Of note here is the fact that, as they go on to admit themselves, these statements are largely unsubstantiated and that little or no research has been done on long-term effects of marijuana. How then can one make this claim with a straight face.
This poorly planned argument against the use of medicinal marijuana, amounts to a high-handed rationalization of a weak position. Difficult to access? How about the fact that MMJ has been produced and provided to qualified patients by Health Canada for decades.
Among regular users it is commonly known that, as with many pharmaceutical medications, these alleged negative side-effects, if they occur at all, generally subside as the the body becomes accustomed or acclimatized to the effects of MMJ. Key word mild but “potentially” permanent impairment”… Again no documented case to qualify this statement. There has been no documented case of any one dying from using marijuana – whether from short, or long term use. The paper also states that testing MMJ would be far less expensive and less complex than testing a strictly pharmaceutical drug – so what’s the problem? Why, supposedly, has it not been done? Pharmaceutical companies are usually the players that fund this research. It stands to reason that, with no place at the table, there is little or no motivation to run these tests.
It is surprising to see statements like this from reputable medical professionals – in particular, comments like “appears to be a risk factor” for lung cancer, are conjecture of a high order – “appears”, and “risk factor” combine to form a double negative. They state themselves there has never been a formal study done.
So whose information are they going by?
Further, there is the question raised by the fact that pharmaceutical cannabinoids are approved and available in Canada. These pharmaceutical cannabinoids would have undergone phase three clinical trials. Again, it stands to reason there must be some kind of research? They would presumeably have had thier hands on real marijuana in order to isolate and produce the active agent. And if these unseemly negative side-efffects do exist in organic marijuana, than what advantage would there be in creating a synthetic version, that carries with it threat of looming side-effects?
In fact, the list of known side-effects caused by Nabilon, from emedicine.com, include: hives; difficulty breathing; swelling of your face, lips, tongue, or throat, hallucinations, paranoia, extreme fear, fast heart rate, fainting, unusual thoughts or behaviors, etc… etc… The site also recommends the following: “talk with your doctor if you have any of these less serious side effects: dizziness, drowsiness, feeling “high”, weakness, lack of coordination; depression, anxiety, confusion; dry mouth; headache, trouble concentrating; or sleep problems,” and, as a parting shot, “Side effects other than those listed here may also occur.”
Dr. Kahan, says that doctors who believe marijuana might help their patients, “should always “begin by prescribing pharmaceutical cannabinoids, rather than herbal marijuana. In addition to having more robust evidence about effectiveness, pharmaceutical cannabinoids appear to be safer,” he explains.
Mark Ware, a research scientist at McGill University, and the executive director of the Canadian Consortium for the Investigation of Cannabanoids, agrees that the evidence for herbal marijuana’s safety and effectiveness is limited. “Very little research has been done to date,” Ware says, “because the climate of prohibition made it very difficult to access research funding, legal marijuana for research purposes, and accurate use data.” He also notes that the prohibition on marijuana has meant that research has tended to focus on its harms, rather than its benefits. But Ware believes that the limited clinical research that does exist is very promising. He is hopeful that Canada’s new rules will facilitate more and better research into the safety and effectiveness of marijuana.
Overall, this (Petch, Konkin, Tierney) poorly framed argument against the use of medicinal marijuana, amounts to a high-handed rationalization of a weak position. Difficult to access? How about the fact that MMJ has been produced and provided to qualified patients by Health Canada for decades.
Any limited research that has been done, focuses on harms, rather than benefits. It begs the question – how do standard research protocols proceed when typical pharmaceuticals are tested? Do they come at it with a “we want to see if this works” mentality, or, “we want to prove it’s harmful” paradigm.
Again, as someone who has been prescribed these synthetic forms of THC and CBD, these are castrated forms of the natural, organic substance and do not have near the effectiveness, and, in many cases – cause side-effects that often result in the patient refusing to take them.
Many of the statements made by the author’s of the paper in question, are tantamount to libelous slander against MMJ, of the grossest form. Hundreds of thousands of Canadians who have found salvation and welcome relief using MMJ for their pain, and for any number of dozens of other symptoms and problems that are managed by MMJ. This kind of transparent, oppositional positioning will only serve to alienate. We have already moved past this position.
Cannabis Use Disorder
Kahan references something that until this point I’ve never heard of – Cannabis Use Disorder – a term that is widely used – but largely in clinical settings or via medical reference – a dependency condition with the following symptions, according to the 5th Revision of the DSM: Cannabis use disorder (CUD) (Also known as cannabis or marijuana addiction) is defined, in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as the continued use of cannabis despite clinically significant impairment, ranging from mild to severe.
As with anything in life, the old adage, anything in excess, whether good, or bad, can be harmful. Though my heart truly goes out to anyone that may be suffering with CUD, and measures certainly need to be taken to get whole again, trashing the efficacy of medical marijuana as an effective, largely non-invasive solution, is counter-productive to say they least. To do this would be to ignore the overwhelming evidence to the contrary.
Simply due to space constraints, we will post the next installment in this Gonzo Okanagan investigative series in the coming days and weeks. Check back for more developments in this emerging story.