There are certain expectations every individual has when visiting their doctor. The first expectation is for a diagnosis to be made, and the second of course is for the most suitable form of treatment to be prescribed. A decision regarding any treatment has to consider the evidence supporting its’ efficacy, knowledge regarding how it compares to other treatments and a reassurance that the benefits obtained will outweigh any potential harms. Should any treatment carry a risk of severe harm, there is a legal obligation to be informed of this, allowing for an opportunity to make an informed decision regarding your health care.
I therefore find it quite interesting that in our country there appears to be an increasing sense of acceptability of the cannabis plant or oil for various ailments. While I find this trend intriguing, I cannot say I am surprised.South Africans today find themselves being drawn into a constitutional court case discussing the possibility of cannabis being classified as a legal substance, as well as a Western Cape High Court judgment allowing for the growth of cannabis on one’s property, which is yet to be validated at the Constitutional Court.
At this point in time there are several countries that have decriminalized cannabis, which is an act to remove a criminal penalty associated with using it. Anyone found to be using cannabis under this law would still face a penalty that ranged from paying a fine to being advised to enter a rehabilitation unit, while those found to be cultivating or selling cannabis would face a criminal record. Decriminalization acts to protect any individual addicted to cannabis, it was not designed to convey a sense of safety or acceptability.
There are fewer countries and states that have acted to legalize cannabis, i.e. removing the penalty associated with using, selling or cultivating. While the act to decriminalize a substance is accepted as being driven from a humans right perspective, protecting those addicted to a substance, there is to this day international concern about making cannabis accessible for either medicinal or recreational purposes.
Budney et al (2017) argues that the ease of accessing an intoxicating substance has an underestimated influence on the initiation, frequency and risk of developing an addiction later in life. The perceived risk of cannabis has declined over the past 20 years (Pacek et al, 2015), and this has been associated with an increase in prevalence of cannabis use and addiction in the United States (Hasin et al, 2015).
The State of Colorado on the 1 st of January 2014 became the first American state to allow for legal sales of non-medical marijuana for adults over the age of 21. Youth perception of risk was found to decrease significantly, an increase in hospitalizations related to cannabis use increased by 70% between 2013 and 2015, poison center calls related to children between the ages 0-8 increased by 63% in the first year after legalization and fatalities where drivers tested positive for cannabinoids increased by 80% between 2013 and 2015.
An editorial published in the May 2017 edition of the Canadian Medical Association Journal condemned the decision by the Canadian government to legalise cannabis, pointing out that “cannabis is not a benign substance and its health harms increase with intensity of use”. In 2016 the Drug Enforcement Agency (DEA) of the USA denied a petition to loosen the Federal Law regulating cannabis accessibility. Federal Law in the United States still classifies cannabis as a Scheduled 1 controlled substance, which means it is considered to have ‘no currently accepted medical use’ and a ‘high potential for abuse’.
An editorial published in the Journal of the American Medical Association in 2015 argues that most of the qualifying conditions approved for medical marijuana in the United States relied on low-quality scientific evidence, anecdotal reports, individual testimonials, legislative initiatives and public opinion, that the current evidence failed to meet the US Food and Drug Administration standards.
In South Africa, our Central Drug Authority published a position statement in 2016 stating “there is insufficient data to indicate that legalisation of cannabis will not be harmful, and that the immediate focus should be on the decriminalisation rather than the legalisation of cannabis”. A position statement published in 2018 by the South African Society of Psychiatrists states that “any potential benefit obtained from cannabis must be weighed against its’ risk of addiction, risk of psychosis, cognitive impairments and a 2.6 times greater likelihood of causing a motor vehicle accident”.
This position statement further states that that “any change to legislature regulating cannabis use should include the views of appropriate regulatory bodies, be based on good quality evidence and take into consideration the availability and accessibility of current drug addiction treatment resources in South Africa”.
While we are yet to discover the outcome of the current constitutional court cases, one can likely assume it has affected public opinion to a large extent. A combination of perceived safety, myth, facts and ongoing legal debate has proven to be a very dangerous thing indeed.
In terms of the medicinal benefit the cannabis plant has to offer, it is highly likely that at least one of the chemicals found within the plant will be of future benefit to us. A WHO expert panel has recently published an article focusing only on cannabidiol and the medicinal potential is has to offer and that further investigations are still required. The plant itself has over 100 different chemicals capable of activating our brain’s receptors and exerting some effect. We know that these chemicals act in an entourage manner, but it remains a system that is not fully understood and is being investigated.
At this point in time there is no evidence comparing these chemicals to medications known to be effective. While we have evidence of the cannabis plant improving symptoms related to certain diseases, we are not at a point where we can with confidence say it is a superior form of treatment for any condition. The recently published outcome of a 4 year prospective study investigating the use of cannabis for people with chronic non-cancer pain (Campbell et al, 2018) found that those who used cannabis had greater pain, lower self-efficacy in managing pain, greater Generalised Anxiety Disorder severity score and no evidence of cannabis reducing prescribed opioid use.
No doctor would prescribe a medication that contains over 100 different chemicals, many of which we still know very little of. Further to this, there are numerous concerns regarding the long-term use of the cannabis plant or cannabis oil.
It is estimated that 9% of those who experiment with cannabis will become addicted to it. The South African Community Epidemiological Network on Drug Use reports that between the periods of January to June 2017 cannabis was the most common primary substance of abuse for teenagers admitted to a drug rehabilitation unit in all provinces of South Africa. Cannabis is known to impair attention, learning, memory and inability to switch between ideas. There is now evidence that these impairments may persist if initiation of cannabis use occurred during adolescence. Heavy use during the adolescent period also places one at greater risk of schizophrenia, or may precipitate an acute event in those known with mental illness. Some studies have found a 2 fold increased risk of motor vehicle accidents while intoxicated. There is growing evidence linking cannabis use with sudden cardiac death, myocardial infarction and strokes.
I firmly believe that every individual should have the right to choose the form of health care they feel most comfortable with, but be sure to make an informed decision. ‘Organic/herbal’ remedies do have harms associated with it and may interact with medications you may currently be consuming. There are numerous known examples of this. While cannabis may have benefitted or been safe to ‘someone you know that has used it’, you simply cannot be reassured it will have the same effect on you.
Stay healthy my fellow South African, your mental and physical health should always be your highest priority, be sure to protect it.
Dr. Abdul Kader Domingo is a Specialist Psychiatrist and Senior Lecturer at Stellenbosch University.