Self-Medication with Cannabis, Chapter 17
Arno Hazekamp and George Pappas
April 2019, 17-Pertwee-Chap17.indd 319
The medicinal use of cannabis is slowly gaining a more general acceptance worldwide. Canada (since 2001) and the Netherlands (since 2003) have government-run programs, in which quality-controlled herbal cannabis is supplied by specialized and licensed companies. Several other countries are now setting up their own programs (Israel, Czech Republic, Switzerland) or import products from the Dutch program (Italy, Finland, Germany, Switzerland). In the US, despite strong opposition by the federal government, so far 18 states including the District of Columbia have introduced laws to permit “medical marijuana use” (Americans for Safe Access 2012). In these states, patients grow it on their own or collectively, or obtain it from larger growers that act as caregivers for groups of patients. In some states, large-scale operations are licensed to supply the entire demand, but almost no official quality control standards have been released so far. But no matter how cannabis is supplied in all of these different programs, it is usually left up to patients themselves to decide how to administer the herb. Self medication with cannabis is therefore probably the most common way of using cannabinoids medicinally. Consequently, there may be a lot to learn from the actual experiences of patients self medicating with cannabis products worldwide.
Self-medication is inherently difficult to study, as it does not happen in the convenient and controlled setting of a laboratory or hospital. Currently, little published data is available on the extent of medicinal cannabis use and the characteristics of patients involved in it. The limited survey data, case reports, and other “soft” means of gathering information that exist make it hard to draw firm quantitative conclusions that can inform clinical practice on how to prescribe cannabis adequately. Fortunately, there is a growing interest in performing scientific studies (Hazekamp and Heerdink 2013; Janichek and Reiman 2012) and large-scale surveys (Hazekamp et al. 2013) on these patient populations, to contribute to the understanding of cannabinoid-based medicine by asking self-medicating patients detailed questions about their experiences.
At the same time, the policy developments that are designed to accommodate legitimate and qualified users are fiercely debated by medical authorities, law enforcement agencies, and politicians around the world, and sometimes with good reason. Although cannabis seems to fill some urgent medical needs, many current systems leave enough incentive for recreational users to act as pseudopatients in order to obtain legal protection for using cannabis. Furthermore, while safety of cannabis is generally accepted to be within the range often deemed to be acceptable for other medications, clinical trials have not yet been able to supply a clear answer on what are supposed to be the “real” medical indications for cannabis use. Finally, there is still much to learn about the risks of potential contaminations with pesticides, growth-enhancing chemicals, microbes, or heavy metals, especially in the absence of quality control. For all these reasons, physicians are often hesitant to play the role of prescriber or “gatekeeper,” even in the official government programs of Canada (Sullivan 2012) and the Netherlands (Hazekamp and Heerdink 2013)
Unfortunately, on both sides of this discussion, arguments are all too often based on personal experiences, political intentions, and emotions, rather than on the growing scientific understanding we have of the cannabis plant. As a result, both the beneficial and harmful aspects of cannabis use may have become somewhat inflated, ranging from “cannabis cures cancer” and “it never killed anyone” to “cannabis will make you psychotic and addicted.” The chemical diversity of the hundreds of varieties of cannabis that are in use today certainly does little to bring certainty to this discourse. Therefore, an important goal in the discussion on the pros and cons of self-medication with cannabis should be to find a sustainable supply model that can fulfil the requirements of medical authorities and policymakers (e.g., standardization, quality control, safety), as well as those of patients and their physicians (e.g., choice of variety and administration form, whole plant preparations), while making a strong but balanced effort to minimize diversion and abuse. Finding balance is crucial, and ensuring that we advance our scientific understanding of cannabis use is the key.
This chapter summarizes some important aspects of the medicinal use of cannabis, including clinical data, administration forms, quality control, dosing, and differences between cannabis varieties. The perspective of the self-medicating patient will be covered by discussing relevant issues such as typical user characteristics, cost, and the social aspects of self-medication. Although the term “medicinal / medical cannabis” is often used, we prefer to use the phrasing “medicinal use of cannabis” in this book chapter instead. While this difference is only subtle, it signifies that cannabis is not inherently medicinal, because the therapeutic effects depend on the variety used, the medical condition it is used for, and a range of other choices such as administration form and dosing regimen. In addition, the term “medicinal cannabis” may imply that the product used is of medical quality (quality controlled, standardized, etc.) which is often not the case with selfmedication. We consider it therefore more correct to refer to the use of cannabis with the intention of creating therapeutic effects. Hence, the term: medicinal use of cannabis.
17.2 Cannabis and medicine : an uneasy combination
According to some, herbal cannabis, also known as marijuana, is a substance whose abuse potential is well documented, but whose benefits are poorly characterized. However, this view overlooks the fact that the harmfulness of cannabis abuse is not as widely accepted as often assumed (Nutt et al. 2007), and that some therapeutic effects claimed by patients are, in fact, clinically supported and sometimes even applied in registered medicines. On the other hand, there is indeed still much we need to learn about topics such as differences between cannabis varieties, synergy of cannabis components, and the sociocultural role of medicinal cannabis.