As a drug, cannabis both enjoys and suffers from its own reputation. Scientific research has shown the drug to hold significant therapeutic potential as a treatment for many different medical conditions, and cannabis has been used as a component in traditional medicine practices going back centuries.
But cannabis has also been presented as a ‘panacea’, capable of treating almost anything if certain areas of marketing hype are to be believed. Further complicating matters, cannabis has been prohibited under international narcotics law since the 1960s, and, as a result, the drug is still largely treated with caution by many consumers, medics and lawmakers.
As a result, many legislatures are inclined to ask that further scientific research and review be done before reform measures are seriously considered. This was seen in the case of the United Kingdom, where the rescheduling of cannabis-based medicinal products was preceded firstly by an extensive review led by the nation’s Chief Medical Officer, and then a secondary review from the Advisory Council on the Misuse of Drugs before being enacted.
This desire for further research to lead policy decisions is encapsulated in the Prohibition Partners’ trend Knowledge is Power. It is one of several key trends identified by Prohibition Partners that have shaped the cannabis industry in recent years, and will continue to greatly influence the market in the years ahead.
Ancient medicine meets modern measures
Evidence for ancient human use of hemp – part of the annabis sativa plant species – dates back around 10,000 years. The Chinese physician and surgeon Hua Tuo (c.140–208AD) is credited as being the first person to use cannabis medicinally for its pain-relieving properties, and as the years went on, cannabis spread from Asia through ancient Mesopotamia, Persia, Arabia and into parts of Europe, where the drug continued to be used as both a textile and a medicine for centuries.
This traditional use of cannabis as medicine continued uninterrupted for hundreds of years until the signing of the 1961 Single Convention on Narcotic Drugs, which saw 73 world governments officially agree to list the cannabis plant as a prohibited substance.
‘Essentially, the 1961 Single Convention was designed to replace all the pre-war conventions that existed at the time to control narcotic substances, and it imposes restrictions in relation to cannabis, opiates, cocaine and other drugs of that ilk,’ explains Elliott Rolfe, Associate Solicitor and Head of Cannabis Law at Mackrell.Solicitors.
‘Signatories to the convention were obligated to criminalise the possession, cultivation and trade of cannabis and the other scheduled substances, and the convention even abolished the traditional and religious uses of these substances. Cannabis got particularly a harsh treatment, considering that some of the far more harmful drugs (such as cocaine and opiates) were granted some medicinal use, whereas the WHO had, by that time, declared cannabis entirely useless as a medicine.’
‘Luckily, in recent years, the world has woken up very quickly to the reality that cannabis is one of the most versatile and important medicines in the world,’ Rolfe adds. ‘So, the question on a lot of lawyers’ lips is to what extent are signatories to the conventions now stuck legally? Is it breaking convention to legalise the substances at the individual country level? Are the conventions and the policies baked into them outdated? Yes.’
After decades of this prohibition under international narcotics law, and the complex legal questions concerning legalisation at the national or state level, policy reform on cannabis has so far advanced at a cautious pace. Instead, many legislators are looking to reform their approach to cannabis research.
Barriers to research
(Source: University of Mississippi)
Despite the appetite for further research, in practice this is still extremely difficult to carry out. Even in regions where cannabis research is not strictly illegal, there are often structural barriers that need to be overcome.
In the United States, cannabis is federally classed as a Schedule 1 substance with ‘no currently accepted medical use and a high potential for abuse’, despite varying state-level cannabis laws. In order to conduct a cannabis research project in the US, researchers must first get approval from the US Food and Drug Administration (FDA) and obtain a special Drug Enforcement Administration (DEA) licence to handle Schedule 1 drugs, which can take up to a year to receive. The National Institute on Drug Abuse (NIDA) then needs to review and approve all research projects before any cannabis can be supplied for research purposes. This convoluted process (and an equally challenging environment to secure project funding) is a prime example of why cannabis research is so stymied.
The chemical complexity of the cannabis plant itself also presents an extra complication, as it can be hard for those conducting clinical trials to interpret results with so many biologically active compounds at play. To date, over 500 distinct compounds have been identified in cannabis, including over 100 cannabinoids unique to the cannabis plant family. Further complicating research matters, different strains of cannabis can have hugely different cannabinoid profiles, which in turn can promote different effects on the body.
This historic lack of clinical understanding makes it particularly difficult to assess the potential benefits and risks associated with cannabis, and as a result medical cannabis has generally lacked the basis it needs to gain widespread endorsement in medical settings.
Improving clinical understanding
(Clinical trial records including ‘Cannabis’ and synonyms, as of 14 April 2020)
Clinical study lies at the heart of understanding cannabis. A search of registered clinical trials available through the ClinicalTrials.gov database found a total of 936 studies that reference cannabis as a part of the trial design, and 629 studies that mention CBD. This pales in comparison to the 7,548 studies conducted on opioids – a class of drugs found naturally in the opium poppy plant – and the 335,815 total studies hosted on the database, which charts trials conducted after February 2000. Notably, however, cannabis research is gaining pace. Since the turn of the 21st century there has been a veritable explosion of clinical-trial research on cannabis, with 82% of all trials listed being conducted post-2000 and 38% since 2017.
Despite cannabis being a controlled substance under US federal law, it is interesting to note that more than half of registered clinical trials on cannabis have taken place within the US.
The US DEA has recently announced that it will begin reviewing other federal cultivation licence applications, in order to improve the diversity and the quality of cannabis available to researchers in the US.
The current lack of clinical-trial data means that many aspects of medical cannabis await clarification: administration, dosages, interactions with other drugs, and the assessment of adverse effects.
A mix of inconsistent legislation, split opinion across governments and health authorities, and cannabis’ status as an unregistered medicine in most countries has meant that clinicians are largely uncomfortable prescribing a product seen as carrying an element of personal risk. Prohibition Partners anticipates that as research and clinical trials continue, these findings and understandings will find their way into the teachings of medical schools and programmes, allowing medical professionals to feel more confident in the prescription and monitoring of medical cannabis treatments, and consequently leading to improved access for patients.
The cannabis industry is actively pushing to improve clinical understanding. For example, healthcare professionals in the UK and Ireland have set up Europe’s first medical cannabis education platform, The Academy of Medical Cannabis, to provide clinicians with information on all aspects of cannabis treatment and prescribing. But there is only so much the industry can do within the confines of the current clinical-trial process.
Cannabis will find a less controversial and more secure place in the medical establishment only once robust, reliable data exists to support it. This and only this will pave the way for creating a legal space for cannabis as a medicine that is recognised and accepted by all.