‘It’s mind boggling’: the complex and growing use of medicinal cannabis in Australia | Health
When Helen was diagnosed with fibromyalgia in her early 40s, her doctor prescribed a range of opioids for her. She has tried morphine, meperidine, and a few others, but none have helped relieve the constant pain caused by her chronic illness.
Long before medicinal cannabis was legal in Australia, when Helen was traveling across North America, a doctor at a dispensary suggested that she try cannabidiol oil. âHe gave me this bottle of tincture and taught me to use a drop or two under my tongue,â says Helen. âMy pain has diminished considerably. I was stunned.
But once she returned from her trip, her only option was the black market.
Helen is one of hundreds of thousands of Australians who have turned to medicinal cannabis to treat many ailments they believe have not been helped by traditional therapies. But as the industry grows after being legalized in 2017, the evidence remains inconclusive and the costs, for many, prohibitive.
Today in Australia, medicinal cannabis products are only available on prescription. Data from the Therapeutic Goods Administration shows that more than 172,000 people have been granted access to medicinal cannabis through its special access program.
Only two products have received TGA approval and are listed in the Australian Therapeutic Products Registry. One is Epidyolex, prescribed for rare but severe forms of drug-resistant epilepsy in children. The other is Sativex, approved in 2012 to treat muscle spasticity associated with multiple sclerosis.
Doctors can request access to 224 different unregistered medical cannabis products through the TGA program or as an authorized prescriber. These products can be capsules, oils, nasal and oral sprays containing THC (delta-9-tetrahydrocannabinol) or CBD (cannabidiol) or a combination of both. Some of them are of plant origin. Others are produced synthetically.
Along with the skyrocketing demand for medicinal cannabis, there has been increasing research interest around its use, with numerous clinical trials attempting to demonstrate its effectiveness for a number of medical conditions.
Yet strong evidence is often lacking and many products still go unregistered, making it difficult for many GPs to prescribe with confidence.
Assoc Prof Vicki Kotsirilos, GP and Australia’s first authorized prescriber of medicinal cannabis, says the process of prescribing medicinal cannabis is “much easier” than it was four years ago.
The main challenge facing GPs is choosing the right product from over 200 unregistered products, for which no clinical evidence is available. âChoosing the right product is a real challenge,â says Kotsirilos.
Professor Iain McGregor heads the Lambert Initiative for Cannabinoid Therapeutics, a University of Sydney research center founded by a donation from former financial entrepreneur and medicinal cannabis entrepreneur Barry Lambert.
âIt’s pretty mind-boggling trying to match a patient’s condition with the right product and the right dosage, because often that clinical trial evidence isn’t there,â McGregor says.
Yet the number of medicinal cannabis users has increased over the past five years. This year alone, more than 86,000 applications were filed, and the number is expected to exceed 100,000 next year.
Like Helen, the vast majority of patients use prescription medical cannabis to manage chronic pain. Yet last March, the College of Pain Medicine at the Australian and New Zealand College of Anesthesiologists issued a statement recommending that healthcare professionals not prescribe medicinal cannabis products available to treat chronic pain not. cancerous, unless they are part of a registered clinical trial.
âThere isn’t yet a single clinical trial that shows that CBD does anything useful for chronic pain,â McGregor says. “The prescription continues nonetheless, and it is not an evidence-based prescription.”
Common uses of medicinal cannabis include the treatment of cancer pain and sleep and mood disorders. Anxiety is now the second most common condition for which patients seek medicinal cannabis.
Larry, a 43-year-old carpenter living on the Gold Coast, has been using it for 18 months to deal with anxiety and depression.
Surf lover, artist and father of five, Larry has struggled with his mental health since losing his father at a young age. âI used to use a lot of cannabis in my late teens and twenties,â he says. “It just took away that benefit of anxiety and depression.”
At the time, Larry was buying on the black market. Now he attends a specialty clinic and uses low dose CBD with 2% THC. “The best thing about [medicinal cannabis being] regulated is that it’s grown in controlled environments – it’s not just someone growing it in their garden or you growing it. You know exactly what you are getting.
Larry says that medicinal cannabis is a tool he uses to manage his anxiety, while staying active, eating well, and living a healthy lifestyle. “[Medicinal cannabis] is not a quick fix, but it just gives you a bit of a break, âhe says.
Putting the puzzle together
Like THC, CBD binds to cannabinoid receptors in the brain, controlling the release of chemicals that regulate functions and processes including mood, emotions, sleep, appetite, and pain. Low levels of serotonin in the brain can cause anxiety, depression, and other mood disorders. Researchers hypothesize that high doses of CBD may help regulate serotonin levels in some people’s brains.
âThere are a multitude of receptors that we know CBD interacts with,â says McGregor. “But the whole thing is very complicated, and we still don’t have the complete puzzle assembled.”
The ability of CBD to act on many different receptors does not translate into significant therapeutic benefits. âBecause it opens so many doors, you would think it would have profound effects, but it’s quite the opposite,â says McGregor.
While some people continue to report considerable benefits from CBD oil, he says, clinical studies have shown that low doses of CBD show no difference compared to placebo.
âParadoxically, the vast majority of patients use CBD oil at doses for which we have no evidence yet,â he says.
Late last year, the TGA approved CBD products with a maximum dose of 150 milligrams per day to be sold over the counter as Schedule Three drugs. But unlike prescription-only cannabis drugs which can be prescribed even if not registered, over-the-counter CBD products must be listed in the Australian Therapeutic Products Registry.
To register their products, companies must prove that they have clinical benefits, and so far there are no low-dose CBD products on the registry.
âA lot of companies claim to pursue over-the-counter registration,â says Rhys Cohen, editor-in-chief of Cannabiz and non-executive advisory member of the Lambert Initiative for Cannabinoid Therapeutics.
âThere are a smaller number of companies that actually attempt this job. Whether or not they are successful is uncertain as no one has previously demonstrated that CBD in these low doses is effective in treating a health problem. “
While clinical trials have proven the effectiveness of some high dose cannabis-derived drugs such as Sativex and Epidyolex, the evidence remains anecdotal for low dose CBD products.
Complex and individual
“CBD has a very complex pharmacological action that we still don’t fully understand, âsays McGregor.
Kotsirilos says that in his experience not all patients experience the same benefits: âEveryone’s response is different. Some people are more sensitive than others.
Starting with low dose CBD oil only is her preferred strategy for most patients, slowly increasing to higher doses if necessary, and finally consider introducing THC. But in patients with severe pain or nausea and vomiting from chemotherapy, such as those in hospice care, she says, there is no point in giving CBD alone.
âUnfortunately, not all general practitioners are familiar with CBD products and don’t feel confident enough to prescribe them to patients,â she says. âThis is a gap that we must fill with a balanced education in Australia. “
Costs and risks
But while the evidence for its effectiveness remains inconclusive, for the many Australians who turn to the drug for the hope of alleviating their pain and other ailments, the costs can be substantial.
The access system disadvantages poorer Australians who are more likely to suffer from the conditions for which medicinal cannabis is most in demand. More than half a million people still turn to the black market for health care, and that carries great risks.
Usually, unregulated products sold on the black market are not pure compounds but contain an indefinite amount of CBD and THC and a mixture of other substances, with unknown effects on the body. And home growers often use a range of pesticides that can cause serious unwanted effects.
When Helen couldn’t find a general practitioner willing to give her a prescription, she looked for a medical clinic specializing in medicinal cannabis.
While these clinics provide patients with access to CBD oil products, most of them are not affordable. âThese clinics charge exorbitant prices,â says Helen, who paid up to $ 350 for a 15-minute telehealth consultation.
This adds to the cost of the products, which average $ 0.14 per milligram, with prescribed doses ranging from 50 to 200 mg per day. The government does not subsidize medicinal cannabis products under the drug benefit plan.
For many patients like Helen, this equates to spending hundreds of dollars each month.
âI’m 70 now and still working to pay for my medications,â she says. âIn the future, I would like to see better education for people and doctors; I would like to see the costs go down; I would like to see a fairer access process for all.