Medicalising the grass and sanctioning weed for enjoyment is top agenda. The momentum seems to have reached the point of oblivion and what has been proven to interfere with higher order brain function has become a panacea, and more innocent than a sip of water. Bigoted arguments and distorted pieces of evidence are being put forth in the direction of the by now formed beliefs and most probably already set goals.
Past key experiences tend to shape our internal belief system. Firmly held ideas formed through repetitive or emotionally-laden events and actions are not only difficult to alter but act as templates of information processing, modifying all sorts of new information in a way that confirms and strengthens the already formed opinions. This is human nature, possibly explaining how different aspects of our personality are carved; two opposing beliefs cannot reside inside a single mind for long. One of them got to give.
A degree of biased thinking is therefore inevitable. More often than not, we do not disagree completely but have different priorities giving more or less weight to different aspects of the same argument. In other words, conclusions are largely determined before information processing begins and depending on how strongly we "feel" about particular issues, new data can only endorse, question or at best initiate the process of slightly modifying our preformed convictions. This would apply to beliefs and opinions concerning any subject that matters to us, let alone when the bone of contention is personal experience with, and views about, a psychoactive substance that primarily disturbs thinking, emotions and memory representations.
Some may argue that medicinal cannabis is a completely separate issue from the legalisation of marijuana for the purpose of enjoyment. However, the process of creating a legal framework for prescribing cannabinoids as a treatment inevitably contaminates the belief system of many by directly or indirectly highlighting its presumed curative properties independent from any research evidence supporting such claims. It is not easy to retain the perspective of the scientifically proven addictive, psychopathological and cognitively disruptive properties of cannabis in the context of the same substance being proposed as a wonder and much desired treatment embraced and prescribed by medical doctors. The awarded therapeutic status of a once harmful drug of abuse consequentially paves the way to its legalisation for less noble uses outside the field of medicine, at a stage where previous beliefs about its dangers have been repressed.
In the space of a couple of days I came across three adults with no previous history of impaired mental function who described somewhat similar experiences with cannabis oil. One was self-medicating for pain and anxiety whilst the second one sought an improved state of wellbeing. The third one used it for no particular reason; he managed to get hold of it and gave it a try. The first claimed that one morning, whilst walking towards his car in his home town, he got lost. He could not recognise the streets and familiar landmarks. It was as if his internal GPS failed to synch with satellites. He had to endure the embarrassment of being escorted back home by a neighbour almost twenty years his senior. His perplexity was evident and it took him many hours to regain orientation. The other person was driving through a busy one-way tunnel. All of a sudden he got the impression that the cars in front were driving in the opposite direction towards him, as if he had wrongly entered the adjacent tunnel. He impulsively swerved against the wall to prevent the perception of a head-on collision. The third had just picked up his grandson from school. He could not recall the series of events which led to an assessment at the emergency department. His relatives claimed he switched abruptly to a different person with very inappropriate and disinhibited behaviours in the middle of the road. The police had to intervene. These experiences seem to have resulted from acute confusion, including a disruption of normal executive brain functions involving orientation, evaluation of sensory information, sustained attention, impulse control, memory registration and insight. The outcome on both the persons involved and others can understandably be very serious. More recently, I got a perturbing snapshot from the world of a ten year old boy who had to repeatedly put up with the indecorous behaviours of his father, fuelled by flawed insight, defective impulse control and explosive emotions in the context of heavy marijuana consumption.
In my opinion, the most worrisome aspect about cannabis prescribing as a medical treatment and the provision of an additional and legal source of marijuana for its sought after mind-altering effects, is the perceived low or absent damage associated with its consumption, compounded by related beliefs of overinflated curative powers extended to all sorts of diseases and ailments. The Center for Behavioral Health Statistics and Quality in the United States published a multi-state report in 2016 and revealed that the wrongly perceived diminished risk of harm from cannabis use was associated with higher levels of consumption. The conclusions of two very recently published papers on the same side of the Atlantic, where experience with legal cannabis for both medicinal and recreational use is substantive, raise other important points. The first report from the US suggests that doctors need to be more knowledgeable about the risks associated with cannabis use such as occupational and social dysfunction so that they are in a better position to counsel patients who consider using it. The second comprehensive study from the Alberta (Canada) College of Family Physicians concluded that the anticipated benefits of medical cannabis are not underpinned by reliable scientific research, and even in specific conditions which demonstrated a degree of symptomatic improvement with cannabis, any benefits were shown to be less than previously thought to the extent that they are outweighed by the known risks. The lead researcher, a Professor of Evidence-Based Medicine, concluded that prescribing cannabis is akin to putting the cart before the horse, referring to exposing patients to a substance with known dangers but without clear evidence of benefit. To that end, clear guidelines were published last month. The main recommendation is against medical cannabinoids for most conditions and patients. When used specifically for some types of chronic pain, nausea and vomiting after chemotherapy and to alleviate the spasticity of spinal cord injury and multiple sclerosis, the same report concluded that cannabis should be prescribed as a last resort after other treatments have been tried and failed. Doctors have a responsibility to discuss the limited benefits and the common harms with their patients when considering prescribing medical cannabinoids. In another continent, the Royal Australian College of General Practitioners's position paper issued in October 2016 highlighted the general dearth of reliable evidence supporting cannabis efficacy as a treatment, the significant risks of adverse events and the need for public and medical education on this contentious issue. The Medical Association of Malta took a very similar position in a statement issued last December.
In the light of the above and the common good, our policy makers should reconsider their options. The pressure that patients put on their doctors as a result of implanted beliefs about cannabinoids' amplified abilities to remedy any condition under the sun whilst blinding their eyes completely to its harms and dangers, is already being experienced by a number of Maltese doctors, same as other places including the US and Canada. This, coupled by an inexistent patient registration system with a single family doctor or group practice that reliably prevents doctor shopping, opens many new doors for its abuse. Other risks, such as diversion of the prescribed cannabinoids to third parties and consumption of more cannabis products obtained from illicit sources on top of the prescribed amount, need to be taken into consideration. In Colorado, where cannabis was legalised, there was a surge of unintentional cannabis overdoses in children in the years after the law was activated.
Taking into consideration the most recent research and medical recommendations from different parts of the world where accumulated experience and evidence of cannabis prescribing and outcomes is substantial, I would suggest that policy makers should be exceedingly cautious when implementing any change that adds new sources and therefore increases the availability of cannabis and cannabinoid products. I can hardly think of another drug that has been so enthusiastically put on the medicine formulary in the absence of a single licensed indication, due to lack of scientific evidence to warrant such a licence, and in the face of solid evidence of harm and abuse.
Our health care system has a number of advantages including the relatively straightforward and timely access to healthcare specialists. This is not without risks especially when what patients strongly desire may not be exactly what they need or what is reasonably safe. Therefore, I believe that to reliably contain the identified risks, the initiation of cannabinoid prescribing should be limited to medical specialists treating the identified diseases that seem to respond to cannabis when other treatments have failed. These include oncologists, pain specialists and neurologists. The other medical doctors should be warranted to continue prescribing and monitoring the patients started on cannabinoid medications by the mentioned specialists and to refer back when medically indicated. The Health Products Regulatory Authority of Ireland in 2017 emphasised the need of a controlled access programme for the treatment with cannabinoids, specified a limited list of conditions which can be treated with these drugs given the current state of evidence, and stipulated that such patients should be under the care of medical consultants who are responsible to input medical information and utilisation data in a central register to ensure accountability.
As it comes to legalising cannabis for enjoyment through its perceived effects of being stoned, I would suggest to put any plans in reverse. In these circumstances making legal what has been illegal mainly due to its inherent harmful effects is not going to make it any safer. The black market will retain its huge advantage of adapting to changing circumstances and new opportunities in the best way that it suits it, unchecked by any rules and regulations. It would be so naïve to assume that a single reform is likely to neutralise the dominance of the deep-rooted and worldwide illicit drug dealing. Harm reduction is a completely different concept used in special circumstances and the main goal remains prioritising health.
I am neither in favour of cannabis legalisation nor against the use of community orders in most cases of cannabis use as an alternative to imprisonment. Community rehabilitation orders should be the main option in most cases but specific programmes to manage these persons should be created and heavily invested in. I have worked abroad in similar programmes run by Probation Officers and Social Workers offering a range of rehabilitative, occupational and other social interventions, apart from mandatory regular urine drug testing and health assessment and treatment wherever indicated. I would add the opportunity of supervised work in a drug residential programme or alternative community work as part of the requirements dictated by the Court Order.
Legal consumption of cannabis whether for treatment or for joy remains a substantial threat to normal brain functioning and its effects can be both immediate and longterm. The associated losses, therefore, not only occur in the present, but more so in the future as the cumulative effects of prolonged or repeated cannabis use catalyses the gradual deterioration of imperative brain functions. Not everyone is effected to the same extent, but the ability to sustain attention and concentrate, plan, problem solve, develop and retain insight, regulate emotions and control impulses is at stake. In terms of achievement, these cardinal functions translate into stable relationships, sustained parental responsibilities, occupational functioning and job satisfaction, financial security, and perhaps more importantly, physical and mental wellbeing. The lifelong loses stemming out of persistent cannabis use are largely unpredictable and unmeasurable at teenage or early adult years but almost certainly unavoidable.
I have to admit that my arguments are biased by what I am confronted with on a daily basis. My beliefs are warped by the narrative of those who have to pay a high price for their affair with marijuana. My views reflect the suffering and the losses of not only the person hooked on cannabis but also by the distress of their immediate others who struggle with the aftermath of the ongoing self-destruction of their loved one.
Anthony Dimech is a Consultant Addiction Psychiatrist