Family doctor Andrew Agius has called on MPs to consider a declaration made by the World Health Organisation regarding a particular cannabinoid known as CBD before passing medicinal marijuana legislation.
Parliament is in the midst of debating changes to the Drug Dependency (treatment not imprisonment) act, which would legalise medicinal products derived from cannabis. In the bill's proposed form, it would not be legal to prescribe preparations for smoking, and the flowering bud of the marijuana plant is still not permitted, however doctors would be able to prescribe capsules, oils and inhalers derived from the cannabis plant.
Having been at the forefront of medical practitioners advocating for multi-purpose plant, The Malta Independent sat down with Dr Agius to gauge what his initial reaction was to the way the Bill has been drafted and the parameters set out.
On the outset, Dr Agius pointed towards a WHO declaration which found that CBD is safe, non-addictive and not a public health risk. It called on the substance to be de-scheduled and made easily accessible to patients.
CBD is a component of the marijuana plant. Unlike its more famous sister, THC, this component does not leave one with a classically 'stoned' feeling, and research has pointed towards its therapeutic conditions for a variety of ailments.
The standard operating procedures to authorise cannabis preparations are proposed by this Bill are to observe the following conditions: All preparations requested by medical practitioners are "to comply with the Medicines Act or manufactured under Good Manufacturing Practice".
All licensed medical practitioners are entitled to prescribe medical cannabis; they must send an application for its use to a generic e-mail at the office of the Superintendent of Public Health. The application is then processed and if accepted, the "prescriber, pharmaceutical wholesale dealer and the pharmacist receive a copy of the application endorsed by the Superintendent for Public Health".
Should the application be rejected, the above parties would be notified with the reason for the rejection listed.
Good Manufacturing Practice and increased costs
Asked about whether the requirement for medicinal products derived from cannabis preparations to be manufactured under GMP will lead to increased costs, Dr Agius said: "GMP means that the medicine will be of a certain standard, it will be pharmaceutical grade and the doctor and patient will know exactly what dose they are being prescribed and consuming.
"It has been implemented to have a certain standard of medication. Like Health Minister Chris Fearne said, there will be an open market so quite a few different importers will be getting different products. There will be competition and the price will go down. It should not really be a big issue having medicines that are GMP because it is the new standard that is coming into Europe.
"Even the companies manufacturing cannabinoids, most of them are not GMP but they are slowly making the necessary changes to become GMP because that is what everyone is requesting. It is good because you know you are getting something of good quality."
Initial reaction to the proposed Bill - no flowering buds
"I think Malta is still not prepared for the full range of medicinal preparations. As we know abroad where it has been established and it is being used, vaporising the raw plant material is the most popular and one of the most effective ways of delivering the medicine.
"As doctors, we would never recommend smoking the product, because we know that smoking combusts the material and it can cause respiratory illnesses such as asthma. This is why we do not recommend it as a method of delivery.
"Vaporising is a safe method of delivery, and very often dried plant material is used, especially in these big dispensaries one can choose different strains and each variety has its own unique effects on the body.
"Patients could be able to try different types and try the strain that works for them the best. That will obviously be missing for now under the proposed Bill, hopefully in the future it might be an option because it is definitely worth considering.
"For now, there are going to be different extracts such as oils, capsules, sprays and inhalers available on prescription."
CBD oil and control cards
In view of the non-harmful effects of CBD, a component of the marijuana plant, as stated by the World Health Organisation, Dr Agius called into question the need to get approval from the superintendent to prescribe preparations consisting of CBD and virtually no THC.
THC is another component of the plant, called a cannabinoid, which leaves one feeling 'stoned' in the classic sense of the word. Therefore, Dr Agius suggests that in medicinal products derived mainly from CBD and has very little-to-none THC, the WHO's declaration should be considered and thus it should be available without a control card.
"Even in the case of medicinal preparations with no THC, one has to go to their doctor, the doctor has to apply for a control card with the superintendent, the superintendent must approve this, and the patient must go regularly for a repeat prescription, even for just CBD. This does not make sense at all because CBD is legal and freely available throughout the whole of Europe.
"Making it very difficult to obtain a medicinal grade CBD product could result in people buying it from the internet. CBD should be adjusted I think in line with the WHO declaration that CBD is safe and should not be scheduled."
Doctors prescribing and patient uptake
Dr Agius was questioned on whether he believes doctors and patients would be slow to try such medicinal products once legalised, he said:
"I think that when doctors start witnessing the therapeutic effect of this medicine, when they try it on their patient in low doses, it will just be a matter of time for patients to start improving. Once patients start going back to their doctor and telling them that their diabetes is controlled, their pain is controlled, they are sleeping better, and they are coping with certain ailments better, I am sure that more people will start to pay attention."
Interest from doctors
In view of marijuana's status as an illegal recreational drug for as long as anybody can remember, one begins to question how many doctors are seriously considering the therapeutic herb as an alternative to already standard practices.
"The plan is to get a specialist to come to Malta to be able to give doctors another perspective and maybe to provide lectures on certain basic topics, on how to prescribe, the endocannabinoid system, the uses of these medicines, when not to give them and when to be cautious, maybe doctors can get some more confidence to be able to prescribe safely without worrying."
He continued to explain that should a patient ask for this avenue to be explored, and that doctor is not well informed on it, then it will be hard for the patient to get access to their medicine.
"Many professionals think it's addictive, it does have its risks and side effects but all medicines do. I believe that much of it boils down to stigma."
Another testimonial
During the last interview conducted with Dr Agius, he described how a fibromyalgia patient's life had changed overnight thanks to the substance. This time he told another story, this time he spoke of another individual, an Italian man in his late 20s suffering from Still's Disease.
It is a condition where the immune system does not function properly. The Italian man in question was suffering high fever, general illness, high white blood cell count and other complications associated with inflammation in the body.
He was treated with high-dose steroids for a few years, during which he put on about 40kg in excess weight and after about a year and a half, he could no longer take the side effects. Apart from the weight he couldn't handle the mood swings ranging from anger to depression. He looked into an alternative and started smoking two joints at night.
The Italian man managed to get off the steroids, bring his weight down to normal and his control his condition. He is still smoking two joints per night, but he is off all other medication and his condition is controlled.
While all cases are different, and not everybody reacts the same way to the same treatment, testimonials such as the woman suffering from fibromyalgia and this young man suffering from Still's disease, in addition to testimonials from all over the world makes it hard to completely ignore using the plant for medicinal purposes.