Hard News by Russell Brown

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More tales from the Medicinal Cannabis Scheme

You may have read last week that two years after the publication of regulations for medicinal cannabis – and three years after the enabling legislation – two local products from a local manufacturer have finally met the minimum quality standards for prescription. You may also be interested to know that it's not quite that simple.

The two products, both CBD oils and both from Auckland-based Helius Therapeutics, are indeed listed on the Medicinal Cannabis Agency website under the SubDrops brand. But their Active Pharmaceutical Ingredient (API) – the cannabidiol itself – is not produced in New Zealand, but imported as isolate from the Netherlands. The isolate powder is formulated – mixed with a carrier oil – at Helius's facility in East Tamaki.

It took some asking around to establish that, but not really because Helius is withholding the information. The rules around advertising of unapproved medicines are so strictly applied that Helius is not allowed to even put out a press release saying it has the products for sale, let alone provide background detail on them. (It did put a little announcement on its website.)

But the timing of the launch is extremely good news for cannabis patients, many of whom were facing sharply higher costs for prescribed CBD medicines after the twice-extended transitional period of the Medicinal Cannabis Scheme ended on October 1, meaning that imported products that had not met the minimum quality standards could no longer be prescribed. It's also a crucial face-saver for the Ministry of Health and Health minister Andrew Little, who are finally able to to point to a local company that has found a way through the regulatory thicket.

The pricing implications are significant. The Helius 100mg product is wholesaling for $115 for a 30ml bottle, meaning that patients should be able to get it for as little $160 from a pharmacy. The comparable product from the Canadian company Tilray is wholesaling for $377 for a 40ml bottle – and selling to patients for $500 or even $600 after pharmacy markup. (I want to emphasise that I did not get this information from Helius and they would be in trouble if I had.)

This is good for Helius too – it's got them into the market at a time when thousands of patients have been cut off from products imported by companies like Medleaf and Nubu and are anxiously looking around for options. But Helius isn't making much money out of this pricing – possibly none at all.

Helius apparently expects to swap out its imported API for a locally-produced one next year and launch a wider range of products, once it can get something past the quality standards. But producing GMP-grade CBD isn't cheap. Helius has a great show at grabbing market share right now – how long it can sustain this kind of pricing isn't clear.

Like Rua Bioscience, the only other local company to have achieved a GMP licence, Helius will be relying on the European export market to stay viable in 2022. Things may get tough for the other New Zealand producers established under the law if they can't get their GMP licences soon.

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Meanwhile, minister Little made a weirdly unhelful contribution to the debate after the transitional period ended by telling the Herald's Derek Cheng that the industry, or "some at least importers who frankly didn't get off their asses and get their applications in when they should have done."

This is unfair bordering on actionable. I know that Medleaf at least has tried repeatedly to get products through the standards, and that when its application for one producer failed because its EU GMP licence wasn't recognised by our ministry, it offered to pay for a remote audit with a telepresence robot. The ministry said no. Medleaf has also repeatedly sought a meeting with Little to discuss its issues. The minister's office said no.

This all wound up in a fairly spectacular radio segment where the minister insisted that our regulations were no different those of countries like Germany. He was followed on air by Medleaf's Shane Le Brun, who explained various ways in which products accepted by Germany have been rejected here.  Short version: New Zealand's regulators have taken the most maximal and least pragmatic path available to them at every step.

The regulations have been eased in a couple of ways recently, most notably in that local producers will no longer be required to do their product testing at GMP labs that literally don't exist in New Zealand. Turns out, ISO-accredited labs are fine. But a broader regulatory review has stalled and won't report until next year.

Little also said in the radio interview that individual prescribers would still be able to import the now-banned CBD products as unapproved medicines for individual patients under Section 25 of the Medicines Act (anything containing THC needs case-by-case ministry approval). Then Medsafe's Chris James went to the press to warn that this right should be used only "sparingly" and bulk imports would be investigated. It's just a bit of a mess.

But that's what's happening. One clinic is using Section 25 to prescribe its own-brand CBD products. Medleaf has also set up an offshore company to supply prescribers under Section 25.

Medleaf's CBD product will be broad-spectrum, which means it contains other compounds, such as terpenes and very low levels of other cannabinoids. Some patients and prescribers regard broad-spectrum products as important for their needs, so there's probably a battle looming over that. The MCS effectively doesn't recognise any role for terpenes or differences between strains, so it's not just a matter of interchangeable isolates.

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The differences between the establishement approach to prescribing cannabis and the broader understanding of cannabis therapeutics are also evident in the long-awaited BPAC guidelines for prescribing cannabis, which are currently up for feedback.

The advice suggests chronic pain, spasticity and childhood epilepsy (CBD only) as primary indications, but warns that "in the absence of large and robust RCTs comparing medicinal cannabis with established treatments, medicinal cannabis products cannot currently be considered a first- line option for any indication." For neuropathic pain, it recommends that at least three other medications should have been tried before cannabis is prescribed and for malignant pain, two others.

Notably absent is any consideration of how patients might feel: as I've written recently, some pain patients simply find prescription opioids and gabapentinoids, which can be freely prescribed, unbearable and feel strongly that cannabis has helped them reclaim their lives. Dr Graham Gulbransen calls prescription cannabis an "exit drug" for that reason.

Yet the BPAC advice declares there is "no evidence that adjunctive use of medicinal cannabis reduces the use of opioids in patients with chronic non-malignant pain", citing a large four-year observational study that did indeed find "no evidence that cannabis use improved patient outcomes." But that study was included in a more recent evidence review that did find quite plentiful evidence of opioid use reduction with cannabis in qualifying studies, but failed it on some familiar basics of evidence quality: not least, what is a dose of cannabis anyway? See also: exactly which cannabis are we talking about?

 The emphasis on clinical trial evidence is inevitable – and it does turn up something interesting. A graphic in the draft advice compares the efficacy of several treatments. For all the problems with funding and conducting high-quality cannabis research, gabapentin and pregabalin actually wash up only slightly better than cannabis does.

There's a kind of cultural gap here too. Anyone who has used cannabis understands that different strains do different things and it's reasonably well established that the respective effects of, say, cannabis sativa and cannabis indica strains are related to their respective terpene profiles, which are thught to modulate the effects of cannabinoids. But the advice to prescribers covers just two isolated molecues, CBD and THC. No other cannabinoids are mentioned, nor terpenes. The gulf between cannabis science and the clinical world still seems hard to bridge.

So it's a baseline for wary GPs, one with a creditable emphasis on conversations with patients and jointly-agreed treatment plans. But I suspect regular prescribers will look more to next year's Helius-sponsored MedCann summit, which will have a prescriber day. Helius is also a sponsor of the mcinfo.com site published by DataPharm, which provides a somewhat gentler introduction for prescribers and their patients.

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Finally, I'm aware that the regulatory battles tend to drown out any good news stories the fledgling industry might generate. So let's focus on a really good news story.

Growing Dope, Wednesdays on Prime TV, tells the story of Rua Bioscience over four years (beginning as Hikurangi Enterprises) with warmth and authenticity. It's striking to grasp how much hope rides on this company and it only increased my respect for Manu Caddie and Panapa Ehau to see how patiently they've worked towards their kaupapa.

You can watch it on your TV and online if you have Neon. Or you can go to SkyGo and sign up for a free account and watch it there. I heartily recommend you do.

PS: Thanks so much to everyone who clicked the support button below the last cannabis issues post and kicked in a little via PressPatron. This stuff is important, but there's a limit to how much I can get in mainstream publications.

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Pearl, prescriptions and patient experts

As I've noted here before, for various reasons, the clinical evidence for cannabis as a teatment for pain and other conditions is not yet compelling. This doesn't mean it won't be, but as the International Association for the Study of Pain put it in a recent position statement, "promising" advances in the science of cannabis as a therapeutic "are yet to be fully translated to efficacious and safe medicines."

"High-quality research is required to elucidate the types of pain, and characteristics of individuals, where there is benefit or harm from particular cannabinoid compounds (personalised medicine). Improved understanding of the clinical pharmacology of cannabis and cannabinoids in a pain relief setting is needed," the association's taskforce concluded.

But as I point out in a story for the Listener this week, there's another way of looking at it: observational studies. These can't prove or disprove any cannabis product as a treatment. But the large patient surveys conducted by Otago and Massey universities in the past couple of years do point to quite a consistent outcome: a substantial group of patients who use cannabis are able to give up or reduce their use of onerous prescription medicines – typically opioids and gabapentinoids – and their lives improve as a result.For the Listener story I also noted two recent Canadian studies that showed the same thing.

And I spoke to three pain patients, one who was using an illicit cannabis balm and two who had more or less found a way through the troubled medicinal cannabis scheme. At least one had been recklessly prescribed to, two had been flagged as drug-seekers for merely enquiring about prescription cannabis, and two had found life on their prescribed pain medications so unbearable that they considered suicide.

I also mentioned Pearl Schomburg, who is the first person I heard this kind of story from. For Pearl, the tipping point was seeing her reflection in a chemist shop window with two full shopping bags of medications for her auto-immune conditions and the pain they caused. She could not, she realised, go on living like this.

Pearl became a patient advocate and medicinal cannabis activist. I couldn't fit most of what we talked about in a recent interview into the Listener story but it warrants airing.

Pearl continues to go through surgeries related to her condition, as her joints erode and need rebuilding. She manages her post-operative recovery with cannabis products from her green fairy, Gandalf, and says she recovers more quickly and without the side-effects (including vomiting) she used to suffer from post-op pain medication.

Until now, she has taken in her products into hospital and used them unobtrusively, but she realised that for her most recent surgery, that wouldn't work.

"This was a hand surgery – and I knew it would be much more difficult for me to manage to do this on my own, which is what I've had in the past. It's a nightmare, you know, fumbling around, trying to get your little bottles and balms, terrified that somebody was going to walk in."

So she fronted it.

"The first appointment was with the anaesthetist and I just said to him, look, you know, this is what I did last time and my response was phenomenal. They kicked me out of rehab in the first week because I had already reached the levels that they required at the end of the six weeks. I didn't have to use any of the medications at all for pain relief.

"I told all this to the anaesthetist and he said that he would be supportive of me doing that on the ward. And he said, if you just wait here, I'll go up and I'll speak to the head of the nursing on that ward and and I'll come back and talk to you. He came back and he said that the nurse was going to come down and talk to me.

"So the anaesthetist, myself and the head of the nursing staff of that ward sat in his office and spoke about what that looked like. And I just said, I use oils and drops under my tongue. I might bring a couple of them and I would do it, depending how I am, something like every two to four hours initially, then easing off over time."

Pearl's surgeon wasn't opposed, so the plan went ahead.

"I was really pleased that there wasn't a policeman waiting for me and there was a nurse waiting! The first nurse that came on when I got back to my ward introduced herself and she did a few of the machine things. Then she said, is there anything else I can help you with?

"And I said, yes, there is. You probably know that I'm a medicinal cannabis patient and I've got my own products to use. Her face lit up in this big grin and she said, 'I was so pleased to get you to nurse on my shift, I really love what you're doing, you know? I think it's really important'.

"So I asked her to get the bag out and I had three oils, all indicas of varying THC strength, and a balm. And each time the nurse helped me, I would ask for a specific one and I'd talk about why I chose that strain, what its ratios were and what I expected out of it. And I did that for every nurse or person that helped me.

"There was one nurse on the ward who I could tell was a little concerned, but part of my talk with the staff was about my belief that this is part of patient safety and harm minimisation and not only for me, but for them. They want to know what patients are using and patients need to feel supported in that environment. And it's better to be open and honest about these things.

"Just before I left the ward at the end of my stay there, the nurse who was very nervous came back to me and she said, 'I really want to thank you for helping me understand this. I have to admit I was really worried at the beginning, but I really appreciate the way you were concerned about my safety as well. And I've learnt a lot, and I really appreciate that'."

This doesn't mean that doctors at Auckland District Health Board are going to routinely prescribe cannabis products for post-op recovery, or even that they should. The products don't really exist in the system anyway. But having Pearl come in and be able to talk about what she was using, when and in what dose, will have been enormously helpful.

Doctors are understandably wary of using medicines they don't know how to dose. People like Pearl (and Gareth Duff and Dan Salter, whose stories I tell in the Listener feature) are not doctors, but they have become, at the least, experts in what works for them

There may also be, as the IASP position statement suggests, a yet-to-be-understood dimension of personalised medicine here – different things work for different people. But Pearl modelling the thoughtful use of green fairy products isn't a bad thing for medical professionals to be able to see and take notes on.

One day, the system, however it looks, will work a lot better than it does now, but until then, it's wrong to criminalise or increase harm to people who are doing the right thing for themselves.

You may be asking: isn't any hospital knowingly allowing the use of Class B controlled drugs putting itself in legal peril? Not in this case.

Pearl was among stakeholders interviewed as part of a review of the statutory defence provided under the medicinal cannabis legalisation. That allows a patient with a doctor's letter saying they are in palliative care to possess and use cannabis. A Supplementary Order Paper late in the process removed the requirement that the patient must be six months from death. The amended Section 4 of the Misuse of Drugs Act requires only that "in the opinion of a medical practitioner or nurse practitioner, the person has an advanced progressive life-limiting condition and is nearing the end of their life."

Pearl says she was told by her interviewer for the review, "your rheumatoid arthritis, which can never be cured, it's only ever going to be managed, that would be one of the many conditions that which would come under that palliation exemption."

The system may have been more compassionate than it meant to here, but Pearl has a letter from her doctor based on this template.

Dr Graham Gulbransen has frequently used the template in presentation and told me he originally sourced it from a page on the Ministry of Health website. I couldn't find it there, so it may have been removed.

Anyway, I've just received a response to my Official Information Act request for advice and communications around the decision not to further extend the transitional period under the Medicinal Cannabis Scheme – you can read my deep dive about that here on Matters of Substance – so I'll be back next week with some thoughts about that.

In the meantime, if you felt able to chip in a little via the supporter link below this post, I'd be very grateful. I tend to do a lot more work on this topic than I can find a paying home for ...

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Testing the fairies

A new paper by ESR scientists, published in the Australian Journal of Chemistry, has confirmed what close observers of the local cannabis community already knew, or at least suspected: the cannabinoid contents of local "green fairy" products vary widely, ratios in many products are not as claimed – and most products claiming to be high in CBD are not.

But, short of real regulation, a solution is in the wings – via the drug-checking law currently making its way through Parliament.

In 2019, the ESR scientists collected and tested a hundred green fairy products, most of them passed on via the Auckland patient advocate Pearl Schomburg. They included cannabis flower, FECO (fully extracted cannabis oil), carrier oil preparations, balms, tinctures and even vape liquids.

The results in this subsequent paper, Medicinal Cannabis – The Green Fairy Phenomenon, are not entirely news: ESR Forensic toxicology and pharmaceuticals manager Mary Jane McCarthy, who led the project, warned in February 2019 about a "product administered to an epileptic child, which "should have been high CBD and low THC – in fact it was the opposite. I would be very worried about a child taking a product like that." She presented the testing results last November at the inaugural MedCan Summit in Auckland – and said that the testing ended because its funding ran out.

I noted at the time that there was "a compelling harm reduction rationale for continuing to test these products and sharing the results." It now seems likely that will happen, via the Drug and Substance Checking Legislation Bill (No 2), which replaces the temporary legislation introduced to allow drug-checking at events last summer and is now at select committee. Like the temporary version, the bill aims to "try to minimise drug and substance harm by allowing drug and substance checking services to operate legally in New Zealand."

I have spoken to the Auckland businessman who has spent $50,000 on cannabis analysis equipment to do just that in the cannabis market. It would be fair to describe him as mild-mannered. He prefers to be known simply as "Tester Guy" (we'll call hm TG) until he secures a licence under the new law (currently, the only organisation licensed to carry out testing is Know Your Stuff) but he has already had discussions with Ministry of Health officials.

"We've been working with them so they know what the processes are to check a product," says TG. "They're writing the legislation, so they need to see what the processes are. But they did say, if you are currently testing illegal flower, stop instantly. That was detailed to me quite abruptly."

It's very likely that ministry officials won't be taking any new licence applications until the permanent law is enacted and accompanying regulations are written, but you can expect to see applications to test for safety outside the purview of Know Your Stuff, including for meth, opioids and potentially synthetic cannabinoid products, where dosage is literally a matter of life or death. Peer relationships are crucial to this form of harm reduction, so it makes sense for testing to be done within the respective user communities.

For TG, this new project is a matter of reaching out to help the community that helped a family member.

"My wife's mother has terrible migraine headaches. She's been on mainstream medicines for a long long time, with awful side-effects – and then taking another pill to offset the side-effects from the first one. It wasn't doing her any good at all.  She's been to every possible facility in the greater Auckland area to try and sort the migraines out, for years. Then she happened across cannabinoids and started to try some of the different [green fairy] products. She's off all mainstream medicines now, completely."

Talking to members of the cannabis community he discovered there was a problem with simply knowing what was in each batch. Patient advocates have been asking for safe access to product testing for at least five years, but for so long as the products have been illegal, that has not been possible.

"I thought, hey, what can we work out? What's in these amazing medicines and flowers? That led me to spend six months investigating the instruments worldwide. I put together a 50-page report on the different instruments available and narrowed it down to the one I purchased."

The equipment, from a North American company, can already provide detailed assays of cannabinoid contents, but TG plans to expand that capability.

"One of the major decision factors with the instrument I've brought in is that it's future-proof. We're working on methods and standards for detecting toxins, including the main pesticides. We're working on 11 terpenes at the moment. You need a gas chromatography instrument for the terpenes, while the best way of testing for cannabinoids is an HPLC instrument, which I have."

One area where TG's service could help curb a real health risk is in plant growth regulators, or PGRs. These are prohibited for use in food crops, but are readily available in grow shops, as "bud hardeners" and the like. They make plants appear more productive, but often at the expense of cannabinoid levels – and they're associated with organ damage and elevated cancer risk in humans.

"That's coming," says TG. "PGRs are so cheap and they're heavily promoted. Buy the 10 different bottles for $400 and that's all you need. All the amateur growers think it's brilliant."

These are all things organisations like ESR could do, but don't have the workflow for. The same is doubly true for Know Your Stuff, which has been turning away people who want to check plant matter almost since it began testing. TG sees his plans as complementary to what Know Your Stuff does.

"I want to help out the green fairies, so they're sure about what they're administering, and the growers to know what they're actually growing before they put it into their tinctures and oils. We want to go right back to the coalface of growing."

The government is unlikely to stand in the way. Health minister Andrew Little, who has been under fire for perceived inaction on medicinal cannabis, told the recent Parliamentary drug symposium that harm reduction via drug-checking would not be limited to festivals, but should be available through the community.

This kind of community testing falls short of the GMP standard decreed under our embattled medicinal cannabis scheme – which is so high that no New Zealand company has yet been able to get a product past the ministry's "minimum quality standard" and only four products, all from the Canadian company Tilray, have passed. But the gulf between no testing at all for quality and contents and our high official bar is very, very wide. There are perhaps 3000-4000 New Zealand patents being prescribed cannabis products (although many of them will be receiving CBD products allowed under the current transitional regime but not meeting the minimum quality standard). The number using illicit cannabis therapeutically is likely 10 or 15 times greater.

The ESR paper acknowledges "frustration at the restrictions to access prescribed cannabinoids in New Zealand" as a key reason for the growth of "a black market of home-made cannabis-based products for medicinal use", but it also seems that public attitudes towards these products have changed in the past couple of years and they are being used in some cases by people who would not have countenanced cannabis previously.

It also notes that product consistency is easier to achieve through a conventional pharmacological process of isolating individual cannabinoids, typically THC and CBD, than in whole-plant extracts, but that this may mean "the loss of potential benefits of the many other cannabinoids and terpenes in the cannabis plant (the entourage effect)."

There's also the simple fact that the transition from a high-THC recreational market established over decades to one where different attributes are sought from cannabis just isn't easy. It can be challenging to grow for CBD levels, let alone for potentially useful minor cannabinoids, especially when the growers are flying blind and can't test what they produce. This doesn't necessarily mean the products are inactive (although a small number seemed to be), but it makes consistent dosing difficult for people who need it.

The paper makes the point that even where CBD was present in the green fairy products, it was often at a level less than that thought to be a therapeutically useful dose (which is typically greater than that for THC). Reliably high levels of CBD are still largely the preserve of imported products, whether they meet the minimum quality standard or not.

It's also worth observing that nearly all the samples which closely matched their claimed contents came from one producer: the Northland green fairy Gandalf. Global investors are already sniffing around New Zealand genetics and our medicinal cannabis law allows New Zealand companies to bring in  illegally-developed strains. This would seem to be an area to watch.

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The Drugs Meetup

"We just kept saying yes," New Zealand Drug Foundation executive director Sarah Helm told me the evening before Through the Maze: On the road to health, where nearly 50 people and organisations were represented on the stage over two busy days.

In contrast to the foundation's last four-yearly symposium at Parliament, there was no carefully-staged policy bid and the pandemic meant that, apart from a couple of visitors from Australia, there were no marquee international speakers in the room. Instead, it was a chance for the diverse group of people who gathered to feel like a community and to reaffirm shared perspectives.

Health minister Andrew Little, the symposium's Parliamentary host, gave the opening speech. He began by addressing "the elephant in the room" – which, to his mind, was last year's referendum on a bill to legalise and regulate cannabis.

The referendum was mentioned several times during the symposium, but the minister's perception that it was somehow hanging over the event was really his alone. The sad truth is that if there was an elephant in the room, it was Andrew Little himself.

There was chatter that he might use the speech to make an announcement, or as a way to shift the policy stasis he himself had ordained. People talked earnestly about whether it would be more productive to protest, or to avoid backing him into a corner, given that he seemed to have responded so poorly to the recent open letter from multiple health and social service organisations calling for drug policy reform. There were few, if any, offstage conversations in which the Minister of Health was discussed as anything other than a problem.

In the end, there were no real announcements. It was a short speech (as someone observed to me, it felt like it suddenly ended two pages early) largely concerned with justifying the government's position. If you were to go looking for nuggets, then the affirmation that the government sees drug-checking as an everywhere-all-the-time service, and not just something that happens at summer music festivals, was one. That sounded like an acknowledgement that these services will need to be funded. It might have made it a little easier to think about a service to test green fairy products under the same law.

It's worth recalling that drug-checking was a reform that the Prime Minister effectively ordained over Little's head, after he'd declared there would be no reform for the foreseeable future about an hour after the referendum result. Nothing bad happened and there was no discernable ngeative impact on public opinion. Indeed, over a summer when eutylone flooded the market, it quite probably saved lives. The minister who declared there would be no reform ended up very happy to own this one.

Little also tossed in what might have been a revealing definition of cannabis decriminalisation – "self-use and some sharing" – before dismissing decriminalisation as an option, and there was some thought that he might have left scope for a broadening of the current palliative defence for the medical use of cannabis. The two Parliamentary journalists present checked with him afterwards: no, he hadn't.

You don't really get to present yourself as compassionate until you can logically explain why someone with a terminal condition who gains relief from cannabis is a patient, but someone with a debilitating chronic condition who finds similar relief is a criminal.

The minister said that "the medicinal cannabis regime is not yet operating as we expected" – he could hardly do otherwise – but gave an assurance there would be more products available later in the year. He may actually have strayed from his prepared text and said that manufacturers had told him so. But that is not really what local producers are telling the ministry.

Medical Cannabis Scheme a "Blazing wreck" read the headline of a release from the patient advocacy group MCANZ on the day following the minister's speech. Not a single new product has been made available under the new regime – and unless the ministry makes a third six-month extension to its transitional rules, which allow prescribers to import their own, the price of CBD products will go up, not down. Meanwhile – more in some districts than others – the police are raiding green fairies who the courts seem increasingly unhappy about punishing. It's a rolling mess.

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With the minister out of the way, the real symposium could begin. Several presentations stood out for me. Firstly, there were the addiction services practitioners – the humble, modestly-paid people who work at the frontline. They explained the way that there's a huge social dimension to helping people with methamphetamine problems get better: forging relationships, making connections.

Rachel Scaife of Odyssey and Lifewise talked about Haven, the drop-in support centre they opened during last year's Covid chaos, making a space for people with alcohol and other drug problems to feel safe and make a first step.

Odyssey's Andrew Munro emphasised that effective treatment for meth dependence needs to encompass families as well. The most destructive stigmatising, he said, can come from close family members. They need to become part of the process. Andrew Hopgood from the Porirua initiative New Zealand P-Pull explained why they don't make clients relinquish their gang membership: "that's their whanau".

Philippa Jones of NZ Needle Exchange revealed that her organisation has been doing work on where it would fit in to a true health-based approach to drugs: some of the services that work envisages, she observed, are simply not possible under current law – criminalisation is too much of a barrier. Even now, Needle Exchange doesn't know basic things about its client base – including how many Māori there are – because it would be imprudent to find out those things.

"Of course," she said, "if our clients weren't criminalised they might feel more confident about sharing that information."

In one way or another, each of these frontline workers made clear that criminalisation is the major barrier to wellbeing for their clients. This isn't really news – it was the clear conclusion of the 2018 Mental Health and Addictions Review – but hearing it directly from the people doing the work gave it an extra resonance.

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In a completely different vein, I found Professor Joe Boden's speech about the conceits of science compelling. Joe, the director of the Christchurch Health and Development Study, has his name on research that was brandished on both sides of the cannabis referendum debate last year. He was critical not only of its misuse by prohibitionists, but, remarkably, of some of the assumptions of the work itself.

Most notably, he revisited Tests of causal linkages between cannabis use and psychotic symptoms (Fergusson et al, 2005), which used data from the CHDS. It also used what now looks like a pretty bad tool for the job, or at least used it poorly.

The most commonly-endorsed items on the SCL-90 checklist used to assess potential psychological issues for the study were  "I sometimes have thoughts that other people do not share" and "never feeling close to another person". If these were removed, the association between regular cannabis use and psychosis disappeared. (It's worth noting that the study was actually criticised at the time for not stating which symptoms were most reported or whether the difference in average symptom level came from a few people having many symptoms or many people having a few symptoms.)

Joe also talked about "the nomothetic curtain": the difference between imvestigating "the thing" (in this case, drug use), which is nomothetic research, and idiographical study of the "unique and contingent aspects of individuals". A focus on nomothetic approaches, he observed "can obscure what's really happening".

He said that he last year led a trajectory analysis of the same CHDS data on cannabis use. That produced something that looked a lot more like individual human lives.

This was important, he explained, because too much research in this field assumes, through labels like "drug addict", a permanence of condition, and pays not enough attention to the dimensional aspect of any condition. That is, its severity.

"Remember there are people out there, and not just things," he concluded.

In sum, it was was an important affirmation that science is not values-free. Or to put it another way, when all you have (or allow yourself to to use) is a hammer, everything looks like a nail.

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Some of the ideas Joe shared were expressed more forcefully in a session on drug stigma.

Director of Māori Development at the Universty of Otago (and former Drug Foundation chair) Tuari Potiki talked about the institutional racism he experienced when he was younger ("the bias didn't seem unconscious at the time"). And how his youthful drug convictions counted for more than everything else he's done with his life when he was asked to address the UN General Assembly in New York. It took seven months to secure him a US visa and it was unclear until five weeks before the event that he'd be allowed in.

He was followed by Wendy Allison, the founder of KnowYourStuffNZ, who talked about the privilege that means her organisation gets reform allowing it to do its drug-checking work, while reform for users of other drugs – who are generally poor, non-white and more marginalised – goes missing.

Thus, we are not willing to be used by the government to show everyone how progressive they are. In fact I would suggest that tutuing about with the Misuse of Drugs Act in a way that makes privileged people safer while not helping anyone else, is not that progressive. We deserve better.

So what can we, as privileged people, do? 

One thing I’ve learned from the KnowYourStuff project is the power of ethical non-compliance, and that privileged nobodies can make things happen if they have the courage. We need to use that privilege get on with doing the things that help the people in our communities who need it, whether the government approves or not.

That’s what the needle exchange did in the 1980s, it’s what KnowYourStuffNZ has done, it’s what the Green Fairies are doing, and if you’re in a position of privilege, then it’s what you should do too. Because vulnerable people die while privileged people wait around for government approval.

That might come at a cost – she revealed that she tanked an interview for a white-collar job last year by refusing on principle to submit to a pointless pre-employment drug test – but those who can bear the cost, should. That might mean coming out as one of the one in eight New Zealanders who uses illcit drugs.

I’m aware that most people aren’t in a position to take that risk, but if you are – if exposing yourself to that stigma won’t ruin your life, I encourage you to do so, even if it's only to those close to you. Change their view, let them change someone else’s. 

It was, she said, "an understanding of the normality of drug use" that underpinned the effectiveness of KnowYourStuff’s practice, which had been praised earlier in the day by the minister himself.

In an environment without judgement, stigma can’t thrive - and in the absence of stigma we create space for real, honest conversations about drugs with our clients.

Without stigma, we'd be able to have real, honest conversations about drugs as a country. We’d be able to take a hard look at the actual drivers behind problematic drug use: Inequality. Disconnection. Trauma. We’d be able to talk about what actually works to reduce harm instead of always focusing on use (and by extension, users). And if we care about reducing harm, it’s our duty to make that happen.

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The Australian researcher Professor Nicole Lee drew a similar distinction between seeking to define success in the rate of use of any drug rather than the incidence of actual harm. She noted that meth use in Australia (they have much better data than us) has been trending down for a decade – at the same time as hospital admissions and other measures of harm are spiralling up. What, we have to ask, is drug policy for?

This is an understanding that has developed in, it needs to be acknowledged, New Zealand law enforcement. Detective Inspector Blair MacDonald, manager of the National Drug Intelligence Bureau, presented on the drug early warning service High Alert and working with "our good friends" KnowYourStuff and the Drug Foundation. It shouldn't escape us that this is a good and remarkable thing.

Perhaps invitably, he was asked whether asked whether legalising real MDMA would help quell the problem of dangerous and sometimes deadly cathinones being sold in its stead. His answer was diplomatic but clear in its way. There had been a shift in recent years, he said, in the police approach to drugs, focusing on preventing harm.

"We don't want to be the ambulance at the bottom of the cliff. That's about as much as I can say."

Noeleen Chaney of Northland DHB rattled through a lot of data on the Te Ara Oranga scheme in her region, under which police work with health providers to offer help to people with meth problems as an alternative to prosecuting them. Short version: it works. (The scheme was launched under the last National government, but I imagine would be derided as "soft on drugs" by the version of the party that festers in Opposition were it to be proposed today.)

I had an enjoyable chat with Tuari onstage at the end of the first day about the prehistory of the war on drugs as it related to New Zealand, based for my part on the history I wrote for the Drug Foundation magazine in 2014, which I think you would still find an interesting read.

Two notes from the introductory video from Johann Hari resonated: one is that our first drug law (the Opium Prevention Act 1901) was bound up in race. The other is that ever since then – through the International Opium Convention, the League of Nations, the United Nations Single Convention 1961 – we've basically been ordered around by more powerful nations. How much easier might medicinal cannabis have been if we hadn't bowed to UN instruction to stop our doctors prescribing tincture of cannabis in the late 1950s?

The story of UN pressure circles right back to America and its chief prohibitionist Harry Anslinger, who drove international policy in his country's name. We got the draconian Narcotics Act after police officer Bob Walton returned from being instructed by Anslinger's people in America and we've been trying to climb out of it ever since. Ironically, America might be climbing out faster than we are.

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There were some politicians in the room: Chloe, of course, and Australian Reason Party member Fiona Patten, who was a delight to meet and talk to. Labour MP Arena Williams stood out on the political panel as someone her party could and should encourage to pursue an interest in evidence-based drug policy.

But over two days of listening – and bearing in mind the mindless Parliamentary squabbles of recent weeks – I started to despair of politics and politicians. As Helen Clark pointed out, Norway's deeply considered move away from its prohibitionst past to decriminalisation is now at risk because there's an election this year and their Labour Party has decided to use that reform as a point of attack. There is no principle in that. Just politics.

I do understand, to an extent, our government's wariness around cannabis reform. Although the referendum result was very close, "Yes" didn't actually win in many electorates – and it fared badly in Labour's South Auckland heartland, where people might have been forgiven for not wanting cannabis retail on top of their problems with liquor retail.

But to declare, as Andrew Little did, that "even though the case for change is obvious", the government didn't get the "social licence" for any reform at all just defies reason. The last government was supposed to review the Misuse of Drugs Act 1975. Little himself promised to do so. The Law Commission called for a review a decade ago. How on earth does the referendum result preclude sending the damn law to a select committee to hear submissions?

There is a debate within Labour's caucus on this stalling of reform and an even stronger one amongst its party membership. Andrew Little simply does not seem to be the minister capable of steering a way through that debate – not least because he will also be stewarding a staggeringly large reform of the entire national health service. Please, just give the drug delegation to someone else.

• If the Salvation Army, the NZMA, the Mental Health Foundation, the Public Heath Association et al collectively ask you to remove the criminalisation from the use of cannabis, don't go off in a huff. Talk to them.

• Acknowledge that the current medicinal cannabis scheme has real problems. Accept that the public increasingly sees the therapetic use of cannabis in a different light to "recreational" use – there are 80 year-olds using cannabis balms – and respond to the real environment, not one that simply fits existing practice. Ask yourself: are these really the people we want to drag though court? If not, do something about it rather than relying on pissweak John Key rationalisations about police discretion. Police would welcome the guidance.

• Send the Misuse of of Drugs Act 1975 to a select committee for review. It's hard to imagine a move with less political cost attached than that.

In short, fear and stigma sometimes make good politics. They very rarely make good goverment.

NB: I was able to take a week to prepare for and attend the symposium, and to write this, because some of you contribute to that work via our PressPatron account. If you appreciated this post, feel free to click the Supporter bar beneath this post and chip in a little. Cheers, RB.

6

A picture of official callousness and detachment

Last night, the New Zealand Herald posted a story from its political reporter Derek Cheng which bundles together a number of current issues around medicinal cannabis. The most alarming is that of Katy Thomas and her epileptic son Eddy, which has recently been taken up by Green MP Chloe Swarbrick. Their story was first reported a couple of weeks ago by TVNZ.

Swarbrick – the only member who seems willing to be caught caring about this stuff – posted her letter to Health minister Andrew Little on Facebook on April 23. I've posted it in turn in the comments below, along with a reply from Andrew Little, the Minister of Health.

The gist is that CBD oil imported from and prescribed by their GP was intercepted at the border twice in a month – and as a result six year-old Eddy's nocturnal seizures are now poorly controlled. This is not only distressing, it's potentially deadly. Any one of those seizures could be fatal.

One oil was apparenty intercepted because of paperwork – the prescription wasn't attached on arrival. I was mystified as to exactly why the other, which was to be delivered to the GP, was confiscated and destroyed. Swarbrick's letter cites Section 2A(1)(b) of the Misuse of Drugs Act, which defines a CBD product. She doesn't actually say the medicines were intercepted because they contain more than 2% CBD, but the two journalists who have reported the story have taken that meaning. But anyway, it's not the case. That's not what the law says.

So they're wrong on a key detail, but not in a way that reflects an iota better on minister Little, the Ministry of Health or New Zealand Customs. What is happening here is an awful picture of official callousness and detachment.

Section 2A doesn't limit the quantity of CBD in a product to 2% (which would be pretty low). It says that "specified substances" – that is, any form (isomer, esther, etc) of THC –  can amount to no more than 2% of the quantity of CBD. The products that have been intercepted did not contain any form of THC. So what actually happened?

I've spoken to Katy and been able to determine that, to an extent.

Since at least 2018, Katy has been importing products from the British company CBD Brothers, a licensed producer of CBD products. Recently, via her prescribing GP, she has been bringing in two products, the Purple Plus Water Soluble and the Red Edition CBD Oil, a full-spectrum oil derived from cannabis indica plants.

According to the WHO, CBD enjoys more evidential backing as a treatment for childhood epilepsy than any other condition, and these ren't dodgy novelty products. Each one comes with a certificate of analysis of the batch from which it is bottled. What happened is not that Batch 68 of the Red Oil contained THC, but that its certificate showed it contained 0.136% CBN, which equated to 3% of the total CBD content. (Ironically, if the oil contained more CBD, there wouldn't have been a problem.)

But CBN, while a cannabinoid, is not THC. In the absence of THC, it is not intoxicating, still less in the trace amount at which it is present in the oil. It's not mentioned on the Ministry of Health page covering the definition of  a CBD product, although Katy told me it is cited on one page I've been unable to find. But, again, it is not THC.

So why single out CBN, when the certificate of analysis shows one or two other innocuous cannabinoids? I wonder if the officials are hanging on these lines in Section 2A specifying:

a substance that has a structure substantially similar to that of any substance described in subparagraphs (i) to (iv);

Where you may find CBN in the real world is in degraded or oxidated cannabis – it's what THC turns into in old weed. That is not the case for the oil in question – and again, it is not THC. If the Ministry of Health believes it is – and this is the ministry that spent years insisting against expert advice that CBD was really THC in drag – then that needs fixing in the regulations.

Little's reply to Swarbrick doesn't address any of this.  Instead, he directs Katy to the only two CBD products that have so far made it through New Zealand's strictest-in-the-world regulations for approved medicinal cannabis products, both from the Canadian company Tilray.

(Last September, the government quietly put a six-month extension on the transitional rules that allowed GPs to import unapproved CBD products in order to prescribe them. Then in March, it extended the transitional scheme for a further six months – because, still, no local producer has been able to meet them.)

Katy has already tried the Tilray products and they are not suitable for Eddy.

"Eddy's particular phenotype is nocturnal seizures, tonic-clonic," she told me. "They are the most difficult to treat. They are the most resistant to anti-epileptic drugs – and they're the most deadly. It also happens that indica CBD works better because it has more sedative properties. But also no one makes it, because it's really hard to harvest CBD from [cannabis] indica plants. There's not a huge concentration in them."

Most CBD oils, including those from hemp, are derived from cannabis sativa. This is why Katy and Eddy's GP have been importing the cannabis indica products from the UK.

"[The Tilray products] don't work for Eddy. Every time we've tried to use sativa strains or isolates, although it does control his seizures, it had adverse effects that almost make the seizures more preferable. They're stimulating – and where Eddy's seizures happen are at the transition between light and deep sleep. So if you give him a stimulant, it's very hard for him to get under and stay under.

"So he's kind popping in and out of those sleep thresholds. And we see more parasomnias – and those parasomnias, if we give him sativa CBD, present as self-harming and screaming fits. Because he has auras, he'll often try to physically run away from his seizures, which when you're quite heavily medicated at night with other things as well as the CBD, is not the time to be running through the hall."

"He just sustains more injuries and he's much harder to control. So those products that we have here are not a safe option for us. They're great for daytime epileptics, they have a place for so many conditions. But not for us unfortunately."

She laughed when I asked her whether anyone at the Ministry of Health had offered to help with what is obviously an extremely distressing situation. Incredibly, she is now facing what looks, at best, like bureaucratic carelessness from New Zealand Customs, in trying to get in a product that has not been deemed unacceptable under the cannabis regulations:

"I received an email to say that I needed to apply for a licence and get my client codes, because the value of the goods that I was bringing into the country were over $1000. Which is completely new to me, because I've been spending more than $1000 on this medicine for years now and I've never required a client code or whatever that process is.

"So I started that on the day that I was asked to. I sent off all my documentation including my ID, then I followed up a couple of days later to see where we were at and they said, oh, we still haven't received it. So I forwarded the same emails again. Over the weekend I got in contact with another customer service agent from UPS and she asked me to send the documentation over again. I spoke to another girl on Monday and she asked me to forward it again.

"Then I just rang Customs and said where are we with this application? Where is the medicine? When is it going to be delivered back to us? And they said, oh, you're going to have to send over the documentation again. So I sent it over again. And then I sad, when is this going to be processed? And they said, two to three business days ..."

This is a mother who is just trying to keep her son happy, healthy and alive.

Happily, CBD Brothers have been more caring and she's been able to talk to the senior analyst at the company, which will now produce an oil for Eddy that will be acceptable to New Zealand officials – either by reducing the quantity of CBN (which she's not keen on, given that CBN may have anticonvulsant properties) or adding more CBD isolate to change the ratios.

"But I guess the issue is that there's no continuity of care for Edward. Every time we make these changes, we don't know if it's going to work – we're just hoping. There's no guarantees and it's actually really dangerous to suddenly change his medicine the way we have been doing."

Eddy's condition is now such that he's been out of school for six weeks. And Katy was scathing about the response from Little to Swarbrick's letter advocating on her behalf.

"We've been told in no uncertain terms that he's not even going to look at it. His reply was so callous and dismissive. It showed a complete disconnect from our lived experience and Eddy's lived experience.

"He really seems to not care in the slightest. Just the fact that he won't even consider any of it. And the idea that we're going to have this thriving local industry that's going to be the panacea to all our problems in September is a joke. Because if it was going to happen in September, then it would've happened in March, or last year.

"And in the meantime, we've still got to get there. And unfortunately, Eddy doesn't meet the definition of palliative even though any single one of his seizures could kill him. So we're not exempt and we just kind of have to go without. There's no urgency. It's not like I'm buying fancy furniture from overseas, or that this is a business product. It's lifesaving medicine. The bureaucratic hurdles we have to jump through are just monstrous."

The ministry may be correct in saying it's just applying the government's rules – albeit according to its own questionable interpretation – but Andrew Little has nowhere to hide on this. This is exactly the kind of case where the minister should be taking an interest, asking questions and looking for a way to help a family that needs helping. He has powers to intervene that he seems simply uninterested in using.

Little seems to have simply disengaged from this and the other issues raised in Swarbrick's letter, such as the prospect of a green fairy amnesty or any widening of the palliative exemption. He needs to be moved on from this part of his portfolio, not only for the sake of Katy and her son, but quite probably for the credibility of New Zealand's medicinal cannabis regime.

"The thing that surprises most people is that they think the law was passed and our problem was solved," Katy said. "But it's gone from bad to worse. It was definitely not improved – it's gone backwards. I actually feel embarrassed for even campaigning for the law in the first place, because it does nothing for us and the patients that we know. It's just a useless piece of legislation."