The bar to get a opinion published about legalising and regulating cannabis is, you'll know, not terribly high at the moment. Anyone can have a crack. But there's a column published on Stuff that I want to take a closer look at because it's by someone who should bring a degree of expertise.
It's by Dr Mark Hotu of Green Doctors in Ponsonby, which bills itself as "the ONLY [cannabis] clinic that has actual medical specialists". I presume that doesn't mean the only one with medical doctors, but with a specialist on staff.
Acccording to the Green Doctors website, Dr Hotu himself himself has been prescribing cannabis products for "over a year" and visited a cannabis clinic in Canada last year. His colleague Dr Anne Craig joined the practice last year. They both have have backgrounds in treating pain and Dr Craig is a pain specialist. Like all New Zealand doctors, their history of prescribing cannabis is a very short one.
UPDATE: In the comments below, Dr Waseem Alzaher of Cannabis Clinic says Dr Craig "works solely for Cannabis Clinic and not Green Doctors. She has requested her name be removed for 2 months now."
Dr Hotu says this in his column:
As a GP I feel a duty to help ensure the public is properly informed when they cast their vote, they should know about the existing availability of medicinal cannabis and the potential risks of self-prescribing cannabis for health reasons.
I’m concerned that many voters have been led to believe a cannabis referendum ‘Yes vote’ equals a ‘Yes’ for medicinal cannabis. This is not the case; patients already have access to medicinal cannabis. It’s legal under the Medicinal Cannabis Scheme and currently available via prescription from doctors who can identify any potential drug interactions and adverse effects that may affect a patient.
At present, that means that they prescribe a lot of CBD, which they've been allowed to do since September 2017. Green Doctors bills itself as offering "the cheapest CBD products in the country". There are nine of them listed on its website, but the Ministry of Health's regulations are such that no one's allowed to tell you what they are.
Currently, doctors can readily prescribe exactly one product containing THC: Sativex, which was approved in 2010. Sativex is approved by MedSafe for treating the symptoms of multiple sclerosis, but since April 1 this year, doctors have been allowed to use their clinical judgement prescribe it off-label, for pain and other conditions. It's not funded by Pharmac and costs around $900 + GST a month, although for some patients it's considerably more.
Another, functionally similar, product, Tilray 10:10, is often cheaper, but it's unapproved, which means a specialist must write the prescription, which has to be approved on a case-by-case basis by the Ministry of Health. (Having a pain specialist like Dr Craig on staff is an obvious advantage.)
The situation will gradually improve as products are approved under the April 1 regulations, but no product has been submitted for approval yet.
Moving on ...
Admissions to psychiatric hospitals for marijuana induced psychosis will go through the roof. Over the last few years we’ve put millions of dollars into the prevention and treatment of mental illness. Speak to any health professional that works in this field and they’ll tell you the impact that marijuana has on psychosis. Increasing access will undoubtedly result in a surge in mental health admissions.
"Through the roof" and "undoubtedly result in a surge" are big claims – and they're not supported by evidence. If they were, you couldn't imagine the directors of our two most important public health research projects, the Dunedin and Christchurch longitudinal studies, being supportive of careful legalisation. Or for frontline mental health staff consulted for the 2018 Report of the Government Inquiry into Mental Health and Addiction to repeatedly emphasise the way crimianlisation makes ther work more difficult.
The rate of Cannabis Use Disorder, which is assessed with a DSM checklist asking about tolerance, dependence and various social impairments, is a good thing to look at here, because it can lead to more serious mental health problems.
One study last year showed small but significant increases in CUD in legal US states among past-year users in 2008-2016 – effectively covering the first two years of legal availability in Colorado and Washington state – but the researchers speculated that the teen rate was influenced by unmeasured confounders.
Another, published at the same time but using the same dataset over a longer period and a slightly different case definition (frequent users, rather than past year users), found a substantial fall in CUD incidence among young people and the authors speculated that "as the cannabis market becomes increasingly regulated, better information about cannabis use risks may be available." In other words, bringing cannabis out into the light may be facilitating better choices.
A new study, published last week and using 2008-2017 data, found the same nationwide decline in adolescent CUD - and that "compared to other states, the rate of admission declined more rapidly among adolescents in Colorado and Washington following the legalization of cannabis."
We may not yet be at the stage of conclusive evidence, but claiming as a fact that legalisation would send psychiatric admissions "through the roof" seems pretty reckless for a doctor.
Dr Hotu continues:
Last year I was in Montreal at a medicinal cannabis summit and spoke to one of the clinical directors of Spectrum Therapeutics, the medical arm of Canada’s largest medicinal cannabis company. Prior to 2019, they increased production of their oral oils and capsules in preparation for the recreational market. When cannabis was finally legalised they ended up having to dump all those products because no one wanted them. Why? Because all people wanted to do was smoke.
Such is the transition from a permissive medical regime to one in which people have access to regulated retail. Spectrum is a medicinal brand launched last year by Canopy Growth – which is increasingly viewed as the Big Cannabis example regulators should do anything possible to avoid.
Although Canopy began in Canada's medicinal regime, its primary shareholder now is Constellation Brands, a booze company. What actually happened last year is that Canopy completely misread the market for cannabis oils, medicinal or otherwise. Now, despite a staggering $4 billion investment from Constellation, Canopy is floundering because the booze barons wanted to focus on cannabis beverages – and it's really only its medical divisions that are making any money.
So Dr Hotu's pretty off-beam there.
He continues:
Home-grown cannabis is not medicinal grade, the THC and CBD levels are unknown making effects on users unpredictable. A patient of mine experienced unexpected and unwanted side-effects from cannabis oil obtained from a green fairy. They were informed the cannabis oil had a high-CBD, low-THC ratio but described effects suggesting it contained much higher amounts of THC.
Even if suppliers provide a cannabis plant’s likely pharmacological characteristics, how the seed is grown and refined into a consumable form can affect the final product. Whereas medical-grade cannabis products receive Medsafe approval following proper testing and certification showing analysis of the CBD and THC levels.
He's right to say (the occasional back-door test at ESR notwithstanding) that green fairy products aren't tested and that many may not be true to label. But the good green fairies would really, really like access to testing. It's actually dangerous that they are denied that access. As the Cannabis Legalisation and Control Bill stands, it would not legalise their products, but it would open the way to creating a safer niche for them – and the people they supply – to occupy. That's what we would do if we wanted to reduce harm. Perhaps the green fairies will gradually fade away as prescribable products appear in the system, but for now, there's a straightforward way to reduce the potential for harm for thousands of people.
Also, the referendum bill would require the THC and CBD content of dried cannabis flower to be listed at retail, and set quality standards. The medicinal regs go further by requiring GMP production standards – the same as other pharmaceutical drugs – which is expensive to do. But it's misleading to imply there would be a lack of information about the products themselves.
Then there's this:
Essentially we’re letting five million non-medically trained New Zealanders decide whether a controlled drug should be sold at the corner store.
Whoa there, doc. No one's going to be selling anything at "the corner store" and it's ridiculous to say so. Licensed cannabis retailers wouldn't even be able to have a storefront, let alone advertise.
It may not have been his intention, but this column does read as if Dr Hotu is rather clumsily trying to defend his market. It's not going to help with the frustrating problem of doctor distrust in the cannabis community and it ignores the public health problems related to criminalisation. Apart from anything else, Dr Hotu would benefit from a little humility. He could learn some things from the green fairies who have been dealing with cannabis patients for years, as much as they could learn from him.
Finally, he writes in conclusion:
Right now there’s a lot of smoke being blown about and as a GP and medicinal cannabis specialist I want to equip Kiwis with the facts.
Those facts need some work.