OPINION: I chair the advisory group that worked with Medsafe to write the medicinal cannabis consultation document released on July 10. I’m a paediatrician and the advisory group also includes experts in paediatric neurology, chronic pain, palliative care, pharmacy, medicines regulation, drug policy, a medicinal cannabis researcher, a manufacturer and a consumer representative. The views in this article are, however, mine alone.
There are some difficult choices to be made and the consultation will determine what the new rules allow. Here are some of those choices.
Quality vs access and equity
Standards for production and manufacture of medicines matter. Pesticides, fertilisers and heavy metals have all been found in medicinal cannabis products in Canada. So reducing the price and improving the quality of medicinal cannabis so people can switch to a safe product is important.
The international standards of Good Agricultural Practice (GAP – for cultivation) and Good Manufacturing Practice (GMP – for manufacturing) are required for any producer wishing to export. The standards reduce the risk of contaminants and also ensure medicines are manufactured to the stated concentration and the same concentration throughout a batch.
However GAP and GMP require complex and expensive science and quality processes. If we insist on these standards, we risk privileging large international companies over small local growers and manufacturers, including Māori. Should we accept lower standards to grow our local medicinal cannabis sector? Is it worth the risk?
Access vs risk
The advisory group agreed that restrictions on access should be in proportion to risk. CBD (Cannabidiol)-only medicines, which are low-risk for most patients, can now be prescribed by any doctor. Prescribing THC (Tetrahydrocannabinol) for children would be a much higher risk. It may be that only certain specialists should prescribe cannabis medicines to children or other vulnerable groups. What do you think?
Chronic, non-cancer pain (CNCP) is a special case. Physiotherapy and psychological therapies have the strongest evidence base for CNCP and should be tried first. However these treatments can be hard to access or expensive and a large and growing number of people with CNCP have become addicted to opiates (morphine-like medicines) instead. These medicines are restricted and doctors know they are not a long-term solution, but patients with disabling and distressing conditions are very difficult to turn away.
Some doctors are afraid that unrestricted access to cannabis medicines will lead to more people with CNCP addicted to cannabis. However addiction is much less likely for cannabis than opiates and we may in fact see people switch from opiates to cannabis, which would be better for them.
Also, some people with CNCP already feel great relief from cannabis medicines obtained illegally. They feel very strongly that their effective medicine should be accessible, affordable and safe. And only four district health boards have a chronic pain service. Is it reasonable to require people with CNCP, including those who already get relief from cannabis medicines, to see a chronic pain specialist in another DHB?
Pharmacy or not?
Your local community pharmacist is your expert on medicines. It’s their job to advise you on what your medicines do and how they interact. However some pharmacies charge more than others and that can make it hard for people on low incomes to afford the medicine. Should consumers be able to fill their prescription for a cannabis product direct from the manufacturer, or from an online pharmacy? Is the reduction in safety worth the reduced cost?
Educating prescribers and consumers
In Canada and Australia, governments have invested heavily in bringing the evidence together and presenting it in a way that is credible, clear and accessible for both prescribers and consumers. The research on cannabis medicines is growing quickly. More conditions are now known to respond to cannabis medicines than before. However cannabis is not a magic cure. It interacts with other medicines and has side-effects. It’s important that everyone – prescribers, consumers and families – understand what these medicines can and cannot do, so we use them wisely – like any other medicine. How do you access information on medicines? Who would you trust to provide this education?
Sometimes in public policy there isn’t one right answer – it really is a choice between two valid options. When this happens, the right thing to do is to ask people what they think, and take their views into account. Please take the time to give your feedback on the consultation document at https://consult.health.govt.nz/medsafe/medicinal-cannabis-scheme-consultation. The consultation finishes on Wednesday August 7.
Dr Russell Wills is a paediatrician with the Hawke’s Bay District Health Board and chair of the Medicinal Cannabis Advisory Group
The Dominion Post