The proposed New South Wales trial of medical cannabis has given people with HIV/AIDS hope that a drug with the potential to help alleviate drug side effects and HIV-related wasting will soon be available legally. But just what is the dope on medical cannabis? KIRSTY MACHON and PAUL KIDD report.
When NSW Premier Bob Carr announced in May that he would be putting forward legislation to run a four-year trial into medicinal cannabis, he was met with the expected howls of outrage.
“Just plain dopey!” yelped the Daily Telegraph, while some opposition MPs fired off a salvo of hostile and scornful criticism, and anti-marijuana advocates invoked predictable images of a generation of bleary-eyed children wedded to the evil weed.
In the other camp, some pro-marijuana advocates behaved like the proverbial cat with the cream, heaping sycophantic praise on the Premier’s head.
Of note was a tentatively supportive response from a number of perhaps unlikely quarters, including Prime Minister John Howard, who offered in-principle support for the trial — provided that the cannabis be administered in a non-smoked form, and that the trial be limited to people who did not have alternative options for treatment.
Over the years, the cause of medicinal cannabis has attracted some curious supporters. In England, even the Prince of Wales is on the record as supporting the availability of medicinal cannabis for people with all kinds of illnesses such as multiple sclerosis.
There’s anecdotal evidence aplenty that people living with illnesses use cannabis to manage aspects of their condition, and swear by its medicinal effects. Cannabis, it’s claimed, can reduce pain, improve the tremors and spasticity associated with muscular deterioration, improve appetite and control nausea, among other things. But just how strong is the clinical evidence for the medicinal applications of cannabis, and what, if any role might it play in the management of HIV?
Evidence drawn from clinical trials is limited, largely because of the legal and ethical issues involved in setting up the research. Nonetheless, there is a growing body of research on this topic, particularly from the United States, which suggests that cannabis may be applicable for a variety of indications, particularly severe pain, nausea, and appetite loss. Several years ago, the US Congress sought an assessment of the scientific evidence for claims about marijuana in medicine, and cautiously reported back that for some groups of patients, including people with AIDS, “cannabinoid drugs might offer broad spectrum relief not found in any other single medication.” But they stressed their opposition to using cannabis in its traditional, smoked, form — a position echoed by many champions of the cause, including Mr Carr.
One of the applications for medical cannabis in HIV for which the evidence is strongest is appetite stimulation and weight gain. In 1996, a San Francisco trial found that people with HIV who used cannabis were more likely to put on weight.
In other areas, evidence has been less conclusive, and despite growing support in the medical fraternity for further research, there remains a body of staunch opponents who insist that the risks associated with cannabis use outweigh any potential medical benefits.
But the NSW Premier is one of a large number of people persuaded that there is a case for the medical uses of cannabis. A NSW Office of Drug Policy working party, commissioned by the Premier to investigate the issue, reported in August 2000 that “some cannabinoid substances may have value in the treatment of a limited range of medical conditions, namely, HIV-related wasting, nausea caused by cancer chemotherapy, muscle spasm in some neurological disorders, and pain that is unrelieved by conventional analgesics.”
That report’s key recommendation was that pharmaceutical cannabis preparations should be subject to further clinical trials, and this has been a major influence leading to the NSW announcement.
The proposed trial was for “a compassionate scheme,” Mr Carr told parliament, particularly for people who are suffering. “We have an obligation wherever we can to minimise human pain and human distress,” he said.
Joining Carr in calling for the trial were experts including a professor of anaesthesia, Laurence Mather, who told the Sydney Morning Herald: “I find it truly amazing there is any negative publicity [about the trial]. It beggars belief.”
Medical cannabis programs already exist in the Netherlands, Canada, some parts of the United States, and Britain.
In a world first, the Canadian government recently announced it would begin directly selling cheap marijuana to seriously ill people — a decision which has attracted considerable criticism from sceptics in the medical community, unconvinced that the body of evidence warrants such a radical move. In the US, the Bush administration has taken a hostile view towards some states’ medical cannabis programs, threatening to shut them down. In Britain, medical cannabis is being trialled for treating several conditions, including cancer and multiple sclerosis.
The proposed NSW trial would involve people suffering from cancer, HIV, spinal injuries, and some other serious medical conditions. Participants would register with a new Office of Medical Cannabis which would make the drug available.
People who had previously been convicted of any illicit drug offence (other than minor personal use offences), people on parole, under 18 or pregnant would be excluded from the trial.
Most of the other details of the proposed arrangements remain to be filled in, and draft legislation is not yet available. The government has admitted that the legislation will not be introduced to the current session of parliament due to the complex legal and moral issues it presents.
The federal health minister, Kay Patterson, has said that, despite the Prime Minister’s cautious support, the federal government has not given approval to the trial at this stage. The Prime Minister insists his support is contingent on two factors: that the drug is not smoked, and that any legislation does not permit people to grow their own marijuana.
Some supporters of medical cannabis, however, suspect that the drug may work best in inhaled forms, and are likely argue that the trial should explore routes of administration other than the currently favoured option of an oral spray or tablet form.
Not all of the available evidence of course, suggests that medical cannabis is entirely benign. Some of the important caveats include:
- a well-established link between tobacco smoking and cancer, suggesting strongly that cannabis should not be smoked in combination with tobacco;
- a more tenuous, but theoretically possible, link between cannabis smoking alone and the risk of cancer;
- the immediate effects of marijuana smoking — ‘being stoned’ — which may affect users’ psychomotor performance, and make it dangerous, for example, to drive a car or operate heavy machinery;
- a body of evidence linking long-term, heavy cannabis use to increased risk of depression or some mental illnesses — this, however, remains a controversial area of research, with some researchers and advocates claiming that the evidence of a clear causal link has been overestimated.
Clinical research into medical cannabis must take these considerations into account for ethical and scientific reasons.
In the meantime, of course, possession and use of cannabis in NSW (and other states) remains illegal. Despite this, there is anecdotal evidence that suggests that cannabis use among people living with HIV/AIDS is fairly widespread.
A recent Californian study found that of 252 HIV patients surveyed, 58 (23 percent) admitted to using cannabis in the previous four weeks. Significantly, when asked why they used the drug, most respondents cited several reasons. While 52 percent used cannabis to alleviate nausea and stimulate appetite, and 28 percent to alleviate pain, the largest number — 57 percent — said they used cannabis to alleviate stress or depression. The fact that many people use the drug to alleviate mental, rather than physical, symptoms, remains a challenge for medical researchers and legislators to consider.
Though many groups have called for the decriminalisation of cannabis, the NSW Premier insists that this is one side effect of any NSW trial that he will not tolerate. Advocacy groups such as the Australian Committee for Medicinal Cannabis, however, are continuing to look at legal mechanisms, such as utilising existing cautioning arrangements (where people found in possession of the drug are cautioned by police rather than charged) to assist people with serious medical conditions where cannabis is potentially of some use to gain access to the drug without fear of prosecution.
HIV/AIDS groups such as the AIDS Council of NSW, PLWHA NSW and the National Association of People Living with HIV/AIDS (NAPWA) have indicated that they support the proposed trial and intend to engage with this important new development in NSW.
“After several years of lobbying, submissions and meetings we are very pleased to see such a great result proposed by the NSW Government, which will see people living with HIV/AIDS being able to utilise medicinal cannabis in later stage HIV/ AIDS,” PLWHA NSW President John Robinson said. Robinson particularly applauded the fact that the trial will enable PLWHAs to escape the stress and stigma associated with using an illicit drug.
