Both types of cannabis are very much in the news. I wish first to state that this article is written to enlighten readers, is strictly non-partisan and should be non-polemical. The facts or ideas, which are not exhaustive, have been gleaned from reliable scientific sources. The terms “medical” and “medicinal” are used interchangeably.

Cannabis and cannabis products in simple terms

You might have seen (from films/photos) or not, the cannabis plant (botanical name: Cannabis Sativa L) but its physical appearance is so peculiar that once you see it, you will thereafter easily recognise it from its conspicuous leaves. What does the plant contain that make it so attractive?

The main psychoactive ingredient (referring to a drug that affect a person’s mental state) present in the cannabis plant is Delta- 9-Tetrahydrocannabinol (THC). This is a chemical substance biosynthesized by the plant, i.e. produced naturally. Other naturally occurring Cannabinoids (as this group of substances are commonly referred to) with similar chemical structures to THC are: Cannabinol (CBN), Cannabidiol (CBD) and many others but only two are relevant in the present context: THC and CBD.

Herbal cannabis, which includes mainly the fruiting and flowering tops and leaves, contain on an average between 2 and 12 per cent THC. The resin (Hashish) contains between 4 and 21 per cent THC. Cannabis resin is a fine sticky powder from the resin-producing parts of the plant that is usually compressed into slabs and imprinted with a logo when distributed on the illicit market. Cannabis oil is a concentrated extract from either the herbal material or the resin and contains up to 60 per cent THC. Synthetic THC, CBD and CBN are also available.

There is a subtle distinction between “medical” and “recreational” cannabis. Medical cannabis, in many countries where it is allowed, contains only relatively pure CBD or CBD/THC in a fixed ratio, i.e. where the composition and dosage, like all prescription drugs, are well-known. On the other hand, “recreational” cannabis, especially in the herbal form, is of uncertain composition and variable amounts of the various cannabinoids present and perhaps with contaminants.

The primary interest of consumers lies chiefly in the THC content that provides the “high”. There is at present on the world black market what is known as super- strength THC “skunk” cannabis (up to 14% THC) which users say gives them a better “high”! The pharmacological action of THC is well documented.

It is chiefly CBD which has been explored for medical treatment. One licenced formulation is Sativex, an oromucosal spray with CBD and THC as active ingredients, and which has been legally prescribed in the United Kingdom (UK) for a long time to treat chronic pain in adults, muscle stiffness and spasms in multiple sclerosis as well for nausea/vomiting caused by chemotherapy. In this regard, there seems to be conclusive or substantial medical evidence.

Cannabinoids, particularly CBD, have received significant attention as a therapeutic potential for epilepsy, a well-known neurological disorder. There is at present only growing anecdotal evidence, if not moderate evidence, especially from patients with refractory epilepsy where fairly good results (significant reduction in seizure frequency) have been obtained.

“It is simple to say that a drug could be legalised but in the background, there are a lot of technical issues that have to be discussed…”

Epidiolex (purified CBD extracted from cannabis plants) was recently approved in the US to treat two rare forms of childhood epilepsy. There is also so far moderate evidence that medical cannabis helps improving sleep in individuals with specific conditions including fibromyalgia (rheumatic condition with musculo-skeletal pain) and obstructive sleep apnoea(temporary cessation of breathing during sleep).

Cannabinoids have also the potential of becoming a useful treatment for glaucoma (an eye condition), as they seem to have neuroprotective properties and effectively reduce intraocular pressure. So far, 44 countries worldwide – e.g. United States (US); 34 states, Canada, Uruguay, Australia, The Netherlands and Germany – have legalised medical cannabis.

In November 2018, after a public outcry over two children with severe epilepsy being denied cannabis oil in the UK, the Home Secretary, Sajid Javid, announced that cannabis-based products will be available on prescription only by specialists. An initial review by the Chief Medical Officer in the UK pointed towards the therapeutic effects of medicinal cannabis. A second review by the Advisory Council on Misuse of Drugs said doctors should be able to prescribe medicinal cannabis provided products they meet safety standards.

Recreational use of cannabis is still banned in the UK. Only Canada, Uruguay and a few US States have completely legalised both medical and recreational cannabis. In 2013, Uruguay passed a new law to legalise both medical and recreational cannabis. In large part, the move was aimed at replacing the links between organised crime and the cannabis trade with more accountable state regulation.

The Netherlands is too well-known for offering recreational cannabis openly in its coffee- shops. Lesotho is the first African country to legalise the cultivation of marijuana (cannabis) for medicinal purposes. Recreational use of cannabis was legalised in Canada in October 2018. Medical use of cannabis was already legal. The legal age to consume cannabis in Canada is 18/19 depending on the province.

Legalization did not come without recasting Driving Under the Influence of Drugs legislation, adding to and modifying the dispositions which were already in place. The main reasons cited by the Government of Canada to legalize cannabis were to cut the black market demand by providing a legal product alternative, to closely monitor and regulate the quality, safety and composition of cannabis in circulation, to reduce the burden on the criminal justice system and to restrict youth access to cannabis while enhancing their awareness of the health risks associated thereto. There will be long term trends to see if Canada has achieved its goals via cannabis legislation.

Psychotic Risks

One proven risk factor for the use of recreational cannabis is dependence, despite its reputation as being non-addictive. People can develop tolerance, i.e. need more doses to get the same effect. There is compelling evidence that a regular cannabis user is twice as likely to develop a psychotic disorder than a non-user (both short term breaks and chronic), particularly in early life (teenagers) and exacerbated by high consumption as their brains are still developing until their mid-twenties. This view is expressed with absolute certainty by the Registrar, United Kingdom Royal College of Psychiatrists.

Addiction and Psychosis ought to be a minor problem for medical cannabis as strains of cannabis plants are bred to usually have high CBD and low THC contents. CBD, it is believed, counteracts the psychotic effects of THC. There is no evidence that medical cannabis increases the rate of traffic accidents or is a gateway to other harmful drugs.

Thailand was the first region in South East Asia to approve medicinal cannabis in December 2018. Recreational cannabis will remain illegal. Consumers will be allowed specific amounts for medicinal purposes if they have a prescription. Licences for production and sale of the product will be strictly controlled.

It is perhaps a justified fear that the medical trade could easily morph into recreational sales and potentially opens an even bigger market. However, cannabis for recreational purposes cannot be traded across borders. Import/ Export of medicinal cannabis is carried out under a licensing system supervised by International Narcotics Control Boards.

There is a serious opioid crisis in the US. A 25% fewer opioid painkiller deaths due to overdose have been noted where medical cannabis is legal. Opioid prescriptions have also dropped when States legalised medical cannabis which is considered safer and less addictive. “Cannabis is on a Legalize Tour” and it seems this tour will not stop any time soon. It is simple to say that a drug could be legalised but in the background, there are a lot of technical issues that have to be discussed and decisions that must be made.

Conclusion: Science rather than Dogma

Any sound policy should be guided by science rather than dogma. The way forward for any country will first and foremost probably be a balanced appraisal of both the benefits and harms of either type of cannabis.