Policy on Cannabis Based Products

BACKGROUND

The concept of “medical cannabis” has been heavily publicised recently, both in the United States, Australia and in New Zealand.

New Zealand has one of the highest rates of cannabis use in the world, (1) and approximately 5% of people aged over 15 years report using cannabis for medical purposes. (2)

Cannabis based products:

■ Is the preferred term rather than medicinal cannabis.

■ Encompasses products containing extracts of the cannabis plant that may be used to treat various medical conditions.

■ Are Class B1 controlled drugs and Ministerial approval is required before these can be prescribed, supplied or administered, in accordance with regulation 22 of the Misuse of Drugs Regulations 1977.

Composition of cannabis:

■ Tetrahydrocannabinol (THC) is the primary psychotropic cannabinoid found in marijuana and is responsible for most of its psychological effects - ‘the high’

■ Cannabidiol (CBD) is a non-psychoactive cannabinoid which can block the high associated with THC. It has anticonvulsant, muscle relaxant, analgesic and antiemetic properties.

Products:

There are currently 3 groups of cannabis-based products:

Pharmaceutical grade product approved in New Zealand

■ Sativex used as a oromucosal spray is the only product currently available.

■ Cost: $1300 per bottle (in all situations) and is not funded.

■ Approved for the treatment of moderate to severe spasticity in multiple sclerosis.

■ May be approved for other medical conditions with application to the Ministry of Health.

Pharmaceutical grade products approved overseas

■ Nabilone capsules for chemotherapy-induced nausea and vomiting (CINV) (synthetic THC approved US, UK, Mexico for CINV).

■ Dronabinol capsules (synthetic THC, approved US Germany for CINV).

■ Cannabidiol (CBD) capsules or spray (CBD unrestricted use).

Non-pharmaceutical grade products

■ Cannabis vapour or smoked (numerous active cannabinoids, approved in 23 US states).

■ THC capsules or spray, or smoked.

Robust clinical trials using cannabis to treat medical conditions are lacking. Observational studies show long-term cannabis use is associated with adverse social and financial consequences, (3) and cannabis use increases rates of psychosis. (4) As with recreational cannabis use, medical cannabis use could also lead to other serious adverse effects. (5)

A Cochrane review and a major meta-analysis, both published in 2015, found moderate quality evidence that cannabinoids (as opposed to cannabis) may be useful for the treatment of chronic pain, including neuropathic pain, and spasticity associated with multiple sclerosis. (6, 7) There is also moderate quality evidence that cannabinoids may be effective antiemetics for adjunctive use in chemotherapy or to assist weight-gain in patients with HIV. (6, 7) There is low quality evidence in support of other uses such as reducing anxiety or improving sleep. (6, 7) Adverse effects commonly associated with cannabinoid use include dizziness, dry mouth, nausea and vomiting, fatigue, sedation, dysphoria and hallucinations. (7)

FACULTY OF PAIN MEDICINE ANZCA STANCE:

• Doctors are not legally able to prescribe cannabis (the plant product that is smoked) in any jurisdiction as it has not received regulatory approval.

• Many doctors will be faced with patients using cannabis for complex symptoms of multiple chronic disabling conditions for which there are limited treatment options.

• Doctors should discuss, in a dispassionate and non-judgmental and supportive manner, the advisability or otherwise of using cannabis to palliate such symptoms.

• There is no clear evidence for effectiveness in treating pain. Any benefits are likely to be modest, and there is no clear evidence that putative benefits outweigh possible harms.

• If the product is legally available, then doctors are free to prescribe it for approved indications.

• If medical use is likely to be long term, patients should be warned that the adverse effects of long term use remain unclear. Patients could also be advised of the adverse effects reported in long term recreational users, such as the development of dependence.

• Clinicians should avoid taking medicolegal responsibility for non-approved or off-label prescribing.

THE NZMA POSITION:

- supports the use of medicinal cannabis in cancer, HIV-related cachexia, and intractable nausea and vomiting associated with cancer-related chemotherapy.

- does not support the use of medicinal cannabis for any other use.

DURHAM HEALTH POLICY AND MANAGEMENT OF PATIENTS PRESENTING ASKING FOR CANNABIS BASED PRODUCTS

1. Durham Health will not prescribe cannabis based products, unless advised to by an appropriate specialist.

2. When a patient asks about cannabis-based products:

■ Discuss the poor quality of evidence for effectiveness in settings other than in MS.

■ Discuss the adverse side effects and dangers of using recreational cannabis for medicinal use e.g. unpredictable dosing and other possible compounds in the product obtained.

■ Ensure all measures have been taken to address symptom control with conventional medicines.

3. If appropriate, request specialist advice regarding ongoing management of the condition presented by the patient.

REFERENCES

1. Degenhardt L, Chiu W-T, Sampson N, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med 2008;5:e141. http://dx.doi.org/10.1371/journal.pmed.0050141

2. Pledger M, Martin G, Cumming J. New Zealand Health Survey 2012/13: characteristics of medicinal cannabis users. New Zealand Medical Journal;129:29–40.

3. Fergusson DM, Boden JM. Cannabis use and later life outcomes. Addiction 2008;103:969-976- 978. http://dx.doi.org/10.1111/j.1360-0443.2008.02221.x

4. Fergusson DM, Horwood LJ, Ridder EM. Tests of causal linkages between cannabis use and psychotic symptoms. Addiction 2005;100:354–66. http://dx.doi.org/10.1111/j.1360-0443.2005.01001.x

5. Poulsen H, Moar R, Troncoso C. The incidence of alcohol and other drugs in drivers killed in New Zealand road crashes 2004-2009. Forensic Sci Int 2012;223:364–70. http://dx.doi.org/10.1016/j.forsciint.2012.10.026

6. Smith LA, Azariah F, Lavender VTC, et al. Cannabinoids for nausea and vomiting in adults with cancer receiving chemotherapy. Cochrane Database Syst Rev 2015;11:CD009464. http://dx.doi.org/10.1002/14651858.CD009464.pub2

7. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA 2015;313:2456–73. http://dx.doi.org/10.1001/jama.2015.6358