The Medicine

by Karen Hitchcock

  I’d smoked tobacco since I was very young and vomited my share of Brandivino (Was it wine? Brandy? Who knew, but it only cost three bucks) into the toilets at blue-light discos all over Melbourne, but that was it. The drug of choice among my new friends was cannabis. I’d been around heavy cannabis users for years – bogan boys with bongs in fist day and night – but had never been interested. My new friends smoked differently. In circles at parties, listening to Led Zeppelin and Black Flag. Or talking. About interesting things. And laughing. I loved cannabis: there was no vomiting and no hangover. Music sounded incredible. Food tasted incredible. A touch, a kiss. Incredible.

  About three months before I was due to fly home, one of the senior boys (a guy with an interest in folklore and psychedelics) asked if I wanted to drop acid with him. I did want to. He took it very seriously and spent a few weeks preparing me for the experience. He educated me about the importance of set (my pre-trip emotional state) and setting (where we tripped) and reassured me that the stuff would be high-quality and that he’d keep me safe. It was and he did. He said it would change the way I saw the world, blow my mind, change my life. It didn’t. But given my mind had already been well and truly blown by that year in that place, the little square of LSD-impregnated blotting paper had a lot to compete with. We spent the night dancing and laughing. By the time inanimate objects stopped gyrating and trailing and I wanted to sleep, I found I couldn’t. So I was extremely tired the next day. And that was it. I went back to smoking cannabis on the weekends until I returned to Australia and found myself, as before, disinclined to hang with the bogan bong smokers.

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  In 2017, Australia’s Therapeutic Goods Administration (TGA) rescheduled cannabis from schedule 9 of the Poisons Standard (“prohibited substance”) to schedule 8 (“controlled drug”), which effectively sanctioned doctors to prescribe it for medicinal purposes. We talked about this change in the hospital where I work, but no one seemed to know what we could prescribe it for, or the steps necessary to obtain permission to prescribe it, or the cannabis preparations that were actually available to prescribe. What would we write on our script pad? Weed. 1 ounce. Smoke as needed (via joint or bong)?

  I started looking into the matter seriously in April 2018. In order to prescribe medicinal cannabis (MC) for a patient, I needed to submit a Special Access Scheme application to the TGA, nominating a specific cannabis preparation, justifying the need for the drug, and documenting that all other available treatments had been unsuccessfully trialled and why they were unsuccessful and that all the patient’s treating doctors agreed with the trial. If approved, I then needed to apply to the Victorian health department for its approval. If the Victorian health department gave me that approval, I needed the patient to sign a consent document and agree to frequent follow-ups. At that point, I could finally write a prescription and send the patient off to the pharmacy of their choice. The pharmacist would (hopefully) order the product and (given MC is not subsidised under the Pharmaceutical Benefits Scheme) it would cost the patient anywhere between $150 and $350 for a month’s supply.

  At the time, I was working in a busy, bulk-billed, public-hospital specialist clinic with a long waiting list of mostly unemployed patients. I estimated that completing the paperwork necessary to prescribe this treatment to a single patient (one who could afford it) would require at least four hours of my time. Prescribing enough opiates to kill them and their family, by way of comparison, would take me thirty seconds, max.

  It was, however, theoretically possible to become an “authorised prescriber” and bypass this administrative load. And so this was what I pursued. I completed a medicinal cannabis course, and conducted and documented a major literature review of the current medical research. My final application to prescribe five different MC preparations for seven clinical indications, following the TGA template, stretched to fifty-two pages.

  In order to submit the application to the TGA, I needed an ethics committee to assess and approve it. My specialist college, the Royal Australasian College of Physicians, declined to do this, just as the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists declined to assess the applications of two of my colleagues. They suggested we try a university or hospital ethics committee. I heard that the National Institute of Integrative Medicine (a not-for-profit education institution based in Victoria) had an ethics committee composed of doctors and scientists who were willing to assess such applications. I contacted them – they were knowledgeable, rigorous and supportive – and sent it in for their appraisal. (I was granted ethics approval. My application is now with the TGA.)*

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  Studies show that approximately 35 per cent of the Australian population aged over fourteen years have tried cannabis. Data from the Australian Institute of Health and Welfare shows that in 2016 approximately one in four adults in their twenties and around 10 per cent of people aged over fourteen years reported recent use of cannabis. It’s hardly a fringe dweller’s criminal activity. I know more people who take or have taken cannabis than not. You probably do too. Netflix even has a cannabis cooking show.

  In July 2018 South Australia’s attorney-general, Vickie Chapman, announced that the state intended to get tough on cannabis possession: introducing prison sentences and quadrupling fines. Her rationale was a 2012 shooting murder of a teen by another teen who tested positive for alcohol, ecstasy and cannabis. In response to this proposal, Dr Alex Wodak from the Australian Drug Law Reform Foundation said, “Most people who smoke cannabis crawl into a corner and fall asleep or they eat ice cream. They don’t go around murdering people … This is just nonsense.”

  Australia already spends twice as much on the (evidently ineffective) policing of drug supply as it does on health and social services aimed at reducing demand, preventing harm and promoting treatment. Use of illicit substances has risen consistently since prohibition in the 1970s. What are we to do? Incarcerate ever-increasing segments of our population, as they’ve done in the US, causing great suffering? To no avail?

  Australian Greens leader Senator Richard Di Natale, a trained doctor, has said, “Right now there are many millions of Australians who have made this choice [to use cannabis recreationally] and the question for us is, are we going to make this a safer choice, or are we going to continue to have them exposed to serious harm?” Legalising, regulating and taxing cannabis for recreational use would unclog the criminal justice system and raise billions of dollars in tax revenue, which could easily fund education and comprehensive substance-abuse treatment programs. The Parliamentary Budget Office has estimated that legalising cannabis would generate almost $2 billion per year for the Australian economy. If a government wanted to be “tough on crime”, it could instantly wipe out entire criminal empires by legalising cannabis.

  None of the countries that have decriminalised recreational drugs has seen an increase in the use of the substances. Overdoses, criminality and related violence are usually the result of the prohibition rather than of the drugs themselves. Decriminalisation has proven to reduce these things.

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  There are more than thirty medicinal cannabis preparations available for prescription in Australia. Most are in oil form. They all contain pure delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in varying ratios. Chemists have isolated and extracted these two cannabinoids from what is a highly complex and diverse ancient plant medicine that contains more than 400 chemical entities and more than 60 cannabinoids. They are the plant’s two most abundant cannabinoids. THC is the major psychoactive substance, whereas CBD acts on cannabinoid receptors in the brain and periphery that don’t make you high but do have psychoactive effects such as decreasing anxiety and psychosis. CBD is also purported to be a potent anti-inflammatory.

  I am filled to the brim with facts about the effects and clinical efficacy of these two chemicals in their variety of Big Pharma–determined ratios. Prettily packaged, they’re indistinguishabl
e from anything else in my pharmacopoeia. It’s what we do in medicine. Reduce and control. Package and sell. There are positives to this: accurate dosing, uniformity of preparation for clinical trials. And for those who have cannabis-treatable conditions and don’t have access to their own plants or a dealer, or for those who are cannabis-naive or “anti-drugs”, it’s both literally and figuratively the most palatable way to take medicinal cannabis.

  The use of the cannabis plant, as a food, fibre and medicine, is estimated to date back anywhere between 5000 and 12,000 years. As such, it’s one of humanity’s oldest cultivated crops. Botanists debate the taxonomy, but in common parlance the two main subspecies are Cannabis sativa and Cannabis indica. Most varieties of cannabis produced in Australia (which is predominantly via illegal hydroponic set-ups) are hybrids of these subspecies, usually ultra-high potency, indica-dominant breeds, as the plants are shorter, bushier and offer a far higher bud yield. It is said that indica is more sedating whereas sativa is euphoria-inducing and cerebral. However, this turns out to be a mythical division. Dr Ethan Russo, an American physician researcher and one of the field’s top scholars, states:

  The differences in observed effects in Cannabis are … due to their terpenoid content, which is rarely assayed, let alone reported to potential consumers … Sedation in most common Cannabis strains is attributable to their myrcene content, [while] a high limonene content (common to citrus peels) will be uplifting on mood.

  It’s a great pity that research into this plant was halted with the dawn of prohibition. If it had not been, I might, as a doctor, have more tinctures to work with. Or access to a scientifically validated menu of whole-herb preparations. We might have clearer answers about what component works best for what condition. Or know if there’s a benefit to using whole-herb preparations due to the so-called “entourage effect” whereby the numerous other chemical compounds augment the effects of THC and CBD.

  The major medical institutions and colleges have been reticent to offer their stamp of approval to the THC/CBD treatment. They have, in the main, cautiously pointed towards the need for larger, more rigorous and standardised trials. (Which is ironic, as the caution and reticence of the major medical bodies have often been a major obstacle to such research.) The Australian Medical Association’s president, Dr Tony Bartone, commented, “Unfortunately, this is a case where the cart came before the horse really significantly because of a considerable amount of political and media interest in pushing this product to the market before it’s gone through its usual channels of preparation and supply and logistical surety.” And to that I’d reply that unfortunately the horse was shot dead in the 1970s and the cart is overflowing with patients who are suffering and have not found relief from currently available treatments.

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  The main reason patients ask me if I can prescribe cannabis is to treat chronic pain – from arthritis, fibromyalgia, bone or nerve damage. Before medicinal cannabis was legalised I knew three people from separate social circles who were accessing black-market CBD oil to treat their pain. One friend said she got it “from a friend of a friend who gets it from some guy in Sydney”. She wasn’t quite sure what it was.

  Pain, according to the International Association for the Study of Pain, is both a “sensory and emotional experience”. The same can be said for pleasure. We are, generally, pain-avoiding, pleasure-seeking animals. That doesn’t describe all of who we are as humans, but it is a major motivating factor in our lives. Joy, comfort, love, euphoria and relief are all pleasurable sensations and emotions. We reap pleasure where we can: sex, sport, conversation, a new dress, a fine meal.

  People love to consume substances that bring pleasure, be they alcohol, sugar or illicit drugs. The experience of pleasure, however one manages to get it, and despite puritanical instincts to the contrary, is mostly good. So long as it does not result in harm to others. Life can be painful or dreary, unfair or intolerable. We do what we can to balance the scale. And, given many are willing to take risks to feel pleasure, chasing it can have negative consequences. Most people, to a greater or lesser extent, are prepared to exchange aliquots of their health or life span to experience pleasure.

  We all know that overeating, smoking tobacco and drinking alcohol (any amount, according to the latest data) will cause harm, and yet the obesity statistics and the widespread smoking and drinking practices of our population tell us that the trade-off is something a majority of people (even when armed with knowledge of the consequences of their actions) are prepared to make.

  Medicine has a puritanical streak. We look at the fat and the “substance-abuse-disordered” as weak and greedy, rather than as people just trying to get by in a world that may offer them little else in the way of comfort. We don’t seem to know how to incorporate a human’s need for pleasure or solace and the fact that they’ll take it where they can. A few things have snuck through prohibition: alcohol, tobacco, junk food. As a doctor I’m sanctioned to dull your pain as long as doing so does not cause you pleasure. The euphoria that might arise from the ingestion of cannabis is listed as an “adverse effect”.

  You’d think a drug that decreases pain and offers some pleasure would be considered the ideal medicine that a humane doctor could prescribe. The side effects are good feelings! If you break a limb I can saturate you with opiates to stop your pain, but if the pain you seek to ameliorate is emotional (or if the opiates induce in you some form of pleasure) you will be deemed a “drug seeker”. The vast and ever-expanding pharmacopoeia of diverse substances that are used illegally for recreational purposes fall under Australia’s schedule 9 of prohibited drugs. Large portions of our population risk legal consequences to partake of them. Given that the production and distribution of these substances has been left in the hands of the illegal underground, the lack of quality control also means it’s difficult to know what else you’re risking.

  Of all the drugs reported to induce feelings of joy and pleasure, MDMA (“ecstasy”) is perhaps the most prominent. Yet in all the years I’ve worked in hospitals, I have never seen a patient admitted because they have ingested MDMA. In 2017, twenty people were hospitalised and three people died after consuming a drug, distributed around Melbourne that weekend, that they believed was MDMA. This received major news coverage, mostly claiming the harm was caused by “super-potency”. The fact that toxicology reports subsequently ascertained that the drug was not MDMA at all but rather contained the novel and largely unknown research chemicals NBOMe and 4-FA apparently wasn’t newsworthy. Studies show that the media pays little attention to deaths resulting from prescription medications (other than opiates) or alcohol or tobacco, but they go nuts over the few deaths that are in any way linked to amphetamines, ecstasy or heroin. They can’t report deaths due to cannabis, because you cannot die of a cannabis overdose.

  Victoria Police decided not to warn the public about the particular compounds in the fake ecstasy, and instead urged the public not to take illicit substances, full stop. Job done.

  In September 2018, two people died and a number of others were hospitalised after consuming pills or caps containing unknown substances at the Defqon.1 dance festival in Sydney. After walking back her initial promise to shut down the festival, the NSW premier, Gladys Berejiklian, has established an expert panel on how to make music festivals safer, but it will not consider pill testing. “The last thing we would want to see is people getting a false sense of security,” Berejiklian said.

  In 2013, after a similar incident in which a young man died, Barry O’Farrell, Berejiklian’s predecessor, said to reporters, “How many times do people have to be told that these things can kill?”

  If by “things” he meant the lack of access to pill testing, he was dead right.

  *

  In 2009 psychiatrist and academic Professor David Nutt was forced to resign from his appointment as chair of the UK Advisory Council on the Misuse of Drugs. Five other scientists quit the council in the wake of his sacking. He was sacked because o
f a conflict between the science and government policy. Nutt collated reams of international scientific and epidemiological data and came to a number of conclusions that the UK government didn’t want to hear, the most inflammatory of which was that alcohol and tobacco were more dangerous than cannabis, magic mushrooms, LSD or ecstasy. Describing the “illegality-logic loop” that was common among his detractors, Nutt wrote:

  This is an example of a conversation I’ve had many times with many people, some of them politicians:

  MP: “You can’t compare harms from a legal activity with an illegal one.”

  Professor Nutt: “Why not?”

  MP: “Because one’s illegal.”

  Professor Nutt: “Why is it illegal?”

  MP: “Because it’s harmful.”

  Professor Nutt: “Don’t we need to compare harms to determine if it should be illegal?”

  MP: “You can’t compare harms from a legal activity with an illegal one.”

  *

  As a teen, I dropped some stats about the low toxicity and non-addictive properties of cannabis on my dad. We were at the dinner table, Channel 9 news blaring in the background, and he’d just cracked his second VB for the night. He hit the roof. “I don’t want to hear any more of that bullshit. You start with marijuana, you’ll end up on heroin.” The old “gateway” drug hypothesis is false, proven both by rigorous studies and the rates of use quoted above. Most people who use non-prescription cannabis do so occasionally, socially, happily, or to “self-medicate”. Another urban myth from my youth was that “drug pushers” were injecting people with amphetamines against their will, rendering them hopelessly addicted. One dose was all it took, and you’d be a helplessly loyal customer for the rest of your life. Scary. (As if a dealer would give anyone anything for free.)