The following blog is from Dr. Bobby Smyth, a child and adolescent psychiatrist from Dublin and on the IASIC medical advisory panel. IASIC is the International Academy on the Science and Impact of Cannabis – Doctors education on the harms of cannabis.
It is time that the medical community takes back the word “medical” to its original meaning. It’s astounding that there is not more outrage by the academic medical community for claiming something is medicine without following the standard of care required to recommend any therapeutic intervention. It takes years of medical school, proctoring, and testing before a license is issued to prescribe a medicine. Overnight the marijuana industry captured the word medicine, and anyone can recommend cannabis for any condition. A doctor would be sued and lose their license if they did that with any other drug.
Visit the IASIC medical library to learn about the various clinical effects of cannabis from the peer-reviewed medical literature. Cannabis is the primary driver of demand for addiction treatment among teenagers and young adults across UK, Ireland and Europe. Dr. Bobby Smyth writes about why cannabis and its harms should be a top priority for all working in the field of addiction, why terminology matters and why the term “medical cannabis” is a misnomer.
As a child and adolescent psychiatrist, I work full time in adolescent addiction treatment, in a consultant role in Dublin since 2003. When I started out, my main focus was the treatment of adolescent heroin addiction. Fortunately, the heroin problem has largely vanished from my age range, so we have been able to develop more general drug and alcohol treatment services for teenagers. To my great surprise, cannabis gradually became the dominant substance driving demand for those services in the past decade.
“The industry is very keen to see the adjectives “medical” or “medicinal” placed before its product. Doing so has the effect of softening up public attitudes and dispelling policymaker concerns.”
These are not the worried well or the consequences of an overzealous criminal justice system, the latter accounting for only 5-10% of referrals. Cannabis addiction is consuming young lives in a manner I wouldn’t have imagined possible when starting out in 2003.
Ireland is not alone in seeing extensive cannabis addiction, the latest EMCDDA report indicates that no drug generated more demand for addiction treatment among new entrants, than cannabis. The latest UK data from NDTMS indicates that cannabis is the substance involved in the largest number of addiction treatment episodes for people under 25 years, being a focus of treatment in over 50% of episodes, surpassing even alcohol.
As psychiatrists, we know the mental health issues related to cannabis use, its contribution to psychosis and the evidence pointing to impacts on cognition in adolescent users [refs 1 – 3].
When looking at NHS data on drug-related admissions to medical hospitals, it is surprising to see that the ICD-10 drug category contributing to the largest number of admissions was cannabinoids in 2019-20, surpassing even opioids and cocaine by 10% and 30% respectively. It is similar in Ireland. Some of these admissions will be due to synthetic cannabinoid products, not cannabis itself. However, an EMCDDA survey of hospitals across Europe found that cannabis was the drug causing the largest number of drug-related attendances at emergency departments, again surpassing heroin and cocaine, and that data specifically excluded synthetic cannabinoid products.
Against this backdrop of evidence that cannabis is a major cause of both addiction and wider health problems, we have a growing chorus of voices telling the general public and policymakers that cannabis is in fact a medicine. The burgeoning cannabis industry, which now attracts major investment from both alcohol and tobacco corporations, is funding this conversation. The industry is very keen to see the adjectives “medical” or “medicinal” placed before its product. Doing so has the effect of softening up public attitudes and dispelling policymaker concerns. As doctors, we understand that it is only bodies such as the European Medicines Agency (EMA) in Europe or the Food and Drug Administration (FDA) in the US that can declare what is medicine. Cannabis itself is nowhere near reaching the required threshold of evidence of effectiveness and safety [ref 4].
“Scientific journals and addiction conferences would not tolerate this activity being described as the use of “medical alcohol”. Unfortunately, they do accept the term “medical cannabis” when referring to use of cannabis with these motivations.”
However, some cannabis-based products, such as cannabidiol for Dravets Syndrome, have reached that threshold. This should not mean that the parent plant is referred to as medicine.
We know that alcohol has analgesic, anxiolytic and anesthetic properties. It is a naturally occurring substance and has been used in tinctures and remedies by shamans, apothecaries and doctors for millennia. Some people still report using alcohol to alleviate stress or for some pain relief. While this is sometimes referred to as ‘self-medicating’, it is never taken as evidence that alcohol is a medicine. Scientific journals and addiction conferences would not tolerate this activity being described as the use of “medical alcohol”. Unfortunately, they do accept the term “medical cannabis” when referring to the use of cannabis with these motivations.
In the area of addiction, we agonize over language a great deal. We recognize that language is important. I am strongly of the view that the terms “medical cannabis” and “medicinal cannabis” are misnomers. While now used colloquially and out of convenience, they are unhelpful and fundamentally misleading [refs 4,5 & 6 ]. Better terms are “cannabinoid-based medicines” for substances such as Epidiolex (i.e. products that have been formally recognized by regulatory bodies as deserving of the term “medicine”), and “cannabinoid-based products” to describe the other potions and concoctions sold for purported health benefit.
Those of us who are involved in treatment, research and public policy in the domain of addiction tend to maintain a deep skepticism of the alcohol and tobacco industries. They have generally been seen as enemies of public health. While pharmaceutical companies fall into a different category, they are viewed with a degree of caution by doctors of all specialties, but especially by those of us working in addiction. Too many of their products have the potential to cause addiction, the current opioid epidemic in the US starkly reminding us of this fact. We must now make a decision about how we view the new cannabis industry and those who receive funding from it. An editorial in Addiction by Humphreys and Hall discussed some of these issues and challenges in 2019 [ref 7].
Given the product it sells, and its ever-growing linkages with the tobacco and alcohol industries, my personal view is that ‘big cannabis’ falls into the same category as ‘big alcohol’ and ‘big tobacco’ at the very best. Others are entitled to hold different perspectives on this industry. In fairness to alcohol and tobacco corporations, they are at least subject to some regulations while it seems to be the ‘wild west’ for the cannabis industry. Sadly, there is absolutely no line dividing the “medical” cannabis industry from the “recreational” cannabis industry, the same companies catering to both markets with similar products and with the same financial backers [ref 8].
For individuals and organizations involved in addiction treatment, research and policy, it is now timely to actively consider (1) our use of language in discussions about potential therapeutic benefits of cannabis products and (2) our views regarding the nascent cannabis industry, and those who receive funding from it directly or indirectly.
Learn more about the risk of marijuana on the IASIC website: www.IASIC1.org