Cannabis old and new, risks and opportunities. Thor Nissen

Almost every paper dealing with the topic of cannabis includes a reference to its millennial presence in the history of humanity, a comment distinguishing between its recreational and medicinal uses, and the notion of its geographical legality.

Traditionally, drugs used to treat medical conditions were derived from plants and other natural sources. The first synthetic drug was introduced late in the XIX century1 as chemistry knowledge from other industries gave birth to the first pharmaceutical companies, later on. Drug design became more and more intricate as the molecular size and complexity of the components started to grow. And then came biologics.

In an era where sophisticated technology and artificial intelligence has proven their efficacy and led to the development of a new vaccine for the COVID-19 virus in a record time, the two main cannabinoids found in the cannabis plant, delta-9tetrahydrocannabinol (THC) and cannabidiol (CBD) are still news and topic of harsh debate. Aside from its recreational and non-prescription, legal or illegal uses, cannabis therapeutic role has been the object of recent publications in wellrecognized scientific sources. Patients’ interest in the use of cannabis products guided the discovery of what was identified as a cannabinoid system in the human brain and body. These findings relate the system with the control of functions, such as cognition, memory, pain, sleep, and immune performance.2 Its potential indications spread into different chronic diseases.

The anti-emetic efficacy of cannabinoids in cancer patients receiving chemotherapy is probably one of the most known indications. It has been featured in some medical television series. Even if Cannabis-based medications have shown to be useful in this setting, some of the available studies present a risk of bias, they were mostly conducted by the end of the previous century, and do not include a comparison with newer antiemetic drugs. “Further research reflecting current chemotherapy regimens and newer anti-emetic drugs is likely to modify these conclusions.”3

1 Jones AW. Early drug discovery and the rise of pharmaceutical chemistry. Drug Test Anal. 2011 Jun;3(6):337-44. doi: 10.1002/ dta.301. PMID: 21698778. 2 European Monitoring Centre for Drugs and Drug Addiction. Medical use of cannabis and cannabinoids: questions and answers for policymaking. Publications Office of the European Union, Luxembourg, 2018. http://www.emcdda.europa.eu/system/files/ publications/10171/20185584_TD0618186ENN_PDF.pdf 3 Smith LA, Azariah F, Lavender VT, Stoner NS, Bettiol S. Cannabinoids for nausea and vomiting in adults with cancer receiving chemotherapy. Cochrane Database Syst Rev. 2015 Nov 12;2015(11):CD009464. doi: 10.1002/14651858.CD009464.pub2. PMID: 26561338; PMCID: PMC6931414.

Other supported indications for medicinal use of cannabis-based products and cannabinoids are chronic pain, multiple sclerosis, and treatment of resistant epilepsy.4 The quality of evidence to support its use in chronic pain and spasticity is modest.5 Still more debatable is the effectiveness of cannabis-containing products in appetite and weight loss associated with weakening conditions such as HIV/AIDS. The list of reviewed settings in which these products might find some benefit extends to, for example, Tourette syndrome, anxiety, post-traumatic stress disorder, and schizophrenia, as much as the evidence shortens.

With more or less scientific support or clinical evidence, cannabis and cannabinoid drugs are used to treat disease or alleviate symptoms in different scenarios. The way of these drugs into acceptable medicinal use should account for their high abuse potential as well as concerns for dependence. If qualified information of its use under well-controlled environments may arise, it will have to deal with a stigma surrounding it as a potential gateway to other uncontrolled and more harmful substances.

One thing for sure is that the place of cannabis in the medical field has been and will continue to be controversial.6

4 Freeman T P, Hindocha C, Green S F, Bloomfield M A P. Medicinal use of cannabis based products and cannabinoids BMJ 2019; 365 :l1141 doi:10.1136/ bmj.l1141 5 Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA. 2015 Jun 23-30;313(24):2456-73. doi: 10.1001/jama.2015.6358. Erratum in: JAMA. 2015 Aug 4;314(5):520. Erratum in: JAMA. 2015 Aug 25;314(8):837. Erratum in: JAMA. 2015 Dec 1;314(21):2308. Erratum in: JAMA. 2016 Apr 12;315(14):1522. PMID: 26103030. 6 Bridgeman MB, Abazia DT. Medicinal Cannabis: History, Pharmacology, And Implications for the Acute Care Setting. P T. 2017;42(3):180-188.

Thor Nissen

Doctor, graduate in Clinical Pharmacology and MBA in Quality Management. He has managed to collaborate for the development of medicines in world leading pharmaceutical companies both in medical matters and in clinical research in new drugs, regulation, marketing and sales departments.