No, this title is not an error. However, it certainly has to do with “confusion” and more in particular about confusion surrounding cannabis these days. Aside of all ‘big money’, ‘big pot’ and ‘big pharma’ discussions I do see an immense amount of confusion among doctors, patients, pharmacists, but also scientists, regulators and politicians. Since cannabis has become ‘hot’ everybody is trying to jump on the bandwagon and be part of the current ride that cannabis is taking in the world. Even worse, everybody nowadays also has an opinion on cannabis. At the numerous conferences and meetings that are now being held on this subject we see so much information either lacking, being false or at least incorrect and certainly not patient-focused.
I am working in the world of cannabis since 1992. So that started only 16 years after fellow Dutchman Harm Dost, was arrested in Kleve (as a tourist). Harm Dost was known for his sales of cannabis in Arnhem, also to German people who he, at that time, treated as patients, calling himself a caregiver. In 1977, after having spent 18 months in a German prison, he was extradited to The Netherlands. In 1986 he was again sentenced in Germany, now to 10 years in prison. In 1987, on appeal the sentence was diminished such way that he was released from prison immediately. Twenty-two years later (2008) Germany imported its’ first medicinal cannabis from The Netherlands and sales through pharmacies, on prescription of a medical doctor started.
So, I have seen the world of cannabis change from a full illicit/grey product and industry, basically without any surrounding scientific knowledge, into one in which science, industry and regulators / politicians have started to see the added (medical) value of cannabis. That doesn’t mean that everything now is perfectly right and ok. As said in the intro, there is still a lot of confusion among many stakeholders. Even today, a lot of politicians and regulators don’t see the difference between cannabis for medical use or recreational use. At the least they are struggling with it. Although the amount of positive scientific evidence is more and more piling up these days, the acceptance of cannabis as a medicine is still highly driven by emotions and (contra-)activism. Lack of consensus among scientists, lack of coherence and harmonization of regulations and an un-unified industry are frustrating development of proper cannabis-based medications, let alone proper access for patients globally.
To unravel this relative complex problem, we have to start with a very basic question: ‘What is cannabis?’ Even till 5 years ago, the general answer was: ‘A plant, well-known for its’ healing, though it has psychotropic effects due to its’ main constituent THC.’ If you will ask today, a majority will tell you: ‘A plant, well-known for its’ healing and non-psychotropic effect due to its’ main constituent CBD.’ In between you will find people talking about terpenes, minor cannabinoids, flavonoids, entourage-effect. But in the end, nobody is able to provide all the right answers. The only thing we do know is that cannabis works well for a lot of people in all kinds of suffering and diseases. However, from that point on, we all got stuck in a swamp of so-called expert-opinions, testimonies, n=1 studies and even hearsay.
Solving this problem is not an effort that can be put on the shoulders of an industry, research institutions or NGO’s only. The consequences of more than 60 years of global prohibition will have to be borne by the politicians who made that decisions back in the early sixties of last century. So actually, that means all of us, represented by our politicians. If we want proper research, proper products and proper access for patients and that way allow cannabis to become the medicine we all think it is, this is a bigger task than making an industry responsible in the traditional pharmaceutical way. Such would have worked 60 years ago, just like it did with other controlled substances producing plants (poppies and coca mainly). Some then would say legalize all cannabis use and thus have the recreational user contribute to the development of cannabis medicines. That is what I call: mixing apples and pears. The 60 years of prohibition were not caused by recreational users or activists and patients neither of course…..
Now a number of governments are telling the newly arising cannabis industry to follow the well-known track of pharmaceutical drug development. That would mean in very broad strokes: develop your product, perform your (clinical) research, register your product, get market authorization and have your product into the patient’s hand hopefully reimbursed partially or in full. Following that track will mean another 10 – 20 years of waiting because that is what this ‘royal route’ brings with it. However, that time is not really available. Cannabis and cannabis derived products already are in the market (licit or illicit); efficacy is shown by means of the numbers and experiences. If you can show a 100.000 times or more positive N=1 (research on 1 person) results, it is a result that cannot be ignored.
In the end it means that the ‘royal route’ is not available, simply because we’re already far beyond that point. The combination of allowing cannabis to the market but having no proper or sometimes very ‘creative’ regulations in place is not good for patients, nor their caregivers. It has become time now for regulators on a global, or at least multi-national level, to come together and unify regulations on the basis of safety and efficacy on one hand and immediate, proper and responsible access on the other. Germany (although still struggling as we all know) is a good example of allowing and regulating at least that combination of factors to happen. Maybe instead of all those business conferences, the industry should focus on more regulator conferences. Let’s make 2019 “Year Of The Regulator”.