No doctor thinks ‘the odd spliff’ is disastrous but cannabis use disorder is a real problem

One of the more neglected aspects of the great “Should cannabis be legalised?” debate is the reluctance of so many doctors to engage with the issue. The reasons for this are straightforward: first, there is the perennial ambiguity of the science. Second, there is the growing abuse of medics who oppose simple legalisation.

What is missed by people on both sides of an increasingly rancorous and polarised discourse is that the withdrawal of professionals from the civic arena is a source of difficulty in developing mature, scientifically-sound and practicable policies relating to cannabis.

Cannabis (also known as marijuana or “weed”) is the most widely used illicit drug in the world. It’s worth noting, however, that the cannabis consumed in the 1970s was generally “weaker” than the modern form, meaning that the level of the key psychoactive component, Delta-9-Tetrahydrocannabinol (THC), is now much greater – and so is the risk of side effects.

The recent advent of hydroponic growing techniques and hybridisation of strains also allowed a flourishing of grow-houses or domestic pot plant cultivation, while driving up the concentration of THC, and sometimes – worryingly – driving down the levels of cannabidiol (CBD). This is the most abundant non-psychoactive “cannabinoid” in cannabis, which is believed to reduce the undesirable effects of THC and is currently being evaluated in medical trials for its potential as a mild sedative and even as an antipsychotic medication.

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The toxicity, as with all chemicals, reflects the cumulative amount of the drug consumed, as well as the level of CBD involved. The unfortunate truth, however, is that the science of cannabis harms is still hugely deficient and self-contradictory. The link between cannabis and psychosis is sometimes described as “bidirectional”, meaning it may accelerate psychosis onset or ease it afterwards. Emergency case reports are piling up but many legislators and big corporations have already made their minds up.

Regardless of the bifurcation between popular opinion, which sees cannabis as basically benign, and the lived experience of those in certain medical specialities, the international direction of travel is towards decriminalisation and legalisation of cannabis. This is primarily driven by the jet engines of profit and pleasure but with the dodgy brakes and steering provided by education, legislation and regulation. So far, 38 American States have legalised “medicinal” use of the drug and recreational use is now permissible in many places.

In practice, cannabis consumption has long been normalised: it is the most commonly consumed illicit drug globally; over 20 per cent of the Irish population have consumed it at some point and many use it daily.

The medical establishment’s consensus is that excessive consumption of cannabis, especially of “skunk” with its genetically-induced preponderance of the THC and dilution of the countervailing CBD, can be seriously psychotoxic. By far the most common medical issues are the more mundane anxiety, demotivation, suicidality and arrested neurological development described in young teenagers who are relatively heavy users – but psychosis and violence are the real worries for people like me with a long career in emergency medicine or psychiatrists.

Cannabis use disorder (CUD) is defined as a “problematic pattern of cannabis use leading to clinically significant impairment or distress”, with varying levels of craving for the drug, unsuccessful efforts to control its use and other factors like collapsing school or college grades and performance on the pitch, loss of old friends and social withdrawal, often seen in teenage males with CUD.

[ Doctors claim Government failing to counteract ‘relentless pro-cannabis messaging’ in media ]

In a recent letter to The Irish Times, a group of psychiatrists and frontline physicians wrote that about 22,000 people in Ireland have such a CUD, while over 1,000 – mostly young – people are admitted to hospital yearly due to the effects of cannabis.

The general direction of scientific studies tallies with many medics’ sense that cannabis users can often be angry, paranoid and, sometimes, violent, which mainly matters because the overall population of users is already very substantial.

Psychiatrists worry that thousands of people in this state who have a cannabis use disorder must go without adequate healthcare because of the chronic underdevelopment of our mental health services.

We don’t have adequate or precise figures to make really secure long-term decisions on the future of cannabis policy in Ireland and, specifically, the issues of decriminalisation and legalisation. We don’t really have accurate figures for cases of cannabis-related violence or hospital admissions or GP attendances.

The “third-party victims” are invisible because you can’t manage what you don’t measure. In truth, much of the epidemiology of cannabis use in Ireland has involved guesstimates, surveys of what people say they do and odd case reports. What is needed are much more systematic studies.

Consumed safely – there’s the rub – cannabis has been a soothing “herbal” remedy for mental and physical pain for millenniums and I’d truly like to see a pharmaceutically safe version in palliative and pain medicine, for a start. I know of no doctor who thinks that “the odd spliff” is disastrous.

I hope we see nuanced proposals from the current Citizens’ Assembly with regard to cannabis policy. I’d like to see a reduction in the vast amount of court time spent on cases of possession of trivial amounts of cannabis and easier access to medical cannabis for those relatively few conditions where cannabis, or more specifically CBD, is scientifically indicated. Most importantly, perhaps, I’d like to hear from the Citizens’ Assembly in relation to the mismatch between the current levels of drug-related mental illness and the existing inadequate services.

These views shouldn’t be controversial and, yet, they’ve seen me described as a “pious temperance movement fanatic” after I recently describe my lived experience of dealing with illicit drug cases over many years in urban emergency departments to the Citizens’ Assembly.

There are two good reasons why doctors and other relevant professionals should engage in the area of drug policy. First, the impact of drug use is genuinely perceived by those working at the healthcare, educational, occupational and policing front lines as considerable and often seriously harmful at the individual and collective level.

Professionals have a moral obligation to argue their case in the court of public opinion. Unfortunately, if their views are disregarded or they themselves are subject to abuse, they are much less likely to engage in the kind of research or debate which could bring about a more sophisticated, democratic and pragmatic approach to cannabis policy. Worse still, as we have seen with access to abortion or methadone in recent times, if medics feel threatened or bullied, many simply disengage and the great promise of progress can suddenly become very hazy indeed.

Dr Chris Luke is a retired consultant in emergency medicine, columnist and author