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The Case Against

In recent times, the debate surrounding the availability and use of cannabis-based medicines (CBMs) for therapeutic purposes has exploded into the public and political domains, with much of the argument centred on the harmless, yet effective, nature of these products. Medicinal cannabis has been touted as a panacea, a natural, readily accessible, safe treatment option for refractory conditions. Unfortunately, this utopia has not eventuated. Although there is some evidence to support the use of cannabinoids in specific patient populations, making these products widely available immediately, without having the appropriate safety and efficacy data available, flies in the face of evidence-based practice. In the early part of the 20th century in Australia, the supply of medications was unregulated. Medicines were claimed to have curative and recuperative powers, and there was little, if any, requirement to prove that they were safe or effective. Fast forward to the early 1960s, and thalidomide was touted as a wonder drug, with claims that it was safer than conventional sedatives and could be used for conditions ranging from insomnia, headache and, tragically, morning sickness. The infamous birth defects caused by thalidomide highlighted the fact to Australian consumers and regulators that medications carry risks, as well as possessing benefits, and led to the rigorous approval processes that we have in place today. Although there is no suggestion that cannabis, or its derivatives, are likely to be the basis of such catastrophic outcomes as thalidomide, the deafening public chorus that this new ‘wonder drug’ is completely safe and effective, and therefore should not need to be assessed in the same manner as other medications, should be cause for alarm. Advocates for cannabinoids point out that they have been used for thousands of years and claim that they can cure or treat everything from insomnia to cancer. The reality (based on the available evidence) is somewhat different. Although there has been a large increase in the number of publications in recent years relating to the use of cannabinoids as therapeutic agents, there is still a marked lack of high-quality, objective evidence that conclusively proves that CBMs are as effective as claimed, with much of the evidence still being anecdotal. Registration of nabiximols (Sativex: GW Pharmaceuticals, Cambridge, UK) already exists to treat muscle spasticity in multiple sclerosis, but the evidence for other indications is not as clear and there are no other CBMs or cannabis derivatives currently registered for use in Australia. When considering whether making cannabis or derivatives widely available, consideration must be given to three key areas: evidence of their effectiveness, their safety profile, and the cost associated with these medications. In A Matter of Opinion, we identify potentially contentious matters and invite experts in the field to contribute a brief piece outlining their opinion on the matter. In each case, a commentator is invited to advocate in favour of the proposition under consideration, and another contributor argues the opposing point of view. The contributions are not comprehensive reviews but rather brief expressions of opinion, backed up by some succinct supporting information. A range of topics are covered, and suggestions from the readership for future matters for consideration will be most welcome.