|CHAPTER 8 OPINION OF THE COMMITTEE
Medical use of cannabis: recommendations
8.1 We recognise that, in all the evidence we have
received, there is not enough rigorous scientific evidence to prove conclusively that
cannabis itself has, or indeed has not, medical value of any kind.
8.2 Nevertheless we have received enough anecdotal
evidence (see above, paragraphs 5.4, 20-22, 27-30) to convince us that cannabis almost
certainly does have genuine medical applications, especially in treating the painful
muscular spasms and other symptoms of MS and in the control of other forms of pain.
8.3 We therefore recommend that clinical trials
of cannabis for the treatment of MS and chronic pain should be mounted as a matter of
urgency. We warmly welcome the fact that, in the course of our inquiry, both Dr
Geoffrey Guy of GW Pharmaceuticals, and the Royal Pharmaceutical Society's working group
under Sir William Asscher, have set off down this route (paragraphs 5.44-48). We welcome
the Asscher group's intention to compare the effects of a standardised preparation of
natural cannabis with those of the one synthetic cannabinoid already available,
dronabinol, on the basis of the same dose level of THC.
8.4 Although neither Dr Guy nor the Asscher group
contemplate trials of smoked cannabis, we agree with the Chief Executive of the MRC that
such a trial should not be ruled out (paragraph 5.57). However we recognise the dangers of
smoking, and we do not envisage smoking being used to administer any medicine eventually
licensed. For this reason we recommend that research be promoted into alternative modes
of administration (e.g. inhalation, sub-lingual, rectal) which would retain the benefit of
rapid absorption offered by smoking, without the adverse effects.
8.5 The Government have said repeatedly that, if
sufficient evidence in favour of cannabis as a medicine were produced for the MCA to be
prepared to license it, they would amend the Misuse of Drugs Regulations so as to permit
it to be prescribed. The problem with this policy is that it will take several years at
least for this to happen. The Asscher group's trials are not expected to be complete
before mid-2001, and will lead only to "proof of principle", leaving others to
proceed with any pharmaceutical development. Dr Guy does not expect to receive a product
licence in under five years. In the mean time, 85,000 people in this country will continue
to suffer the very unpleasant symptoms of MS. Only a small proportion of these are known
to have tried cannabis illegally; but of these, significant numbers report great relief of
their symptoms. We do not believe that this position is satisfactory.
8.6 We therefore recommend that the Government
should take steps to transfer cannabis and cannabis resin from Schedule 1 to the
Misuse of Drugs Regulations to Schedule 2 (see Box 3), so as to allow doctors
to prescribe an appropriate preparation of cannabis, albeit as an unlicensed
medicine and on the named-patient basis (see Box 6), and to allow doctors and
pharmacists to supply the drug prescribed. This would also, incidentally, allow
research without a special licence from the Home Office (see Box 8).
8.7 It is argued in some quarters that some of
those who campaign for medical use see it as a stalking-horse for the legalisation of
recreational use (paragraphs 7.28-30). We do not see this as a reason to resist medical
use if, as we believe, it is justified by the evidence. We prefer the argument recently
advanced by Austin Mitchell MP in the House of Commons (14 January 1998, col. 317):
at present, people who use cannabis for medical reasons are caught in the front line of
the war against drug abuse. This makes criminals of people whose intentions are innocent,
it adds to the burden on enforcement agencies, and it brings the law into disrepute.
Legalising medical use on prescription, in the way that we recommend, would create a clear
separation between medical and recreational use, under control of the health care
professions. We believe it would in fact make the line against recreational use easier to
8.8 Before moving cannabis out of Schedule 1, the
Government are required by law to consult the Advisory Council on the Misuse of Drugs. We
recommend that they do so at once, and respond to this report only after receiving and
considering the advice of the Council. We recognise that this may take longer than the
time normally allowed for such responses.
Medical use of cannabinoids: recommendations
8.9 Unlike cannabis itself, the cannabinoid THC
(dronabinol) and its analogue nabilone are already accepted by the Government as having
medical value (paragraphs 5.11-17)producing the anomaly that, while cannabis itself
is banned as a psychoactive drug, THC, the principal substance which makes it
psychoactive, is in legitimate medical use. Some of our witnesses are prepared (paragraph
5.50) to contemplate wider medical use of the cannabinoids, but not of cannabis itself. We
disagree, since some users of both find cannabis itself more effective (paragraph 5.51).
We do, however, welcome the inclusion of THC in the trials proposed by the Asscher group,
in like-for-like comparison with cannabis itself.
8.10 Dronabinol (THC), though not licensed in this
country, has already been moved to Schedule 2 to the Misuse of Drugs Regulations, and
nabilone is a licensed medicine and not a controlled drug; so no Government action is
required in either case to permit clinical trials or indeed prescription. All cannabinoids
other than THC remain in Schedule 1, and transferring them would require agreement through
the WHO under the 1971 Convention. We do not regard this as a priority, since we are not
persuaded that any other cannabinoid has a convincing medical use; but we recommend that the
Government should raise the matter of rescheduling the remaining cannabinoids with the WHO
in due course, in order to facilitate research.
Why change the law?
8.11 Our principal reason for recommending that the
law be changed, to make legal the use of cannabis for medical purposes, is compassionate.
Illegal medical use of cannabis is quite widespread (paragraphs 5.2-3); it is sometimes
connived at and even in some cases encouraged by health professionals (paragraph 5.6); and
yet at present it exposes patients and in some cases their carers to all the distress of
criminal proceedings, with the possibility of serious penalties. We acknowledge that, if
our recommendation were implemented, the United Kingdom would be moving out of step with
many other countries; we consider that the Government should not be afraid to give a lead
in this matter in a responsible way.
8.12 As a secondary reason, we would observe that
the law in this area appears to be being enforced inconsistently, and in some cases with a
very light hand (paragraphs 7.2-5). Some cases are not brought to court; where users of
cannabis for medical purposes have been prosecuted, the sentence has sometimes been light;
and there have even been cases where juries have refused to convict. The Minister told us
that he was content to leave this as a matter for the discretion of the prosecuting
authorities and the courts (QQ 668-673). That is a constitutionally proper position
for a Minister; but it is not the right position for Parliament. If statute law is not
enforced, Parliament is brought into disrepute; either enforcement must be tightened up,
or the law must be changed. In this case, we recommend the latter.
8.13 A further subsidiary advantage of transfer
from Schedule 1 to Schedule 2 would be the encouragement which this would give to research
(paragraphs 7.18-26). There are exciting research opportunities in this field (see Chapter
3), which (on the basis of the number of grants by the MRC and the Wellcome Trust, and the
number of Home Office research licencesparagraph 5.39 and Box 8) are not being fully
taken up in this country, despite the excellence of British biomedical science. We are
satisfied that the Home Office are not being deliberately obstructive; and we are glad
that they have already taken up our proposal for a meeting between the research community
and those responsible for the research licensing regime (paragraph 7.26). But, now that
research in this field has taken off, and the existence of important medical applications
is (in our view) well established, it is not appropriate for research to continue to be
subject to this extra layer of administration. Transfer to Schedule 2 would also go some
way to removing the stigma which many of our witnesses believe hangs over research in this
field, deterring researchers, funding bodies, pharmaceutical companies and local ethics
committees alike from involvement in research which might turn out to be of great
8.14 As the Minister pointed out to us, a doctor
who prescribed cannabis on these terms, in the absence of a product licensed by the MCA
for the relevant indication, would take on himself full responsibility for the
consequences (Q 679). This is true. However we have received evidence from doctors
who are currently prescribing nabilone on an unlicensed basis (Notcutt Q 405). We believe
that the overwhelming majority of members of the medical profession can be trusted not to
be reckless in this matter, and that the professional regulatory bodies will deal
effectively with any who are.
8.15 The Minister also observed that, in some
cases, someone charged with a cannabis offence may claim medical use as a bogus defence or
plea in mitigation (Q 674). We do not doubt that this happens at present; and, in the
case of some people, it may be hard to tell where recreational use stops and medical use
begins (paragraph 5.5). Rescheduling so as to permit prescription would in fact make
this problem easier to deal with: rather than having to investigate individual medical
histories, as at present, the authorities would simply ask to see the prescription.
8.16 As with any medicine, there are some groups of
patients for whom cannabis-based medicines will not be appropriate. On the evidence before
us, cannabis-based medicines should not be prescribed for persons with, or predisposed
towards, schizophrenic illness (paragraph 4.12) or cardiovascular conditions (paragraph
4.4); nor, pending further research, should they be prescribed for pregnant women
(paragraphs 4.15-16). As with many medicines, users should be warned of possible effects
on driving ability (paragraphs 4.6-9) and cognitive function (paragraph 4.13). As with any
potentially addictive medicine, the risk of addiction (paragraphs 4.23-33) should be
weighed up when deciding whether to prescribe, and the user should be warned. Therefore,
if doctors are permitted to prescribe cannabis on an unlicensed basis, the medical
professional bodies should provide firm guidance on how to do so responsibly
8.17 As with any medicine which is open to abuse, safeguards
must be put in place by the professional regulatory bodies to prevent diversion to
improper purposes (paragraph 7.27). These might include a system of declarations to be
signed by the doctor and the patient.
8.18 It is believed in some quarters that the
current absolute prohibition on the recreational use of cannabis and its derivatives is
not justified by the adverse consequences for the user and the public. On the evidence
before us, we disagree. On the contrary, we endorse the Government's statement in Tackling
Drugs: "The more evidence becomes available about the risks of...cannabis,...the
more discredited the notion that [it is] harmless" (paragraph 6.16).
8.19 The harms must not be overstated: cannabis is
neither poisonous (paragraph 4.3), nor highly addictive, and we do not believe that
it can cause schizophrenia in a previously well user with no predisposition to develop the
disease. However, we are satisfied that:
It is intoxicating, enough to
impair the ability to carry out safety-critical tasks (such as flying, driving or
operating machinery) for several hours after taking (paragraphs 4.6-9);
It can have adverse psychic
effects ranging from temporary distress, through transient psychosis, to the exacerbation
of pre-existing mental illness (paragraphs 4.10-12);
Regular use can lead to
psychological dependence (paragraphs 4.23-33); and, in some dependent individuals (perhaps
5-10 per cent of regular users), regular heavy use can produce a state of near continuous
intoxication, making normal life impossible;
Withdrawal may occasionally
involve unpleasant symptoms (paragraphs 4.23-25);
Cannabis impairs cognitive
function during use (paragraph 4.6);
It increases the heart rate and
lowers the blood pressure, carrying risks to people with cardiovascular conditions,
especially first-time users who have not developed tolerance to this effect (paragraph
8.20 Moreover, it is possible, though not proved,
that the effects of cannabis on driving etc. may last longer than a few hours after taking
(paragraph 4.7); that the damage to cognitive function may endure after withdrawal
(paragraph 4.13); and that cannabis has adverse effects on the immune system (paragraph
5.16) and on fertility and reproduction (paragraphs 4.15-16).
8.21 In addition, smoking cannabis carries similar
risks of respiratory disorders to smoking tobacco. It is also possible, though not proved,
that exposure to cannabis smoke increases the risk of cancers of the mouth, throat and
lung (paragraphs 4.17-18).
8.22 Therefore, on the basis of the scientific
evidence which we have collected, we recommend that cannabis and its derivatives
should continue to be controlled drugs.
Summary of recommendations
(i) Clinical trials of cannabis for the
treatment of MS and chronic pain should be mounted as a matter of urgency (paragraph 8.3).
(ii) Research should be promoted into
alternative modes of administration (e.g. inhalation, sub-lingual, rectal) which would
retain the benefit of rapid absorption offered by smoking, without the adverse effects
(iii) The Government should take steps
to transfer cannabis and cannabis resin from Schedule 1 to the Misuse of Drugs
Regulations to Schedule 2, so as to allow doctors to prescribe an appropriate
preparation of cannabis, albeit as an unlicensed medicine and on the named-patient basis,
and to allow doctors and pharmacists to supply the drug prescribed (paragraph 8.6).
(iv) The Government should consult the
Advisory Council on the Misuse of Drugs on this matter at once, and respond to this report
only after receiving and considering their advice (paragraph 8.8).
(v) The Government should raise the
question of rescheduling the remaining cannabinoids with the WHO in due course (paragraph
(vi) If doctors are permitted to
prescribe cannabis on an unlicensed basis, the medical professional bodies should provide
firm guidance on how to do so responsibly (paragraph 8.16); and safeguards must be
put in place by the professional regulatory bodies to prevent diversion to improper
purposes (paragraph 8.17).
(vii) Cannabis and its derivatives
should continue to be controlled drugs (paragraph 8.22).