We have all been moved by stories of people suffering long-term pain or other chronic conditions and felt deep compassion for them. Perhaps conventional medications have not worked or have had unacceptable side effects. Perhaps the person may have used marijuana and found great benefit. How could a compassionate doctor, politician or friend respond other than by supporting ready access to medical cannabis? It seems a simple solution.
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But, while compassion is a crucial part of what makes us human, it needs to be counter balanced by our analytical capacity. In health care, compassion needs to be balanced by scientific evidence. The need for evidence challenges medicine just as much as it challenges people who are ill. There is no doubt that Western medicine is very effective in treating short-term conditions. Its track record in chronic conditions is much less impressive. In fact, evidence shows that lifestyle approaches are much more effective than medicines in treating many chronic conditions. With chronic pain there is strong evidence that lifestyle change can wind down a sensitised nervous system and reduce pain. On the other hand, evidence shows cannabis use is likely to hinder lifestyle change, and thus cause more harm than benefit in chronic pain. Many patients who use cannabis reportedly to treat chronic pain (recognising that this has not been legal) have been seen in pain clinics over the years. Those who use cannabis still report high pain levels and they remain one of the most highly disabled groups. Demotivation and mental health conditions are common.
There are major concerns about using cannabis regularly over the long term. The Dunedin Longitudinal Study highlighted the risk of loss of IQ points, particularly in those who start using cannabis in adolescence. The developing human brain is particularly vulnerable to the drug’s neurotoxic effects. Adult brains are not protected either with studies showing impaired thinking, with even short-term use.
The double blind randomised controlled trial is the highest level of scientific evidence. The double blinding (neither patient nor observer know which is the real treatment) allows for the placebo effect to be taken into account. The most definitive meta-analysis, pooling results of randomised controlled trials, was done by the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain (Finnerup and colleagues, 2015). They examined nine trials (1310 patients) using Sativex a mixture of tetrahydrocannabinol and cannabidiol. The authors recommended against using Sativex for nerve injury pain or mixed pain due to “negative results, potential misuse, diversion and long-term health risks of cannabis particularly in susceptible individuals”. Clinical trials are underway in Australia to study cannabis products in settings of greatest promise. These are: difficult to control epilepsy in children, chemotherapy induced nausea, vomiting and loss of appetite and distress at end of life.
If good quality clinical trials do not show benefit we need to be bold and not make cannabis available medically. If despite a lack of clear positive evidence we are driven by misguided compassion to make medical cannabis widely available we risk destabilising society with higher rates of disability and ever more taxes required for the care of chronic conditions.
