When cannabis was compared to a placebo for pain relief, predictably it was more effective.
The debate on whether marijuana should be legalised in India has gained heat. But in a country where people are known to smoke with kids in their arms, on the roadside, or bedside, nobody quite knows what legalisation would lead to.
There has been some brouhaha in the media about Union minister Maneka Gandhi’s suggestion that marijuana be legalised for medical purposes in India. Legalisation of medical marijuana is different from legalisation for recreational use. One of the statements made in favour of legalising marijuana is that it will reduce illicit drug use and curb illegal uncontrolled trade. But people who want it for recreational purposes, will not get access to marijuana if it is made legally available for medical use. Hence, medical use of marijuana will not have any impact on illicit drug use, unless we are expecting recreational users to abuse the system and get access to marijuana meant for a medical purpose.
Unfortunately, in India, this is highly possible. In fact, we could end up making the drug widely available for recreational use under the guise of medical use. In India we are already battling illegal use of medicines as recreational drugs, such as cough syrups, sleeping pills and anaesthetic agents, among others. By adding another drug such as marijuana, which does not have any strong research-based proof that it could bring about the benefits presumed, we may complicate matters further without adding any benefits to patients.
It is no secret that the number of cancer patients in India is going up every year. Medical studies suggest that by 2020, there will be more than a million new cases every year in India. Due to lack of awareness and logistical issues, cancer is detected in the later stages in most patients in India and hence may not be amenable to a cure. Since advanced stage cancer can cause significant amount of pain, these patients need solid painkillers. Even in a city like Mumbai, good painkillers such as morphine are available at very few places.
Since morphine has a very high chance of being used as a recreational drug, the government controls the manufacturing, storage and sale of morphine very tightly. This makes it difficult for smaller pharmacies and hospitals to get access to the drug. One can imagine the ordeal of patients and their caregivers in procuring this essential drug. If the government works on making opioid drugs such as morphine and codeine available to more hospitals and pharmacies, there is no need to legalise a less effective drug such as cannabis.
The role of cannabis in the management of cancer is of interest because of its effect on an individual’s mood, pain, and its hallucinating effects. Several reports have suggested that cannabis may be an effective treatment for the nausea, vomiting and lack of appetite that cancer patients experience.
In patients with advanced cancer, it may help them sleep, elevate their mood, improve appetite and give relief from pain. Cannabis has also shown some effects as an anti-tumour drug in cancers such as breast, prostate, certain brain tumours, skin, colon, pancreatic cancer and lymphoma, in laboratory samples.
There is no evidence to suggest its benefit in any clinical trial done on patients.
When cannabis was compared to a placebo for pain relief, predictably it was more effective. We do not have any study which compares cannabis or its products to any standard painkiller such as morphine. Studies of cannabis as a drug which would improve appetite in cancer patients, or reduce nausea and vomiting, have also not showed any benefits. The American Society of Clinical Oncology (ASCO) and European Society for Medical Oncology (ESMO) guidelines do not recommend cannabinoids as first-line therapies for treatment of cancer-induced nausea and vomiting.
We have seen parents smoke with babies in their arms and at their bedside. Will they be responsible with marijuana if it is legalised in India? I doubt it. Cannabis, in fact, could be linked to a number of serious health hazards. Cannabis smoke contains many carcinogens, and could itself lead to development of cancer. Since a large number of cannabis smokers also smoke tobacco, it is difficult to determine with any accuracy the impact of cannabis in causing various cancers.
Moreover, cannabis has a strong potential for causing addiction. It has many side effects — short-term memory loss, impaired attention, impaired coordination and even psychosis. People who use cannabis for a long time may be hampering their learning capacity, memory, suffering loss of IQ, and may develop other drug and alcohol addiction.
Recently, a young IT engineer, who was getting his mother treated for cancer of the large intestine, asked my opinion on a drug he had found online. I was shocked to learn that it was a bottle of cannabis oil, which is not legally available in India. He was keen to get it for his mother to fight the cancer. There are some who ask me about allowing patients to smoke marijuana in the hope that it will control the pain or effect a cure.
Cannabis as a domesticated plant has a cultural history spanning thousands of years, many continents, and has many uses — recreational, medicinal, and even for ceremonial purposes in Hindu festivals such as Shivratri and Holi.
The medical fraternity was rather late in identifying the effects of cannabis on the body. The first cannabinoid receptors were identified in the brain in 1988. For any drug to reach from laboratory to patients, it must go through a rigorous process of testing in tissues, animal models, then phase I, II and III trials. In these studies, scientists test safety, and effective dosage of the drug for a certain condition. In the last three decades, very patchy medical research has been done to test the benefits of cannabis for various illnesses mainly because the use of cannabis is illegal and it was thus difficult to get regulatory approvals for medical research.
We already have a number of good drugs available for control of cancers, pain, and other treatment-related side effects. The current problem is that these drugs are either inaccessible to the common man or are too expensive.
Rather than trying to make cannabis legal — which will have very little impact on quality of life or cure rate of cancer — the government should focus on making standard effective drugs available to not just people who are living in the cities, but also in smaller towns and villages.
(Dr Prasad Raj Dandekar is head of radiation oncology at the Sir H N Reliance Foundation Hospital, Mumbai)