Introduction

Cannabis, despite being the world’s most abused banned drug, has for a long time been recognised for its potential health benefits.¹ In treating cancer, there have been many mechanisms driving cancerous growth shown to be stunted by cannabis use.⁶

However, countries must consider the risks versus the benefits of cannabis use. Already widely prohibited, this drug is legally considered potentially dangerous to both the mind and body.⁹ One of the key issues some countries may want to prevent is “a medical system only by name.”¹¹ Countries may consider:

• Regulation in the same manner as other medical products¹¹
• Whether or not to combine medicinal cannabis into the recreational market¹¹
• Pricing policies¹¹
• Reducing¹¹ vs increasing possession arrests
• Full or partial cannabis legalisation
• Rigorous research¹¹

This article will cover some discussions around the legal approach to medical cannabis to treat cancer patients.

What are the medical properties of cannabis?

Cannabis is often thought of as a way to get “high”.⁸ However, although at times used recreationally or as a source of fibre, cannabis is an aromatic plant with potential as medicine. It is cultivated around the world, with its origins in Central Asia.² Marijuana is derived from cannabis, as it comprises the leaves and flowers of the Cannabis plant.⁸ This article will use these terms interchangeably, especially as many references regarding the United States refer to it as marijuana. There are two species of marijuana most often used for medicinal purposes: Sativa and Indica. These two species grow in different conditions and can have different effects between people. Cannabis can actually be a combination of both of these.⁸ Cannabis can come in many forms, such as oils, concentrates, edibles, infusions, lotions and balms.³

Cannabis may contain up to 100 chemical substances called cannabinoids, and otherwise around 300 known as non-cannabinoids.⁴ Two of these cannabinoids are of particular interest: tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the active chemical compound in marijuana, and is known to produce the psychoactive effects experienced with cannabis, causing the feeling of being ‘high’.^2,4 On the other hand, CBD is thought to calm the body down, counteracting the effects of THC for a more relaxed state.^2,4 It may therefore play a role through calming mechanisms that help minimise symptoms associated with having THC, e.g. anxiety. To achieve such effects, THC, CBD, and cannabinoids in general act upon the body’s central nervous system.⁴ They bind to cannabinoid receptors, of which the most prominent type (cannabinoid receptors 1) are mostly located in the brain. Outside of the brain these receptors are linked to peripheral effects on tissue function.⁵

The medicinal effects of the cannabinoids in cannabis are both present and interesting. Cannabis does show potential in medicine, however, in an unclear and complex manner. It has been used to help people with cancer. Cannabinoids appear to help tackle mechanisms that normally assist cancer growth, such as by blocking cell growth, preventing angiogenesis (the production of new blood vessels), reduce metastasis (the spreading of the cancer in the body) and reducing inflammation.⁶ However, it has also been shown to have additionalunwanted effects, such as the encouragement of cancer cell growth and damaging existing blood cells.⁶

The uncertainty and differing effects of cannabis make assignment of cannabis-related products to medicinal ranking difficult and complex. Thus, there is the need for in-depth legal considerations for using medicinal cannabis in cancer treatment.

Global overview of cannabis legislation

Cannabis legislation differs greatly across the world. Some areas have made use of cannabis either entirely legal or entirely illegal, such as Canada and Russia, respectively. Others use some form of middle ground, where cannabis may be legal for purely medical purposes, decriminalised, legal for private use only, and prohibited to sell.⁷

Fully legalised

One of the only places in the world where cannabis is fully legal is Canada,^7,11 without full prohibition on whether it may be

• owned
• grown
• turned into products
• bought, shared, or 
• sold 

These rules fall under The Cannabis Act, which outlines the laws for cannabis use in Canada.¹¹

There are strict limits and regulations surrounding this full legalisation, such as age restrictions and prohibited driving under cannabis influence.¹³ You can read more about them here.¹¹ The allowances listed above are based on the legal approach appointed from 17 October 2019.¹¹ 

However, medical use of cannabis has been legal since 1999.¹² Looking at Ontario, Canada specifically, Ontario Health described cannabis as ineffective in treating cancer, as well as having no impact that lowers the risk of getting it.¹³ It instead stated the need for further research on whether cannabis may cause cancer.¹³

Other places that have legalised recreational cannabis include Uruguay and Thailand.^7,15,16 In other areas, such South Africa, it is legalised but selling is prohibited.^7,14

Medical use approved with restrictions

Many places have legalised cannabis to a medical extent only. How this is achieved depends on the region. For example, across the United States the legislations vary, so there is no blanket term to cover medical cannabis approval.⁷ This applies to recreational cannabis too. Most states, however, do allow medical cannabis use, with differences in how they manage the program.¹⁷

Prohibited or highly restricted

Many regions have fully or almost entirely made cannabis (both medical and recreational) illegal. This includes Russia, China, Saudi Arabia, Greenland and many other countries.⁷

Federal vs. state/regional regulations

Marijuana (earlier described as the derivative from the flowers and leaves of the cannabis plant)⁸ is federally illegal across the United States. This includes both medicinal and recreational use.¹⁸ However, some states, as earlier mentioned, do approve the medical use of cannabis. A few of these are limited to CBD/low-THC products, specifically for medical conditions that qualify.¹⁷

The differences between federal and state laws does create some issues. Aside from financial concerns, transport between states could endanger drivers to lose their Department of Transportation certifications if they are tested positive for cannabis. This may be independent of whether they are driving intoxicated.¹⁹ Perhaps this could impact patient travel when they have used medical cannabis.

Regulatory approval and prescribing standards

The methods by which cannabis drugs can be classified as medical products and even prescribed differs between different regions. In the United States, the U.S. Food and Drug Administration (FDA) confirms the “safety, efficacy and security” of such products.²⁰ One drug derived from cannabis (Epidiolex (CBD)) has been approved by the FDA, as well as three synthetic drugs related to cannabis: Marinol and Syndros.²¹ 

In the UK, the Medicines and Healthcare products Regulatory Agency (MHRA) sets out important regulations to ensure that medicinal cannabis is safely manufactured, stored, distributed and labelled.²² One cannabis-based product, Nabilone, is approved for treatment during chemotherapy to help soothe related symptoms like nausea and vomiting.²³

Insurance coverage and cost considerations

In the UK, medicine derived from cannabis may be obtained through the National Health Service (NHS), however this is only via prescription from or under the supervision a specialist hospital doctor.²⁴ This is a rare occurrence, but it may be considered to help in treating symptoms associated with chemotherapy.²⁴ Aside from this, insurance would have to be sought out privately, however these appear not to cover the cost of privately-bought medication like cannabis.²⁷ 

There are few countries that will cover medical cannabis under public health insurance, where Germany is one of them. Bought privately, medical cannabis can cost up to £300 a month.²⁵ Similarly, in the United States, medical marijuana costs $326.06 on average.²⁶

Legal risks and protections for patients and healthcare providers

As mentioned earlier, in the United States, using marijuana is a federal crime. It is state-by-state dependent on whether it can be used for medicinal purposes. Therefore, where a state makes allowances for medical marijuana use, both healthcare providers and patients are, in fact, guilty according to federal law. Previously discussed were the conditions whereby commuting across state lines and testing positive for cannabis may result in a criminal offence. 

Perhaps this could impact on patients who have taken medicinal marijuana. Despite directly differing against federal law, proposition 215 in California allows patients to have medical cannabis based on advice from a medical professional. Other states have implemented similar.²⁸ This is not only for patients, but for the protection of the physician who recommended it. In the UK, physicians may recommend medical cannabis use, but this is rare.²⁸

Ethical and policy considerations

As with many treatments, ethics regarding the patient’s health involve a risk-to-benefit ratio.²⁹ Aside from this, the formation of policies must also consider:

• Whether the evidence for the condition to be treated is well-established (can cannabis improve patient health?). Considering this versus any conditions currently set out by the law²⁹
• The patient-provider relationship (sharing the decision-making process)²⁹
• Adverse effects on patient health (and differences of these effects based on age)²⁹
• Education on using cannabis safely²⁹
• The type of cannabis use (e.g. smoking tobacco versus other methods)²⁹
• CBD versus THC content²⁹
• Mandatory self-education for physicians²⁹

Summary

Regions and countries currently vary vastly in their stance of medical cannabis use. The legalisation (or lack of it) is probably one the most significant factors in using cannabis to treat cancer. It seems the most common use for cannabis in this area is for treating symptoms associated with chemotherapy such as nausea and vomiting. There are many implications for leaders to consider, on an ethical, legal, cost-based, long-term versus short-term and regulatory basis.