A global glance at medical cannabis

This referenced paper highlights some of the medical cannabis changes that have occurred globally in recent times.

Prior to the 20th century, cannabis sativa was a legal plant primarily used in Western cultures for industrial hemp material, intoxication and medicinal purposes. Along with many Western nations, Australia and the United States (US) were signatories to the 1925 Geneva Convention on Opium and Other Drugs, which saw the use of cannabis restricted for medicinal and scientific purposes only, along with morphine, cocaine and heroin.

Following the signing, Australia and the US enacted laws consistent with this Convention for various Poisons and other Acts. California was the first western US state to include cannabis as a poison, though it later legalised marijuana for medical use in 1996. The Californian Poison Act was passed in 1907 and amended in 1909 and 1911, and in 1913 an amendatory act was established to make possession of "extracts, tinctures, or other narcotic preparations of hemp, or loco-weed, their preparations and compounds" a misdemeanour1.

The US Federal Government passed laws to harmonise the states legislation by the mid-1930s. The US Marihuana (Marijuana) Tax Act of 1937 effectively made possession or transfer of cannabis illegal throughout the US under federal law, excluding medical and industrial uses. Interestingly, it is the wording of this Act that supports the continued use of the slang term marijuana (and the unusual marihuana spelling) for leaves of cannabis sativa in the US (see factsheets for more information on cannabis nomenclature).

A new federal drug prohibition agency in the US, known as the Federal Bureau of Narcotics, encouraged national and international drug prohibition in the 1930s. Global prohibition was established following the United Nations Single Convention of 1961 (with subsequent amendments and supplements in the 1970s and 80s)2-4.

Within a short period, the Netherlands (through the Opium Act of 1976) made the world s first official distinction between drugs in the narcotics class and noted that from their policy perspective, cannabis was considered less harmful than other illicit drugs such as cocaine, heroin and ecstasy. In line with this, 25 years after an initial proposal by the Advisory Council on the Misuse of Drugs in 1978, the UK (under the Thatcher government) introduced cannabis cautioning. In the UK, cautions can be given to anyone aged 10 or over for minor crimes, if the offender admits an offence and agrees to be cautioned. A caution is not a criminal conviction, but it may be used as evidence of bad character if the offender goes to court for another crime.

In the climate of these changes, the Netherlands began to tolerate (through case law) the sale of cannabis by caf -like outlets known as coffee shops5. Several European countries have since relaxed their laws (or law enforcement) about possession offences, although sometimes just for cannabis. Other European countries, however, continue with a predominantly prohibitionist policy. Sweden claims to have achieved relatively low levels of drug use with a firm prohibitionist approach, which includes compulsory treatment of drug users, and considerable public resourcing of drug rehabilitation and education programs, after an earlier period of liberalisation6.

Since the 1970s two cannabinoid receptor agonists Dronabinol and Nabilone - have been used to examine the effects of delta-9-tetrahydrocannabinol (THC) and investigate its medicinal uses. Dronabinol (Marinol) is a US schedule III oral medication approved for AIDS-related wasting and chemotherapy-induced nausea and vomiting7. Nabilone (Cesamet) is a schedule II oral medication approved for spasticity secondary to spinal cord injury8. Later, in 2005, a third cannabinoid receptor agonist, the oral botanical spray nabiximols (Sativex), was approved first in the UK and then in multiple jurisdictions, including Australia, for pain and spasticity related to multiple sclerosis.

In 1996 Californian voters approved the Compassionate Use Act which was a world first and is the complete removal of the criminalisation for obtaining, using and growing cannabis for medicinal use in that state (medical use is defined as any illness for which cannabis provides relief). This was an unprecedented move to make a drug available as medicine outside the Food and Drug Administration approval processes for safety and efficacy. Following this, and a series of incremental changes by the Canadian federal government, under the new Medical Marihuana Access Regulations , cannabis also became legal for medicinal use in Canada for the first time in 20019-11.

Despite legalisation for medicinal use, the Government of Canada claims it does not endorse the use of marijuana, but the courts have required reasonable access to a legal source of marijuana when authorized by a physician 12. In contrast, the US Federal law maintained the prohibition of any cannabis use until the policy memorandum in August 2013, which allowed states to carry out initiatives without federal interference as long as the state adheres to certain guidelines regarding the regulation and enforcement of cannabis policies13.

Notably, the question of the status of cannabis as a Schedule I drug in the US that is, it has a high potential for abuse and no currently accepted medical use in treatment in the United States and there exists a lack of accepted safety for use of the drug under medical supervision 14 was recently tested in the US Supreme Court in a California hearing and was upheld against multiple defence witnesses.15

Following the significant changes in the mid-to-late 90s, several other US states introduced medicinal cannabis laws and until now, 23 states and Washington DC have had them enacted in various ways. A number of these only relate to cannabis that is low in THC and high in cannabidiol (CBD)16, although no systematic testing regimes are in place to monitor the levels of cannabinoids.

In 2010, California became the first state to introduce a ballot initiative to legalise the recreational use of cannabis, however, this received only 46.5% of the vote 17. Later, in November 2012, a proposition initiated by the public and the new industry of medicinal cannabis was put to the people as Amendment 64 in the US state of Colorado. This was an amendment to the State Constitution which resulted in the legalisation of cannabis use, sale and production, and the requirement of the Colorado Department of Revenue to license and regulate the industry.

In November 2012, Washington voters approved Initiative 502. This was also an amendment to State Constitution which resulted in the legalisation of cannabis use, sale and production, and the requirement of the Washington State Liquor Control Board to license and regulate the industry. This initiative also received significant funding from cannabis entrepreneurs. In addition, in November 2014, residents in Alaska, Oregon, and Washington, D.C., also voted for the legalisation of cannabis for recreational use, with more states expected to vote on similar propositions.18

Outside of the US, the Portuguese and Czech Republic governments decriminalised cannabis use in the early 2000s19, as did some Australian jurisdictions (South Australia in 1987, the Australian Capital Territory in 1993 and the Northern Territory in 1996)20. Other jurisdictions in Europe and Latin America including Spain, Germany, Belgium, Argentina, Colombia, and Jamaica have also decriminalised cannabis use21-26. In December 2013, Uruguay legalised the recreational use, production and sale of cannabis. It became the first state to do so through a government-led initiative without a pre-existing medicinal use industry. Interestingly, the Uruguay public is nearly two thirds against this policy change and it may not be supported by the new government.27

Despite these changes over time in some jurisdictions no developed country has made any serious attempt to opt out of, or call for repeal of, the 1961 UN Single Convention.


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