Professor Jennifer Martin, Chair of Clinical Pharmacology at the University of Newcastle and Director of the Australia Centre for Cannabinoid Clinical and Research Excellence, explores research, innovation and policy in Australia.
Professor Jennifer Martin is Chair of Clinical Pharmacology at the University of Newcastle and Director of the Australia Centre for Cannabinoid Clinical and Research Excellence, as well as a member of MCN’s Editorial Advisory Board. We spoke with Professor Martin about the use of medical cannabis in elderly care, emerging research, and legislative successes in Australia.
What factors do you take into account when determining individual dosages of CBD and medical cannabis?
The determining factors are similar to those we consider when prescribing other medicines, like the age of the patient, their size and what condition or symptoms they are experiencing. We also have to find a balance between toxicity and efficacy and take into account what side effects people may become unable to tolerate as the dose goes up.
What are the key benefits of cannabis in the treatment of ageing and end of life patients?
The main symptom that cannabis really helps with is anxiety – we have had a few patients who find it causes their existing anxiety to get worse and they become paranoid, which sometimes occurs in younger people just using cannabis recreationally, but medical cannabis has certainly been helpful to some end of life patients who are anxious. It can cause sedation, which can be beneficial to end of life patients, but a lot of people find that sedative effect makes them less cognitively sharp; they say they feel ‘woolly’. That’s a side effect we sometimes see with opioids as well, which may be one reason why people have been interested to try cannabis rather than morphine.
There are studies currently in progress investigating cannabis use among the elderly population; and anecdotal reports indicate it may be helpful for anxiety, sleep and sedation. However that does come with a cost: patients may not be as sharp, and there is the risk of heightened anxiety or psychosis, in addition to potential gut problems.
Is current Australian policy entirely beneficial for research and innovation in cannabis? What policy changes would improve the situation for scientists?
The policy framework governing cannabis in Australia has come on in leaps and bounds: compare the situation now to, say, 2015, it was much more difficult to conduct meaningful research on cannabis. It was too difficult to get high quality products and far too difficult to get regulatory approval. In the last few years there have been incredible changes with regard to support for research in Australia.
I’m involved with a study exploring real world use of cannabis, which is overseen by an ethics committee comprising scientists and clinicians, but also lay members, MPs and representatives of the church; and the study has been held back by about two years because there is a lot of concern from the committee we might be seen to condone drug use. The committee was concerned that using a drug which is not yet registered might have an impact on the community; that participants might not store the cannabis they received as part of the study securely and other people might get hold of it.
Another issue we had with the study was the challenge of ensuring a reliable supply of high quality products for the full period of the trial: there are a lot of startup companies and people wanting to make a quick buck, and then they have cash flow problems and their drugs are pulled from the Australian market; and then we have to complete a new application and find new products somewhere else. I’m not sure that the policy framework could change much more, it’s probably get as good as it can get: it is now down to the industry to ensure it can provide a high quality product with all the correct paperwork.
Companies which have already worked within the pharmaceutical framework tend to be aware of the need for pharmaceutical grade products and all the administrative demands it entails, while businesses which have not previously operated in drug development can’t understand why it all takes so long to get things done. From the perspective of the medical community and patients, we feel that the government has moved a significant amount to facilitate research and clinical applications.
Are there any specific areas of medicine in which further research should be conducted to better support the role of cannabis in treatment?
There are some conditions and symptoms which don’t respond particularly well to conventional chemical treatments; many of these would traditionally have been treated with morphine, but that does lead to addiction problems. These areas include chronic pain syndrome, which is often not so much a chemical issue – there are a number of psychological issues intertwined with it – but unfortunately as medical practitioners we have tended to give people chemical treatments; and that population often feels that a new chemical will help them with their pain. However, the evidence coming out now suggests that we shouldn’t be prescribing drugs for these patients; instead we should give them good psychological therapy and help them overcome some of the issues which may be contributing to their pain. Chronic pain is a very pretty complicated symptom: I’ve seen patients who suffer from neuropathic pain, but that is then overlaid with chronic pain derived from psychological issues because they can’t walk, or they’re not getting enough sleep, or they’re generally under stress. The whole area of pain would be interesting to study, breaking down the aspects of chemical pain, nerve pain, psychologically triggered pain and their causes.
In end of life treatment, more research should be done into the distinctions between anxiety, sleeplessness and distress: patients experience existential distress, they just do not feel good in their body. People say they take cannabis and feel much better, but it’s not really clear whether the cannabis is having a beneficial effect on the anxiety or their pain or whether it’s treating broader issues such as enabling them to enjoy their food a bit more. These overlapping symptoms like sleeplessness, pain, low appetite and anxiety have been difficult for the medical model to cope with over the years, but it is possible that researching the effects of cannabis might help us better understand some of the biology and physiology behind those symptoms and find the optimal way to treat them.
Professor Jennifer Martin
Australia Centre for Cannabinoid Clinical and Research Excellence