Interview with Dr. Ilan Nachim. The medicinal use of marijuana

Dr. Ilan Nachim, specialist in family medicine with a particular interest in pain and addiction medicine. Above, marijuana leaves (photo © Tjasulja).
Dr. Ilan Nachim, a specialist in family medicine with a particular interest in pain and addiction medicine. Above, marijuana leaves (photo © Tjasulja).

Considered a personal victory of Prime Minister Justin Trudeau, Canada will be the first G20 country to legalize marijuana for recreational use.

Starting in September, new federal regulation will enable the production, marketing and consumption of cannabis, repealing a law from way back in 1923. The product, whose medicinal use had already been authorized in Canada in 2001, will be monitored by the government, from its production by authorized companies to the establishment of a limit for its possession.

Wave spoke to Dr. Ilan Nachim, a Brazilian and a specialist in family medicine with a particular interest in pain and addiction medicine. He opened one of the first medical cannabis clinics in Canada and regularly lectures about medical cannabis. He currently works at the Centre for Addiction and Mental Health (CAMH), and community clinics helping people who have issues with substance dependence.

Wave: What is the World Health Organization’s position on the use of substances in marijuana as medication? And what are the main diseases that can be treated with these substances?
Dr. Nachim: The cannabis plant has over 200 compounds, most of which we know very little about. The two most studied compounds are tetrahydrocannabinol (THC), which is the main psychoactive compound of the plant, and Cannabidiol (CBD) which does not cause euphoria but is being studied for its medical potential. The World Health Organization (WHO) recognizes several studies that have demonstrated the therapeutic effects of cannabinoids (either phyto and synthetic) for certain conditions such nausea and vomiting in the advanced stages of illnesses like cancer and AIDS. Much of the research revolving around cannabinoids is in the early stages, but there are some studies showing that cannabinoids might have therapeutic uses in a wide range of medical conditions ranging from treatment of neuropathic pain to certain types of seizures, symptoms of multiple sclerosis, and a myriad of other conditions.

Wave: It has been used in medicine for several centuries, so why is there still resistance and prejudice in relation to marijuana in prescriptions?
Dr. Nachim: Much of the prejudice surrounding the use of cannabis today is the result of a campaign that started in the US in the 1920s and 1930s to demonize the new Mexican immigrant population. Although cannabis oil was widely used for medicinal purposes and the plant itself was useful for the manufacture of hemp products at that time, Americans were led to believe that smoking marijuana, as the Mexicans called it, led to violence and other antisocial behaviours.

In my opinion, over the next few years, the stigma associated with cannabis use will decrease, and it will be seen in a similar way to alcohol and tobacco. With research, education, a strong public health policy, and strict marketing guidelines, I think people can become informed about the risks of cannabis use, while at the same time minimizing the harms if they choose to use it, especially for the youth and people at high risk.

Wave: There is a school of thought in medicine that claims the product is responsible for psychiatric illnesses. What is your opinion?
Dr. Nachim: There is definitely a relationship between cannabis use and psychiatric illness. In some people, cannabis use may increase the risk of developing mental illnesses like psychosis or schizophrenia This is one of the reasons why cannabis is not recommended for young people whose brains are still in development and whose psychiatric tendencies have not necessarily become apparent yet. People with a family history or personal history of these and other mental health disorders should stay away from cannabis altogether. Cannabis use can lead to addiction in 9 to 10% of users, and it has been associated with an increased risk of suicide, depression, and anxiety disorders in some cases.
That being said, there is emerging evidence that strains high in CBD may help dampen or counteract some of the psychoactive effects of THC such as disturbances in mood and psychotic symptoms.

Wave: As a physician and citizen, what is your position regarding the legalization of marijuana for recreational use under terms approved by the Canadian government?
Dr. Nachim: First and foremost, I do not think cannabis or any other drugs should be criminalized. As we have seen, criminalization leads to increased and more dangerous use substances, coupled with an overall rise in crime and the financial and social costs associated with it.

The difficult part is deciding what regulation looks like, and how it is carried out and enforced. Portugal created a drug policy in 2001 which decriminalized all drugs and users are not seen as criminals. This approach likely produced positive results to their society in the form of decreased drug use among adolescents, increased uptake of treatment, decreased burden on the criminal justice system. I think that, as a first step, the Canadian government should have decriminalized cannabis use prior to outright legalization, thereby starting the legalization process in a slow and careful manner. The risk of full legalization is that policies can be too liberal, leading to increased harms in society.
However, preceding the impending legislation, the government should start a public education program highlighting the risks of cannabis use. It is crucial at this point to establish standards for the marketing of cannabis and cannabis products that are not influenced by commercial entities.

Wave: What is your recommendation for users who use recreational marijuana?
Dr. Nachim: One of the main problems that occurred after the legalization of cannabis in Colorado and Washington states in the US was a sharp increase of visits to the emergency room due to complications from ingesting cannabis products. Users did not realize that cannabis in this form can take up to two hours before the effect is noticed. Additionally, it is very difficult to know what dosage of cannabis is in a product once it has been mixed with a number of different ingredients and then divided into pieces as in the case of ‘hash brownies’. As a result, people were ingesting very high doses, which led to them feeling extremely ill.

This story illustrates the need for education. Not only must the government reach out to users with guidelines for safe use, but users must educate themselves, as they should with any medication or regulated substance.

The Centre for Addiction and Mental Health (CAMH) in Toronto has come out with low risk guidelines for recreational users which I think is one of the best pieces of information available at the moment. These include using lower potency strains, using a vaporizer or ingestion instead of smoking, delaying using cannabis until later in life, not using cannabis daily or almost daily and avoiding driving or operating heavy machinery while under the influence of cannabis. They also encourage pregnant women and people who are at risk for mental health complications to avoid using cannabis altogether.