Why Government of India should not legalize Cannabis till further research?

https://www.financialexpress.com/opinion/why-cannabis-shouldnt-be-legalised-in-india/1455236/

The earliest known reports regarding the use of cannabis in India come from the Atharva Veda estimated to have been written sometime around 2000–1400 BCE. Cannabis has historically been consumed in many different ways –Smoking (Ganja), chewing (Bhang), Drinking (tea) etc. Cannabis plant has also been used for manufacturing clothes, shoes, ropes, paper etc. In the ancient India, it was used for the purpose of treating or alleviating the symptoms of several diseases.

Marijuana and Hemp are members of the Cannabis family and contains a variety of different chemicals with varying degree of psychoactive properties. While marijuana induces intense psychoactive effects, Hemp is low on that. Ganja, Charas and Hashish are well known to cause hallucinogen, euphoria, temporary loss of senses and funny behavior. The International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders designate cannabis (such as ganja, bhang, hashish, charas) as an addictive substance, with recognized dependence disorders. Around 9% of people who try Cannabis ultimately become addicts. Cannabis withdrawal syndrome is a known condition with symptoms such as irritability, sleeping difficulties, dysphoria, and etc. For those who try to quit, the relapse rates for addicts were as high as 71% at 6 months. National Drugs and Psychotropic Substance Act 1985 prohibited the cultivation or production of any cannabis plant by anybody, while reserving these rights with both the Central and State governments if they wish to do so, by creating rules later. It is alleged that NDPS was result of an intense international pressure following Single UN Convention on Narcotic Drugs, 1961.

Recently, there is emergence of an international wave of legalization of cannabis. The push for legalization is based on the medicinal properties and commercial utilities.  Buoyed by success in the west (Uruguay, certain states of USA, Canada) the Cannabis supporters are pushing for legalization in India too. In the United States, use of marijuana (more addictive derivative of cannabis) for medicinal purposes is legal in a number of states, whereas its use for recreational purpose has also been legalized in various states. Canada in the recent time has legalized the use of Marijuana for recreational as well as medicinal purposes. Europe recognizes use of Marijuana for recreational purposes as a criminal offence; however, its use for medical purposes is permitted across many countries. This article aims to critically evaluate the available data regarding medicinal benefits, health hazards and long term outcomes of legalization.

Does cannabis have proven medicinal benefits? One of the proposed indications of Cannabis is in the control of Nausea and Vomiting. However, careful review of all studies shows there is no statistically significant benefit of cannabis derivatives over currently available drug. One study showed that cannabis was associated with greater complications as compared to other commonly used drugs. Paradoxically, few case reports have described a condition which is known as cannabis hyper emesis (excessive vomiting) syndrome seen in Marijuana addicts. With regards to the appetite stimulating actions of cannabis, we already have more effective drugs that are easily available. Cannabis is indeed effective in pain control. However, it is weaker and less safe than opiates that are already approved for use. A study did show beneficial effect of cannabis in a small percentage of extremely rare form of epilepsy and Multiple Sclerosis. However, most of the studies aren’t designed properly to offer any conclusive evidence. Needless to say, these studies have reported an increased risk of adverse effects when Cannabis was used. There is no good evidence that cannabis is beneficial when used in other diseases such as Crohn’s Disease, Sleep disorder, Glaucoma etc. Similarly, there is no data to support its use in oncology practice outside of clinical experiments. We cannot ignore the fact that Cannabis derivatives are known to have immunosuppressive that can promote cancer. In summary, the medicinal benefits of cannabis aren’t as strong as presented by the proponents of legalization.  Fortunately, safer and effective alternatives to cannabis derivatives are already available in the market. Some argue that Cannabis has been part of Indian tradition and our ancestors used it regularly for thousands of years. The rise in the life expectancy from 32 years in 1947 to 68 years in 2018 proves that we are living longer than our ancestors. The U.S. Food and Drug Administration has approved Cannabis as a treatment for only one disease i.e a very rare form of epilepsy.

What are the health consequences of cannabis use? The severity of the adverse effects of cannabis depends upon type (Marijuana being worst), duration and frequency of its use. When compared with people who don’t use Marijuana, adults who smoke marijuana regularly show impaired neural connectivity. The areas of brain which are affected are the ones involved in functions which need high degree of integration, learning and memory functions. There is a significant decline in IQ of such subjects. Marijuana users are at an increased risk to develop chronic psychotic disorders (including schizophrenia). The risk for the onset of symptoms is much higher in young people with a predisposition for psychosis. These patients also suffer from Anxiety, depression disorders and have an increased suicidal tendency. There is an increased incidence of motor vehicles accidents in those who may be either short term or long term users of Marijuana. Cannabis smoking is associated with an increased risk of bronchitis, pneumonia and respiratory distress. Patients smoking Marijuana are at an increased risk of suffering from Transient Ischemic attacks, Stroke, Myocardial infarctions and Cannabis arteritis. Various studies have shown a positive association between Marijuana smoking and cancers of the lung, showing a twofold increase in its incidence.  There are also reports of an increased risk of developing other cancers. Moreover, the interactions between cannabis and chemotherapy (or any drug) are largely unknown. To summarize, cannabis use has several serious consequences that cannot be ignored.  

Are we depriving patients of a possible hope or cure? As discussed, cannabis derivative have very little role that too in very rare medical conditions for which some alternatives are already exist. However, the pursuit of better drugs in such illnesses remains an intense area of research. Fortunately, there is no restriction for cultivation and procurement of Cannabis for therapeutic or experimentations. The Indian government has been increasingly generous in giving license for such purposes. One would argue that there are bureaucratic hassles and complex paper work required to get Narcotic Drugs for research and dispensing. Is Cannabis legalization solution for ineptness of Health Care or Research institutions to obtain a regulatory license that aims to protect public health?

If the risks outweigh benefits, why did USA and Canada legalize it? With increasing number of youth (though still a minority) supporting legalization, most policy makers don’t see it is a battle worth fighting even though justified. In US, public opinion was largely built on decades of misinformation, racial discrimination, police excesses, degree of punishment, incarceration in jail, craving for liberty etc. In addition, the policy makers seem to be excited about another source of revenue.

Does legalization really help? Let’s evaluate the long term outcome in the states where marijuana has been legalized. Colorado became the first state in the United States to legalize Marijuana around 5 years back. The Colorado Department of Health and Environment constituted an expert committee to review the harmful effects of Marijuana. The committee noted that there is substantial evidence that its use may lead to cancer, cardiovascular illness, lung diseases, road accidents, impaired adolescent health, serious drug interaction and disorders of reproductive health. The committee reported that there is robust evidence that legalization may substantially increase unintentional use by children at home. It also noted that the fetus born to mothers who uses Marijuana may be seriously harmed. It is ironical that committee didn’t seem convinced and suggested future “research” to understand the health impact better. What is surprising that, despite this damming report, Colorado Government proceeded to legalize marijuana.  The 5 year result of this experiment was publicly available in October 2018 and shown some startling facts. The number of calls to poison control mentioning human marijuana exposure increased over the past 10 years. Organized crime cases almost tripled in five years. Marijuana possession related arrests have halved but not decreased dramatically as anticipated. Post legalization there is newer types of crimes have emerged such as illegal cultivation, sale, production etc. Number of vehicular fatalities with cannabinoid ‐only or cannabinoid‐in‐combination positive drivers increased by 153%. Rates of hospitalization with possible marijuana exposures increased steadily. Colorado has not experienced an increase in marijuana use among young people. However, the number of adults who use marijuana increased between 2014 and 2017. Marijuana accounted for 22% of all expulsions and 24% of all law enforcement referrals in Colorado public schools. It is clear from above statistics that Marijuana legalization has failed to achieve its objectives.

Now let’s review what happened in Uruguay after legalization in 2013. The illicit trade continues because of increased demand (than supply), foreign tourists (legal marijuana can’t be sold to foreigners), lower cost (than the price at government dispensary), ease of access and more satisfying. Moreover, as anticipated, the spin-off industry failed to take off. In the back drop of UN Regulation (1961), for the fear of international sanctions, the banks refused to work with agencies linked to sale of marijuana. This affected the pharmacies, the growers and agencies that desire to market spin off products such as consumer good, medicines, cosmetics, food etc. Medicinal use, which was portrayed as the substantial source of income, has failed to materialize. Only one third of Uruguayan consumers are registered with pharmacies or clubs that are supposed to sell Marijuana. That means, majority are still buying it illegally!

India has a very long history of misuse of even prescription drugs that are truly beneficial for the patients. Weak opiates (derivatives of opium) are one of the easily available alternatives to cannabis in above medical conditions. Spasmoproxyvon was a very popular pain killer that contained weak opiate dextro-propoxyphene. Tramadol is another very commonly used pain killer especially following surgery. Codeine based cough syrup were very effective in control of severe cough. However, after reports of rampant misuse by addicts and healthy people, Narcotics Control Bureau (NCB) asked the Drug Controller General of India (DCGI) to substantially reduce their availability despite their proven effectiveness. To be precise, in Indian context, when prescription drugs are grossly misused, how will ensure disciplined used of Cannabis? This is only going to create serious law and order problem rather than give relief to our police personnel. Cannabis proponents have been claiming that Hemp (low THC variant of cannabis sativa) is a good source of oil,fibre, paper, clothe, rope etc. Nowhere in the world has commercial viability of such products have been shown. Why is there so much interest in Hemp when other safer plant sources already exist? It is obvious that arguments of medicinal and industrial use are simply smokescreen to fool policy makers and swing public support.

Why will cannabis legalization worsen India’s already overburdened health care system? India is already struggling to control 3 addictive substances Tobacco, Alcohol and Areca Nut. As per Global Adult Tobacco Survey nearly 270 million Indians use tobacco and it kills around 1.35 million Indians every year. The number of Areca Nut users in India is estimated to be very high because nearly 200 million smokeless tobacco users chew it along with areca nut. Nearly 30% of India’s adult population is using Alcohol leading to 3.3 million deaths. Legalization of cannabis is not only going to worsen these alarming statistics but also serve as a gateway for one of these carcinogens.

It is well evident that our younger generation is growing in an era of personal liberty, rising affluence, more prone to addiction and struggling with personal relationships. Introduction of another psychoactive drug will wreak havoc in a population still struggling with Tobacco, Alcohol and Pan Masala. It is also unlikely to solve the drug menace in Punjab, Rajasthan and various parts of India. Moreover, predatory marketing of cannabis companies will hit the vulnerable population most such as youth, poor, insecure, illiterate etc. Once introduced, it will quickly establish a big market that would make subsequent tighter regulations impossible. Following legalization in the West, various newer products with Marijuana are available in the market and on online portals without proper prescription procedures. These products include Marijuana containing chewing gum, Marijuana containing candies etc meant for youngsters.

Cannabis prohibition is being portrayed as paternalistic nanny-state policy by wealthy party hoppers of Metros. However, promotion of addiction and sufferings among millions is a heavy price to pay for protection of individual freedom of the handful of libertarians. We cannot allow the future of our next generation get trapped into vortex of poor performance, indiscipline, addiction, psychosis, isolation, insecurity and bleak future. 

Published by Chaturvedi Pankaj

Deputy Director, Center for Cancer Epidemiology, Tata Memorial Center, Mumbai. Professor, Department of Head Neck Surgery, Tata Memorial Hospital, Mumbai

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