A silver lining in the dark clouds: Medical Marijuana, in the Neurological disorders and its future in Pakistan.
V O L .
future in Pakistan.
Qamar Zaman 0
Shifa International Hospital 0
0 ShifaTameer -e- Millat University , Islamabad
A silver lining in the dark clouds: Medical Marijuana,
in the Neurological disorders and its future in Pakistan.
1FCPS (Neurology), Specialty certified in Neurology.Neurologist, Shifa International Hospital, Islamabad
2FCPS (Medicine), FCPS (Neurology). Associate Professor of Neurology, ShifaTameer -e- Millat University, Islamabad
Date of submission: April 11, 2017 Date of revision: May 25, 2017 Date of acceptance: June 16, 2017
Marijuana has been included in the list of illicit drugs for a long time despite its use as a remedy for several medical
problems. However this use has been on the basis of the individual experiences with no concrete scientific
evidence. Its positive effects have been mostly overshadowed by its recreational use worldwide. It has recently
become the topic of hot debate due to several studies showing its role in various medical and especially
neurological disorders. These new findings have created a controversy and world is still divided on its legalization
for medicinal purpose. Several countries and states have legalized it recently, but many experts have raised
concerns about its misuse and long term legal, ethical, financial and health implication, that need to be answered
yet. Pakistan is considered as one of the largest cannabis producing country and with increasing evidence for
potential medicinal benefits; we need to develop a consensus on this topic, considering health, legal and ethical
perspectives linked to its medical uses in our society.
KEY WORDS:Marijuana, Epilepsy, legal, cannabiniods.
ABBREVIATIONS:(THC)Tetrahydrocannabinol .FDA( Federal DrugsAgency )
ALS(Amyotrophic Lateral Sclerosis )
To date, about 86 Cannabinoid compounds have
been identified in nature and some other are
synthesized chemically. They have been mostly used
for recreational purposes with major psychoactive
ingredient being delta-g-tetrahydrocannabinol (THC)
and some of these compounds like dronabinol and
nabilone have been used as prescription drugs1.
Cannabis has been used for various therapeutic
purposes for thousand of the years. Initially it was
grown as an agricultural crop called Hemp, in China
which then traveled through Asia into Middle East and
Africa where it was used for pain and other various
conditions like gout, malaria, Rheumatism, and poor
memory for a long time alongside its use for
recreational purposes as well2.
In 1970, it was categorized as Schedule 1 drug and
was listed as having no accepted medical use and
further research was restricted until recently where it
was found to be of several uses and less side effects
than previously documented2 . These findings have
lead to its legalization for medical purposes in April
2015 in about 23 states of USA. Several other
countries including Holland, Germany, Spain France,
Colombia, Czech Republic, Canada have legalized
its use for medicinal purpose.According to a study, in
USA about 17% of past-year marijuana users
reported its use for medical purposes recently3.
U S E S O F C AN N ABI N O I D S I N VAR I O U S
Currently, pill form of “dronabinol” and “nabilone”
has received FDA approval only for nausea caused
by chemotherapy and to increase the appetite of
people with AIDS 4. Various studies have shown its
beneficial effects in several neurological disorders
recently. For some indications, significant data has
been found to recommend its use where traditional
therapies were not found to be effective while for
several other disorders its use is still on the
experimental basis and we still have insufficient
evidence to use it.
1. INDICATIONS WITH GOOD EVIDENCE:
Epilepsy: Dronabinol and Nabilone have been
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S 5 2
found beneficial in various childhood onset epilepsies
including Dravet and Lennox-Gastaut syndromes
that are resistant to the traditional therapies. Their
addition may reduce median monthly seizure
frequency by about 36.5% . They were also found
useful in the management of super refractory status
epilepticus6. But we still need evidence to recommend
it as alternative to traditional antiepileptics in more
common epilepsies and as a first line agent in drug
Multiple Sclerosis:Cannabinoids (nabilone and
nabiximols) have been found useful for various
symptoms of multiple sclerosis like pain, spasticity
and urinary dysfunction7. Although these indication
have not got FDA approval, health agencies like
American Academy of Neurology (AAN) recommend
that it can be considered in suitable patients as
alternative to typical therapies8.
Neuropathic and other type of pain:These may
provide effective analgesia in conditions that are
refractory to other treatments including refractory
neuropathic pain cause by diabetes mellitus, central
neuropathic pain, pain in cancer patients, and in
HIVpositive patients. According to a study about 90% of
patients reported an improvement in nerve pain after
cannabis use9. Several guidelines recommend its use
when traditional therapies are not helpful.
Depression and anxiety: Data about anxiety
suggested a greater benefit of cannabinoids
(dronabinol, nabilone, and nabiximols) than placebo
and can be consider for suitable patients10. However
no difference between cannabinoids and placebo in
outcomes of depression was seen and some reported
a negative effect at high doses.
Tics and Tourette syndrome:There is insufficient
evidence to support or refute the clinical use of
cannabis for tics. However, it could be an option in
resistant cases as positive effects of THC were seen
in few studies11.
2 . I N D I C AT I O N S W I T H BE N E F I T S BU T
Dementia:Recently few studies have found that
tetrahydrocannabinol and other compounds may
reduce B-Amyliod in the brain12. A recent study has
concluded that cannabis extract containing THC can
relieve various cognitive and psychiatric symptoms of
Alzheimer's diseaseand found them to be safe and
promising treatment option13.However more data is
required for its use in dementia clinically.
Parkinson's disease:It has been studied in the
context of improving motor features, functional
outcomes and in dopa related dyskinesiaswith mixed
results11. Evidence is needed for its recommendation
for these and target symptoms (e.g. dystonia,
psychosis, sleep) related to Parkinson's disease.
Huntington's disease:Although limited data is
available to recommend its use in Huntington's
disease but various case series and small studies
showed significant improvements in chorea and the
neuropsychiatric symptoms in patients with
Huntington's disease. Further large scale studies
may be needed to find its usefulness for these
Dystonia: Data for its use in dystonia is limited to few
small randomized placebo-controlled clinical trials
with mixed results. Further large studies are needed
to clear its role11.
(Amyotrophic Lateral sclerosis (ALS): Some studies
showed that theymight be helpful in some aspects in
ALS patients like delaying the onset of ALS and
slowing the progression. Thesemight also help to
manage pain, appetite loss, depression, sleep
problems, spasticity and drooling 14. However more
evidence is needed for recommendation of its use in
Migraine: They have been found to inhibit pain
response in migraine patients, but clinical trials are
needed to recommend its use for this indication 15.
Prion disease: On the experimental basis they have
shown to reduce the risk of prion disease and protect
from prion toxicity but still need to be tested
Stroke: They seem to reduce the infarct size and
improve functional, histological and neurobehavioral
recovery but no large scale data is available for its
Sleep disorders: There was some evidence that
cannabinoids may improve sleep in some patients.
Cannabinoids were associated with a greater
average improvement in sleep quality and sleep
disturbance than the placebo18. Further large scale
studies are needed to find its benefit for this purpose.
Other uses: Some studies have shown its anti tumor
activity, as it showed to inhibit growth of the cancer
cells. Its benefits have also been observed in Spinal
cord injury and Fibromyalgia as well19.
Despite significant positive data, several factors pose
a challenge to its use as a medicine. These include
Medical, ethical and legal and economical factors.
Medically it is found to be much safer to traditional
pharmacological agents and addictive potential of
cannabis is quite low. The risk of dependence on
cannabis is reported to be 9% in long-term users,
significantly less than the addic on rates of heroin,
cocaine, alcohol, and prescribed anxioly cs20 Its side effect
profile includes euphoria, disorienta on, drowsiness,
dizziness, motor in coordina on, and poor concentra on.
The peripheral adverse effects include tachycardia,
hypotension, conjunctival injection, bronchodilation,
muscle relaxation, and decreased gastrointestinal
motility. Long term effects include risk of psychiatric
disorders, apathy and cognitive impairment and
hazards related to pregnancy21. So its use should be
based on the benefit outweigh the risk assessed by
Ethically in various cultures a negative image is linked
to its use and possession. Good awareness
campaign may help patients, their families and
societies to make a decision based on evidence and
knowledge. Ultimately, the medical cannabis debate
is not about making it widely available for a broad
range of health conditions but about giving a small
number of patients an option where they may have
Legally in Pakistan under The Anti-Narcotic policy
201022, person may get punishment up to 6 months on
possessing the cannabis, but still it is the most
commonly used drug with prevalence of recreational
use being 3.6 % in our population23. Due to increasing
argumentation for its use for medicinal purpose, like
t h e o t h e r m a n y d e v e l o p e d c o u n t r i e s l a w
amendments will be needed for relaxation regarding
its use for medicinal purpose in Pakistan.
Various necessary measures should be taken for its
controlleduse that may include:
Only be prescribed by experts. Specific registered points with monitoring units to monitor the dose or amount each time.
Regular follow ups by experts to monitor side
effects and check the possibility of misuse.
When to stop or taper the use in case of
Law amendments will be important as there is risk
that if its judicious use is not legalized then patients
may start acquiring it from illegal ways, which might
lead to the poor quality and uncontrolled use opening
ways for more hazards than bringing the good.
Cannabinoids have been found useful in many
neurological and medical disorders. To keep its
use judicious and controlled, a frame work by the
health authorities in collaboration with law
agencies should be made so that it might be
available when other hopes are lost and its use is
justifiable and only under a strict protocol. The
three forces scientific knowledge, social and
political acceptance and legislation may help to
reach a consensus about its medicinal use.