Editorial
The allowance of cannabis to be used as a medicine in the absence of adequate data to inform basic clinical decision-making is rooted in compassion for individuals with life-threatening illness, or substantially debilitating illness, and no other course for treatment. However, this relatively simple tenet has now morphed into a large-scale for-profit industry that is fraught with public health concerns. Access to cannabis has been expanded to include treatment for a multitude of health conditions, many of which are neither life-threatening nor debilitating, and for which effective alternative treatments exist. Data from which to determine the risk-benefit for an individual considering the use of cannabis is sparse at best. Quality control issues abound in this industry as there are no established standards for cultivating, processing, testing, or labeling cannabis products. There is also concern over advertisements and product labeling that include misleading or unsubstantiated health claims, as these products have not been vetted by traditional drug development methods. The speed in which cannabis policies are changing is rapid, and the fact that these are happening as a direct result of legislation or by voter referendum is reckless given the absence of consensus standards and, in many cases, appropriate regulatory oversight. The impact of revised cannabis laws, both with respect to medicinal use for a variety of health conditions, and for non-medicinal (aka ‘recreational’) use of cannabis by adults, will likely have a substantial impact on psychiatry.
This special issue of the International Review of Psychiatry is focused on cannabis science, but with a very targeted theme of cannabis regulatory science. Recently in the US, the Food and Drug Administration (FDA) was granted regulatory authority over all nicotine and tobacco products. This was a landmark event, and has engendered a bolus of thoughtful, policy-oriented research that has already resulted in tobacco regulations which are likely to positively impact public health in the US and abroad. Studies have included careful scientific evaluation of the impact of nicotine on cigarette reinforcement and self-administration, packaging and flavoring on youth initiation, the harm reduction effects associated with nicotine delivery devices other than cigarettes, and other important topics. The parallel need for a cannabis regulatory science is urgent. Novel products and cannabis delivery devices are rolling onto the shelves of dispensaries at a rapid rate, product development appears to be geared towards high potency/high dose products, and it is all being carefully marketed to increase consumption. Contributions in this issue highlight lessons learned from tobacco, alcohol, and opioid regulatory science that are relevant to cannabis, detail important factors surrounding tobacco and cannabis co-use, and detail the potential impacts of regulatory changes on cannabis use in the workplace.
In addition to the need for regulatory science, there is a very obvious need for additional data about the risks and benefits for both medicinal and non-medicinal cannabis use. Currently there is inadequate data for a confident determination of risk/benefit of cannabis use as a potential therapeutic in psychiatry, yet it is being recommended to individuals for use in the treatment of anxiety, post-traumatic stress disorder (PTSD), attention deficit-hyperactivity disorder, opioid use disorder, dementia, and psychotic disorders. In some cases, there exist plausible mechanisms for select cannabinoids to provide beneficial effects, and there are numerous case examples of individuals who have received substantial benefit from the use of cannabis or cannabinoid products. This cannot be ignored, and should be utilized as motivation to increase knowledge about the therapeutic potential of cannabis, and to spur development of reliably formulated cannabinoid medications. However, currently there is an overall dearth of data. Research that has been conducted to date are limited to small, often open label studies, of short duration, and with no direct comparison of safety or efficacy with other medications/treatments. Moreover, much of the research has been conducted with single molecule synthetic medications (e.g. dronabinol or nabilone) rather than cannabis. As such, cannabis should not be considered as a first-line therapeutic until such studies have been completed with carefully defined formulations in targeted health conditions.
Clinical decision-making about medicinal cannabis use, or the health impacts of non-medicinal use, are further complicated by the fact that there are hundreds of varieties of cannabis and related products from which a patient could choose, across a range of doses and routes of administration. There is a need for more systematic research on the comparative pharmacokinetics and pharmacodynamics across doses, routes of administration, cannabis/cannabinoid product types, and understanding the relative contributions of individual cannabis constituents on the overall effects of cannabis. In addition, more research is needed to understand individual differences in response to cannabinoids and drug–drug interactions to identify sub-groups of individuals (e.g. those with a family history of psychosis) for which use of cannabis requires more careful deliberation.
Data collection about positive and negative health outcomes at both the population and individual patient level is sorely needed to help evaluate, design, and implement informed cannabis policy and clinical decision-making. I would encourage both physicians and patients to engage in open and honest conversations about cannabis use to ensure that decisions to use or not use, and what type of product is being used can be evaluated and incorporated into the continuum of care for each individual. As with any other novel therapeutic, decisions about medicinal use of cannabis or cannabinoid pharmaceuticals must be determined based on expected risk/benefit at the individual patient level. One important component of this will be integration of cannabinoid science in medical training and continuing education programmes. Included in this issue are reviews of Cannabis Use Disorder, as well as a summary of the neurocognitive effects associated with cannabis use. Additional contributions detail how cannabis legalization is likely to uniquely impact individuals with psychiatric disorders, as well as a commentary piece that discusses different approaches to cannabinoid medication drug development.
I hope that this issue provides new and interesting insights, encourages increased interest and engagement in science and policy related to cannabis/cannabinoids, and encourages thoughtful consideration of how to proceed in challenging clinical situations. I am indebted to all the contributing authors and to the publishers for their effort and patience as this issue came together.
