By Yuval (Tuby) Zolotov
Yuval (Tuby) Zolotov is a medical cannabis researcher and a PhD student at the School of Public Health at the University of Haifa. He completed his Master in Health Administration at Bar Ilan University where he investigated adherence to medical cannabis among licensed patients in Israel. Before joining academia in 2012, Yuval was a licensed Patient Instructor and has been involved with the local industry since its inception. While working on his thesis – Medical Cannabis Recommendation: Understanding and Predicting Physicians’ Behavior – Yuval is also involved in various research projects.
Meet the Experts is a series of interviews conducted by experts from the field of Cannabis to world leaders in research and clinical practice of Cannabis as medicine.
Dr. Raquel Peyraube is a doctor in medicine and a specialist in the problematic use of drugs. She has trained in psychiatry, toxicology and psychoanalytical psychotherapy and in subjects such as childhood, adolescence and social exclusion. She has 28 years' experience in the field. Throughout her career, she has made contributions in training, prevention, treatment and damage reduction, including innovating theoretical and methodological developments with emphasis on ethical issues.
As a former clinical director of ICEERS, she is now an ad hoc consultant of the Uruguayan National Drugs Secretariat giving advice on reform of the public drugs policy and of the Institute of Cannabis Regulation and Control. She is a clinical researcher and a member of research teams for monitoring the law in Uruguay. She sits on several international scientific committees and is an active member of the IACM (International Association for Cannabinoid Medicines). She currently works on the development of clinical trials, medical education on medicinal cannabis, and dissemination of information and advice for reform of drugs policies in various countries.
Yuval Zolotov: Dr. Peyraube, can you please tell us how you initially got involved with medical cannabis?
Raquel Peyraube: I am a physician, and so my perspective on cannabis is medical. Originally, I focused on the problematic use of drugs. This is how I was educated as a physician – to view the use of cannabis as a pathology and to typify cannabis as a problem. I was taught that it is a satanic drug. As I gained clinical experience, I developed a more comprehensive perspective on drugs, and more specifically on cannabis, which is the most common drug that people use. I adopted more pragmatic views. Specifically regarding cannabis, I started to understand that most people who use it are in fact not sick, they are functioning members of our society. This is not to say that there are no risks associated with cannabis use, mainly with its heavy use. Some people can develop serious problems, but in the majority of these cases this is due to a lack of education about cannabis. This is exactly why we must set our focus on reducing this potential harm, and educating people on what to use, how to use it, how much and when. There must be safe ways to use cannabis, but currently we are all victims of the legal situation.
YZ: Please explain what you mean regarding the legal situation.
RP: While cannabis remains illegal, who is delivering information about cannabis to the users? And what kind of information? The current policies have no vision of public health or harm reduction. Cannabis is banned because of the legal prohibition, but still so many people use it. In a comprehensive perspective, I believe that instead of discussing cannabis in terms of yes or no, we should put other kinds of questions, such as how, how much, by whom, etc. Because of prohibition, we can barely investigate these issues. In my opinion, this balance is completely wrong, and it really doesn't make any sense. I often speak with regulators, and when they ask me where the evidence is, I show them some evidence and then turn the question back on them, adding, "Show me the evidence that supports prohibitionism and its maintenance even after more than 50 years of its failure." So I think that the regulation of cannabis must be changed – for the benefit of our society.
YZ: Can you please share your thoughts on the differences between medical cannabis and the use of cannabis for other purposes?
RP: I feel that the regulations are currently forcing us to make this distinction, but I don't think that it is so easily done. As a mental-health specialist I think that if someone uses cannabis to overcome social anxiety, for example, then it is a medical matter. I really prefer to use the term 'adult use (of cannabis)', because it is more inclusive and comprehensive. When people talk about recreation, it reminds me that I need a vacation. We should not use stigmatization or labelling. Adult use of cannabis also carries the message that people should not start using cannabis until they are adults. And this is an important message, because earlier use might cause harm.
YZ: Can you elaborate on the harm and adverse effects of cannabis?
RP: It is very hard to address this in a general way. But I still find it important to say that people shouldn't think that cannabis has no risks at all. Many people who are promoting the legalization of cannabis make that claim, but I don't think that's right. We should be careful. In some situations, THC might not be a good option. There are interactions with other substances. People sometimes suffer cardiovascular effects which we cannot always predict. But cannabis is not a satanic drug. As physicians we prescribe drugs all the time. Cannabis has very few side-effects, and they are mostly mild. So it has a relatively good safety profile. And we can have even lower levels of harm if we adopt a more rational way of thinking about cannabis. So I think that cannabis must be normalized in our society, because only then do we take into account not only the risks but also the benefits. And as physicians this is our role – to assist our patients and to secure public health.
YZ: What is your current perspective on medical cannabis in Uruguay? How is it currently integrated into the clinical practice?
RP: Unfortunately, I need to start my answer with the word "unfortunately". Uruguay passed a law on cannabis already at the end of 2013, and I think it is a good law. But we have seen many challenges in its implementation. Although this law recognized the medical properties of cannabis, patients today still don't have access to any medical cannabis product. I think that they are trying to force regulations on herbal cannabis which might not even be feasible. So I believe we are still not in a good situation. But despite this situation, we have organized an academic course that more than 100 physicians have already completed. Education is the only way that we can move forward, because I think we have had enough of ignorance.
YZ: In addition to your clinical work, you are also very involved in public debates and in the design of policies in different countries. Can you share with us your vision about your role and about the role of physicians generally in the evolution of policies?
RP: We physicians have been an integral part of this irrational development in history, that only the negative features of cannabis are considered – with no concern for public health. Physicians have always supported prohibition. But after so many years of experience and so many cases of patients being helped that I have witnessed, I feel obligated to take part in changing the course of history. We are required to treat our patients with honesty. Thus, I think that we, as physicians, have the responsibility to integrate cannabis into our clinics based on knowledge, and not on beliefs. Cannabis is not a religion. I always invite my colleagues to start studying cannabis, but many of them tell me that they don't believe in this therapy. But this is not a matter of belief. Of course we need more knowledge, but we should also acknowledge what many researchers have already done. People commonly think that there is no evidence, but this is not a black or white matter. There are many established researchers who have studied cannabis. So instead of a belief, I wish physicians would read more and investigate more. This is harder work, but I think it respects our profession and our patients better.
YZ: How do you think your colleagues perceive your ideas?
RP: I know that many colleagues don't agree with me. But honestly, as physicians, we don't usually cure our patients. We prescribe medications to relieve symptoms, or we try to change the evolution of the pathology, but we don't cure. So I believe we should be compassionate, and assist patients, and stand with them when they make their decisions. Otherwise we abandon our duty to them. I advocate the three pillars of public health to my colleagues and to the public, which are very relevant to medical cannabis regulations. The first is "to cause no harm". Currently, we are harming our patients because of policies. And these policies also dictate the conceptualization of cannabis. The second pillar is social justice. Right now, high-quality cannabis is already available to people who can afford it, while others have no access at all, even though it may help them with some conditions. And the third pillar is the self-autonomy of patients and their right to decide for themselves. I have had very serious discussions with many colleagues of mine who sometimes forget that patients have the right to decide what is best for them. For me this is obvious, but our regulations don't support my vision unfortunately.
YZ: What do you think about the change of policies that is currently happening in many places?
RP: The current regulations are irrational. For example, in some places they allow medical cannabis for epileptic children, but only for refractory epilepsy – meaning that cannabis is allowed only after trials of all conventional medications have failed. I think this logic is completely irrational. Why not use cannabidiol as a first-line treatment for epilepsy? Cannabidiol is such a safe substance, so why do patients have to go through so much suffering before being allowed to use it? I just can't understand it. I think this situation is changing, but for the sake of our patients we need to go forward much more quickly. I think that our laws should be evidence-based, and this can only happen if cannabis is normalized. We should allow full regulation of cannabis – not only for medical use, but also for industrial use and for adult use. This is an issue of public health, of human rights, and also of security and public safety. Because the black markets of drugs should be eliminated, and this is only going to happen through regulation. I believe that regulators are starting to understand this in many places, also here in Latin America. They know that sooner or later things will change. So although the regulatory changes are very timid and cautious, I think that we are going in the right direction. And I am always optimistic.
YZ: As an advisor to policy-makers, what do you think are their challenges regarding cannabis policies?
RP: It is not easy for policy-makers to make such decisions. In Latin American countries many people have died while fighting the war on drugs, so it is obviously not easy for leaders to reverse the policies. I understand why politicians are afraid of this, but it is our role as professionals to assist them, and to assure them that this is the right thing to do. It is my duty, as it is the duty of physicians all around the world – to break down this wall and get out of the ghetto of ignorance. Because of prejudice, people are not aware of so much of the scientific work that is being done. They are only reading one part of the library, and this is not right. Obviously, we also need more scientific developments and more clinical trials, but prohibition is not allowing this. We definitely need a change.
YZ: Do you have a final message for your peers and our readers?
RP: I think we should not wait any longer. It is time to move on. We cannot deny people treatment because we are waiting for evidence. And the evidence will not show up if we don't change the regulations and also change our thinking. I think this is our ethical duty to our patients. We need to take into account the pre-clinical data that is there and also the clinical experience. Many of us have been working for years in this field, and this experience is valuable. It is interesting to note that in many places around the world, medical cannabis is being authorized because of Supreme Court decisions. I think this serves to support my claims. So I encourage physicians, regulators and everybody to consider cannabis in a rational way. Alcohol is legal, but we pay a lot of attention to drinking and driving because it is very dangerous. Benzodiazepines are legal, but we know for sure that they are causing so much harm. But cannabis is illegal. Why? I can't understand this, and I can't accept it. This is why it is so important for me to promote education – to patients, to physicians and to the public as a whole. Regulators, and also physicians, need to decide if they want to serve the people and to help the public, or if they just want to control. Of course I am also aware of the UN conventions on drugs, but we should not forget that there are conventions on human rights. And I see a conflict between these conventions, because if we strictly follow the drug conventions, we find ourselves in violation of human rights. This is wrong, and we need to change it.
YZ: Thank you very much, Dr. Peyraube, for giving us an insight into your work and for sharing your vision with us.
RP: It has been my pleasure – thank you.