should cannabis be legalised in the uk essay

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Why the UK should legalise cannabis

Prohibition does more harm than the drug itself.

By David Nutt

The serious criminalisation of cannabis users started as a result of Richard Nixon being elected US president in 1968 and then perpetrating his “ war on drugs ”. The rest of the world followed suit, with the UK doing so in part, many would argue, because of antipathy to the growing Caribbean population, many of whom used cannabis. Now the US has reversed its policy. Almost half of Americans have legal access to recreational cannabis and Joe Biden, the president, has now pardoned thousands of people convicted of cannabis possession.

In the UK we seem to want to go backwards. We have calls from Conservative police commissioners to make cannabis a Class A drug with enhanced sentences. Suella Braverman, our new Home Secretary, seems to support this approach and still to believe the long-discredited rhetoric of serious harms from cannabis use . Both parties appear ignorant of the overwhelming evidence that policies of prohibition and criminalisation cause much more harm than cannabis itself does, as well as being much more expensive. Hopefully once the cost burden of this regressive proposal becomes apparent its supporters will U-turn like the Chancellor did on tax cuts.

The way forward is surely to legalise recreational cannabis in the form of a regulated market. This could take the form of special shops that only sell cannabis products – perhaps even with smoking areas, as exist in the Dutch coffee shop model.

The advantages of legalisation are manifold. First, purchasers know what they are getting and can get advice on type strength and method of taking it from experienced registered sellers. This separates the purchaser from the street market with its uncertain levels of active ingredients and possible contaminants. Thresholds for d9THC (the active ingredient that gets users stoned) can be set, probably at about 15 per cent total content, to reduce the risk of acute accidental excessive intoxication with possible anxiety and paranoia.

Further, it could be required that all sold products contain cannabidiol, the other main ingredient in the cannabis plant, which we now know acts as a protective element against some of the worst effects of strong d9THC and can mitigate the risk of psychosis and dependence . Currently, for predictable reasons, about 95 per cent of all illegal street-sourced recreational cannabis maximises d9THC and so has no cannabidiol. Most experts who used to believe cannabis caused schizophrenia now agree that this risk – if it exists at all – is only present in strong d9THC variants that are devoid of cannabidiol.

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Experience in states in the US where cannabis is legal has shown that, paradoxically, use in young people may reduce after legalisation . This is probably because of the need to show evidence of age to purchase, which the street dealer certainly doesn’t require.

And if these huge harm reduction benefits are not enough there is the value to the Exchequer of taxing cannabis sales. These could be in the region of several billion pounds within a couple of years, and probably more later as the recreational use of cannabis becomes more accepted.

[See also: How John Cleese became the hero of the right ]

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Pros and Cons of Cannabis Legalisation in the UK

• Medical Cannabis is legal in the UK, but there is strict control of prescriptions.
• Cannabis is still a Class B drug in the UK, and therefore recreational use is illegal.
• Scientific research has suggested that Cannabis can be used to help people suffering from pain and nausea.
• The legalisation of Cannabis will help support the economy.

Medical Cannabis was legalised back in 2018, meaning in recent years, accessibility has increased both through Private dispensaries and doctors within the NHS. Patients across the UK now have access to medical Cannabis like never before, yet under current UK legislation, recreational usage of Cannabis is illegal and classed as a Class B substance. 

So why is medical Cannabis legal in the UK? And will Cannabis be fully legalised in the UK? In this blog, we’ll look at the pros and cons of Cannabis legalisation in the UK. 

What is the difference between medicinal Cannabis and illicit Cannabis? 

The Cannabis plant contains over 100 cannabinoids. THC is the cannabinoid responsible for creating the psychoactive effects of consuming Cannabis. Medicinal Cannabis usually contains a lower dosage of THC than Cannabis you can buy on the illicit market, making it safe for medicinal use. Additionally, trained practitioners will look at a patient’s condition and health history to prescribe medical Cannabis that has the right levels of THC and CBD tailored to each individual and their specific needs.

It’s also important to remember that there are some major differences in the quality and safety of Cannabis for medical and recreational use. Medical Cannabis is pure and doesn’t contain any harmful substances or chemicals. Thus, it is safe to use.

CBD is another form of cannabinoid which is more widely known – you might have seen it in supplements, food, drinks, and skincare products. CBD is different from medical Cannabis. The latter is considered to be a food product and can be purchased online or at your local health food store, whereas Medical Cannabis contains a combination of CBD and THC and is only obtained via prescription.

As part of Cannabis legalisation in the UK, only specialist doctors can prescribe medical Cannabis for people suffering from certain health conditions after they meet specific criteria. 

Benefits of Cannabis legalisation in the UK

There are several strong arguments in the case for legalising Cannabis in the UK. Let’s take a look at the many benefits of legalising medical Cannabis. 

Cannabis helps with chronic pain

For people suffering from chronic pain, Cannabis is known to help reduce the symptoms, as it is a powerful anti-inflammatory. Equally, it can also help with pain caused by nerve damage. For many of our patients, medical Cannabis has helped to manage pain and thus provide a higher quality of life.

A review of 28 clinical trials carried out by Dr Kevin Hill in 2015 found that there is strong scientific evidence that Cannabis can reduce pain in patients with MS and nerve damage. 

Cannabis reduces sickness

For people suffering from side effects of chemotherapy or HIV, AIDS and anxiety, nausea can be debilitating. The active ingredient in Cannabis – THC, has been shown to help reduce sickness in people with HIV by up to 22%. A 2015 study by M. Badaowski and S Pere also showed that Cannabis could increase appetite by 38%. Thus, we can conclude that this medication helps to reduce weight loss and improve the quality of life for people with HIV and other illnesses that cause nausea.

Medical Cannabis is a safer option

Cannabis is often a safer option than other treatments for pain, for many, Cannabis provides a natural alternative to the highly-addictive opioids initially prescribed. Patients can safely use Cannabis for long-term pain management as long as they are ingesting oil rather than smoking the drug. 

Medical cannabis helps reduce epilepsy

Cannabis is known to reduce epileptic fits and thus can improve the quality of life for people living with epilepsy. At the moment, you can access medical Cannabis for two types of epilepsy, and there are clinical trials underway to assess whether it can be used to help with the third type of epilepsy. 

Legalisation of Cannabis increases access to the medication

The legalisation of Cannabis in the UK will inevitably increase access to the medicine for people suffering from chronic pain and other ailments such as epilepsy. As only specialist doctors can prescribe medicinal Cannabis at the moment, this can create a barrier for those who need help to access it.

Legalisation of Cannabis means a stronger economy

Legalisation of Cannabis in the UK is expected to shift around £2.5 billion into the economy and away from criminal gangs. A survey by the Evening Standard found that 72% of people in the UK are supportive of this move. 

Legalisation of recreational Cannabis usage means better control

If Cannabis was legalised recreationally in the UK, it would mean that medical professionals would be able to regulate the strength of Cannabis, reducing some of the negative side effects of this substance. In the same Evening Standard survey, 68% of people were supportive of this. Equally, the legalisation of Cannabis would help to destigmatise a wrongly labelled plant medicine as a drug, decreasing fear.

Dangers of legalising Cannabis in the UK

While there are many convincing arguments for the legalisation of Cannabis in the UK, there are some cons to legalising this drug as well. Some of these dangers can have a lasting impact on the quality of life, and others present issues for the public. 

The long-term effects of Cannabis use are unknown

Whilst Cannabis is grown all over the world and has been used as a medicine since the beginning of man, it remains widely illegal around the world. Thus, there are limited studies on the long-term impact of regular Cannabis use. This makes it difficult for the UK government to gather the full facts they need to make a safe judgement about the further legalisation of Cannabis use. There is a need to do more studies into the effects of  Cannabis long term to understand all risks. At the moment, there is simply not enough information to do this. 

Cannabis can increase anxiety and paranoia

Cannabis is known to increase anxiety and paranoia in some users, and there is a high level of risk for people with conditions like schizophrenia. This is one of the reasons why only specialists can prescribe the drug for medicinal use. 

There is an increased risk of accidents

The consumption of Cannabis is known to increase the risk of accidents. A 2021 study by Preus et al. found that people are more at risk of having a car crash if they drive within two hours of using Cannabis. This is dependent on the levels of THC in the dose, and, of course, the risk increases if alcohol is also present in the driver’s system. 

However, there are many prescription drugs that come with a recommendation for the user not to operate heavy machinery. So it shouldn’t be a significant problem to have the same recommendations for medicinal Cannabis. 

There is a strong argument for the full legalisation of Cannabis in the UK to enable an increase in accessibility for medical users. While some questions around recreational Cannabis remain, the issue seems to be more about erroneous perceptions of the medication than any severe side effects a patient may experience. Moreover, there is significant support in the UK for legalising Cannabis and a wealth of medical evidence that shows that this remedy improves the lives of those suffering from painful conditions. 

As more data becomes available, the current legal status may change, but this will need the support of medical professionals, the public and politicians. Until then, people meeting certain criteria can continue to access medical Cannabis from their specialist providers. If you’re interested in getting a prescription for medical Cannabis in the UK, schedule a remote consultation with one of the experts at Lyphe now.  

Why legalise medical Cannabis?

Having better controls around the levels of THC in Cannabis will help more people access Cannabis for their medical needs. It will also help them safely purchase the drug. At the moment, there are uncontrolled Cannabis products that are sold illegally and without support from medical professionals in the UK. This can increase some of those negative side effects we mention above. Plus, when buying Cannabis off the illicit market, you cannot know the levels of THC in the product. Carefully balancing the benefits of controlled Cannabis use through specialist doctors can help more people safely access help for their symptoms.

Will Cannabis be legal in the UK?

It is unclear if Cannabis will ever be legal in the UK. There are plenty of compelling arguments for legalising Cannabis, but these need to be weighed up by the risk. As more American states start to allow legal medicinal Cannabis use, more data will inevitably become available for the UK to continue balancing the risks and benefits of legalising the substance.

https://jamanetwork.com/journals/jama/article-abstract/2338266

https://www.dovepress.com/clinical-utility-of-dronabinol-in-the-treatment-of-weight-loss-associa-peer-reviewed-fulltext-article-HIV

https://www.epilepsy.org.uk/info/treatment/cannabis-based-treatments

https://www.standard.co.uk/news/uk/will-cannabis-be-legal-decriminalised-us-laws-sadiq-khan-b998931.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3931635/

https://www.ox.ac.uk/news/2014-07-16-how-cannabis-causes-paranoia

https://www.frontiersin.org/articles/10.3389/fpsyt.2021.643315/full

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Cannabis in the UK: Your views on making it legal

• Published 2 August 2019

People have been debating whether to legalise cannabis in the UK for decades, and the response from government has always been no, so far.

Last year the law changed when it came to some medical use of the drug.

A group of MPs recently visited Canada - where recreational cannabis was made legal in October - and told Radio 1 Newsbeat they think the UK will legalise the drug within 10 years .

Our documentary, Legalising Weed: Canada's Story, came out this week - and since then you've been telling us what you think about making cannabis legal in the UK.

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Cannabis: Should it be legal?

Whenever Newsbeat discusses the subject we get lots of very strong views on all sides and this was no exception.

It wasn't just on social media that we saw a lot of debate.

"I think cannabis should be made legal because it stops people going to street dealers that can then try to push other drugs like cocaine and ecstasy," said 23-year-old Ryan from Birmingham.

He featured in our radio programme, as did Sam - who doesn't want to see a change to the law.

Legalising Weed: Canada's Story

Sam told us he feels he's lost his step-brother to cannabis.

"He was doing well at school and then his friends introduced him to cannabis. Now he doesn't have a job and he's been in trouble with the police," he told us.

"It's sad to see because he could have had a great future."

Currently cannabis is designated as a Class B drug in the UK and anyone caught with it could face up to five years in prison.

However, there has been a shift in approach towards medicinal cannabis products, which can now be legally prescribed to some patients.

The debate around mental health

Using very strong cannabis - commonly called skunk - has been linked to serious mental illnesses .

This is disputed by some pro-cannabis groups and the debate around whether we should legalise the drug often centres on this.

We heard from Sarah who works in mental health. She doesn't want to see the laws changed when it comes to cannabis.

"It is a gateway drug and the effect can be like opening Pandora's box with serious mental health issues from which some people never recover."

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On the other side of this argument we heard from Ailsa in Glasgow who thinks we should follow Canada's lead.

"With any drug there will always be people who take it too far and that's the same for legal drugs like alcohol.

"If cannabis is legalised then there should be a system that runs alongside it that can help people who have a problem with the substance."

The political debate

As part of our Canada cannabis coverage we posted a video of serving MP Sir Norman Lamb taking the drug - and that got you talking too.

As you would expect, the MPs we followed on the trip joined the debate.

We even had a well-known billionaire join in the discussion.

Follow Newsbeat on Instagram , Facebook , Twitter and YouTube .

Listen to Newsbeat live at 12:45 and 17:45 weekdays - or listen back here .

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The Arguments for and Against Decriminalising Cannabis in the UK

Do you think cannabis should be legalised in the UK? Take a look at both sides of the argument here…

It is illegal to buy, sell, possess or  cultivate cannabis in the UK . If you are caught in possession of cannabis, you may be punished with up to five years in prison, and up to fourteen years for production and supply. Additionally, if you are caught with Class B drugs, you can receive an immediate £90 fine from the police with much more serious fines for supplying.

Despite this, cannabis is considered the most popular illegal drug in the UK, with over 10 million adults between the ages on 16 and 64 having tried the drug at least once according to the BBC and annual crime survey.

So why is this drug illegal and should it stay this way? There are many different opinions regarding the decriminalisation of cannabis in the UK. Below is a breakdown of the arguments for both legalising the use of cannabis and keeping it illegal…

Should Cannabis be Decriminalised in the UK?

Many people in the UK believe that cannabis should be decriminalised and there are a lot of arguments for this. This Includes its use in medicine and the ability to have more control over production and distribution. However, others believe that, due to cannabis being highly addictive and a gateway drug, it should stay illegal.

Here are the key arguments for each side…

Arguments for Decriminalising Cannabis

1.    the ability to implement better regulation.

Despite the fact that cannabis is currently illegal in the UK, millions of people still use it each year. This cannabis is bought off the street and there is no way to know if it contains harmful substances or poses serious risk to those who are buying it.

By decriminalising cannabis, there is the opportunity to gain better control of the distribution and cultivation of the drug. This includes safety precautions like product testing, regulating potency, and more restriction on who is able to buy the drug, for example under eighteens.

2.    Cannabis is No Worse Than Alcohol or Tobacco

Many believe that cannabis is no more dangerous or addictive than alcohol. Because of this, it could be considered immoral and hypocritical for the government to allow drugs like alcohol and tobacco but make the use of cannabis illegal.

In fact, cannabis is known to have health benefits and is regularly  prescribed by doctors  to prevent things like epilepsy or glaucoma.

Tobacco, in particular, is considered more addictive and damaging than cannabis, yet it is available in every supermarket. Many people find it strange that so many addictive and damaging drugs are legalised, but the line is drawn at cannabis.

3.    Economic Benefits of Decriminalising Cannabis

Another argument for the legalisation of cannabis is that it would allow for more controlled and taxed markets that are likely to bring money into the economy. The cannabis industry is also very large and growing quickly. This means that legalising cannabis can open up the opportunity for both skilled and unskilled jobs.

4.    Reducing the Amount of Money Going to Gangs and Criminal Organisations

By taking the production and distribution of cannabis away from criminal organisation the influence and power of these groups can be dramatically reduced. Significantly damaging the revenue stream of these organisations can prevent may things like aggressive selling tactics, drug pushing and illegally shipping or smuggling cannabis into the country through dangerous methods.

5.    Make it Easier to Get Help

By decriminalising cannabis, you open up a conversation that will allow people suffering with addictions to feel safe coming forward and receiving help and support. Instead of being arrested, individuals who are unwell due to drugs like cannabis can be directed to legitimate programs that can help them recover.

Arguments Against Decriminalising Cannabis

1.    it can be bad for your health.

Despite its uses in medicine, smoking or consuming cannabis recreationally is not very good for the body. It can have  negative effects on the brain, lungs and heart  as well as putting you at high risk of accidents.

There is a higher risk of developing schizophrenia, depression, and other mental health issues for regular cannabis users. On top of this, it’s addictive nature can make it very dangerous for younger people.

2.    Increasing the Number of People Using Cannabis

The legalisation of cannabis will increase the number of people who regularly use the drug. Cannabis is addictive and, like tobacco, its users can for a dependency which will then lead to withdrawal symptoms and other side effects like anxiety.

By making cannabis more readily available, there is the risk of exposing more people to this drug, leading to many more addictions.

3.    Increasing the Profits of Drug Gangs and Criminal Organisations

Some people believe that the legalisation of cannabis will help reduce the influence of drug gangs. However, it is also a possibility that these gangs may just see a large boost in profits as their product becomes legal.

It is also believed that legalising cannabis will increase the number of crimes being committed as the number of drug users increases.

4.    Cannabis as a Gateway Drug

Commonly known as a gateway drug, the use of cannabis has been tied to the use of harder drugs, with people much more likely to engage in more extreme drugs like heroin after trying cannabis first. This makes cannabis much more dangerous, especially if it became legal.

5.    Deterring People from Using Drugs

Although there are many cannabis drug users in the UK, some people believe that the criminalisation of the drug deters people from using in the first place. This is due to the fear of consequences like fines, and prison time, which many people would rather not risk.

On top of this, the need to hide possession from the police, airport security or bouncer when going to a venue is a great deterrent.

The Decriminalisation of Cannabis in the UK

The topic of decriminalising the use of cannabis in the UK is interesting because here are many arguments for and against both viewpoints. From making it easier to get help with addictions and implementing safer regulations by legalising cannabis, to increasing the number of users and mental health issues, each side has a fair argument.

There is a fair amount of evidence to suggest that a good partition of the UK’s population would be happy with a reducing in the restrictions regarding cannabis. However, with the two largest political parties still very much in favour of keeping cannabis illegal in the UK, it doesn’t appear like there will be any drastic changes in the near future.

Please be advised that this article is for general informational purposes only. Be sure to consult a lawyer if you have been arrested due to drugs like cannabis. We are not liable for risks or issues associated with using or acting upon the information on this site.

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Medical cannabis in the UK: From principle to practice

Anne katrin schlag.

1 Drug Science, London, UK

2 King’s College London, London, UK

David S Baldwin

3 Clinical and Experimental Sciences, University of Southampton, Southampton, UK

4 University of Cape Town, Cape Town, South Africa

Michael Barnes

5 University of Newcastle, Newcastle upon Tyne, UK

Steve Bazire

6 School of Pharmacy, University of East Anglia, Norwich, UK

Rachel Coathup

7 University of Manchester, Manchester, UK

H Valerie Curran

8 Clinical, Education and Health Psychology, University College London, London, UK

Rupert McShane

9 Interventional Psychiatry Service, Oxford Health NHS Foundation Trust, Oxford, UK

Lawrence D Phillips

10 Department of Management, London School of Economics & Political Science, London, UK

Ilina Singh

11 Department of Psychiatry, University of Oxford, Oxford, UK

David J Nutt

12 Department of Brain Sciences, Imperial College London, London, UK

Background:

In the UK, medical cannabis was approved in November 2018, leading many patients to believe that the medicine would now be available on the NHS. Yet, to date, there have been only 12 NHS prescriptions and less than 60 prescriptions in total. In marked contrast, a recent patient survey by the Centre for Medical Cannabis (Couch, 2020) found 1.4 m people are using illicit cannabis for medical problems.

Such a mismatch between demand and supply is rare in medicine. This article outlines some of the current controversies about medical cannabis that underpin this disparity, beginning by contrasting current medical evidence from research studies with patient-reported outcomes.

Although definite scientific evidence is scarce for most conditions, there is significant patient demand for access to medical cannabis. This disparity poses a challenge for prescribers, and there are many concerns of physicians when deciding if, and how, to prescribe medical cannabis which still need to be addressed. Potential solutions are outlined as to how the medical profession and regulators could respond to the strong demand from patients and families for access to medical cannabis to treat chronic illnesses when there is often a limited scientific evidence base on whether and how to use it in many of these conditions.

Conclusions:

There is a need to maximise both clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.

Introduction

Cannabis is arguably the world’s oldest medicine. After a period of being banned for political reasons in the second half of the 20th century, cannabis has now been restored as a medicine in an ever-increasing number of countries. Interest in the therapeutic benefits of medical cannabis has grown rapidly in the past 20 years. This often has been the result of patient interest ( House of Commons Health and Social Care Committee (HSCC), 2019 ) in using cannabis and cannabinoids to treat a variety of conditions, from chronic and cancer pain, through depression, anxiety disorders and sleep disturbances to neurological disorders (amongst others) ( Couch, 2020 ). The scientific evidence in this field is still developing and has been summarised in various meta-analyses (e.g. National Academies of Science, Engineering, and Medicine (NASEM), 2017 ; Whiting et al., 2015 ). For some indications this evidence is substantial, for others it is only moderate or limited. Yet many countries (and the majority of US states) now allow or are considering allowing the medical use of cannabis in some form.

In the UK, cannabis was made a medicine on 1 November 2018, largely as a result of patient pressure, including high-profile media campaigns for children whose intractable epilepsy had been remarkably improved (such as Alfie Dingley) ( HSCC, 2019 ). Nevertheless, by March 2020, the medicine is still unavailable to most patients.

The current National Institute for Heath and Care Excellence (NICE) guidelines recommend the prescription of two cannabis-based medicinal products (CBMPs) for the treatment of four main conditions: Sativex for spasticity of adults with multiple sclerosis (MS), Nabilone for chemotherapy-induced nausea and vomiting, and Epidyolex for severe treatment-resistant epilepsy, i.e. Lennox-Gastaut syndrome and Dravet syndrome ( NICE, 2019 ).

Whilst welcomed by patients as a move in the right direction, these guidelines have been criticised by patients, campaigners and some doctors as too limiting ( Busby, 2019 ). Many question the narrow choice of recommended products and the lack of recommendation of medical cannabis for the treatment of chronic pain ( The Pharmaceutical Journal , 2019 ). Despite the lack of scientific evidence in many cases, there is significant patient demand for access to medical cannabis.

Definitions

There is often confusion about what exactly is cannabis, cannabinoid or tetrahydrocannabinol (THC), as well as the different formulations available. It is important to distinguish between cannabidiol (CBD; not a controlled drug in the UK) and CBD plus THC to ensure a clear understanding of the distinctions in active ingredients and in formulations as these relate to specific applications. Freeman et al. (2019) provide a useful overview, highlighting that cannabis is not one medicine but rather a whole family of medicines. We focus on CBMPs as defined by The Misuse of Drugs (Amendments) (Cannabis and Licence Fees) (England, Wales and Scotland) Regulations ( 2018 ):

[A] cannabis-based product for medicinal use in humans means a preparation or other product. . . which a) is or contains cannabis, cannabis resin, cannabinol or a cannabinol derivative (not being dronabinol or its stereoisomers); (b) is produced for medicinal use in humans; and (c) is (i) a medicinal product, or (ii) a substance or preparation for use as an ingredient of, or in the production of an ingredient of, a medicinal product.

Current evidence of medical value

The previous status of cannabis in Schedule 1 before 2018 severely restricted scientific research in the UK, resulting in a lack of essential information on the health implications of medical cannabis. Despite extensive changes in global policy on medical cannabis, there is still little definite evidence regarding its short- and long-term health effects (both harms and benefits) contributing to the discord between scientific and patient-reported evidence.

Research studies

The 2017 review by NASEM (2017) provides a wide range of research conclusions on the health effects of cannabis and cannabinoids which are presented in Box 1 with recent additions by Drug Science (2019) . The scientific evidence (or lack thereof) is controversial, emphasising the need for further research in most areas.

Box 1: Current evidence of the medical value

This panel summarises findings by NASEM (2017) and is kept within the style of their seminal review.

There is substantial evidence that cannabis or cannabinoids are effective:

• For the treatment of chronic pain in adults (cannabis)
• As antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids, THC specifically)
• For improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids, equal amounts of THC and CBD specifically)
• Epilepsy (cannabinoids, CBD specifically) ( Drug Science, 2019 )

There is moderate evidence that cannabis or cannabinoids are effective for:

• Improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnoea syndrome, fibromyalgia, chronic pain and multiple sclerosis (cannabinoids, primarily THC)

There is limited evidence that cannabis or cannabinoids are effective for:

• Increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and oral cannabinoids)
• Improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids)
• Improving symptoms of Tourette syndrome (THC capsules)
• Improving anxiety symptoms, as assessed by a public speaking test, in individuals with social anxiety disorders (cannabidiol)
• Improving symptoms of posttraumatic stress disorder (nabilone; a single, small fair-quality trial) and schizophrenia (cannabidiol add-on to current medications) and attention deficit hyperactivity disorder (ADHD) (nabiximols; one small-scale trial)
• Reducing cravings and anxiety for people with opioid use disorder (cannabidiol)
• Better outcomes (i.e. mortality, disability) after a traumatic brain injury or intracranial haemorrhage

Focusing on the effectiveness of cannabinoids in the treatment of psychiatric conditions, including depression, ADHD, Tourette’s syndrome, post-traumatic stress disorder (PTSD), psychosis and anxiety, a recent meta-analysis found the evidence to be limited and of a low standard, concluding that a prescription for mental health treatments cannot be justified ( Black et al., 2019 ). However, in that study the main focus was on pharmaceutical cannabinoids, rather than plant-derived medical cannabis for which the therapeutic potential may differ widely, and is broadly used in the USA, Canada and Germany.

Patient-reported evidence

Notwithstanding the lack of evidence in many cases, people are using medical cannabis for a broad variety of conditions, including many mental health indications. A survey by the United Patients Alliance (UPA; 2018 ), a UK patient-led medical cannabis support group, found that indications range from (in order of self-reported use) pain, depression, anxiety, insomnia, arthritis, fibromyalgia, muscle spasms, irritable bowel syndrome and migraines to headaches and more.

These findings were largely replicated with a representative sample, drawing attention to patient-reported outcomes (PROs). PROs emphasise the patient’s wellbeing and have been shown to be more sensitive to the effects of medical cannabis than traditional symptom-based measures. For example, a large recent naturalistic study on pain syndromes using PROs found adding a CBMP to ongoing medication significantly improved outcomes in patients with neuropathic pain ( Ueberall et al., 2019 ). Further real-world benefits from CBMPs using patient reports have been reported for Parkinson’s disease ( Balash et al., 2017 ), autism (Bar-Lev Schleider et al., 2019), pain, depression, and anxiety symptoms ( Gulbransen et al., 2020 ). Many patients experience therapeutic satisfaction when using medical cannabis and report improvements in or relief of a range of symptoms ( Gulbransen et al., 2020 ; Stith et al., 2018 ; Sexton et al., 2016 ). Others report using cannabis as an alternative to pharmaceutical prescriptions ( Sith et al., 2018 ) and this can lead to reduced use of opioids for example ( Ueberall et al., 2019 ). Many of these also report that the medical cannabis improves their quality of life ( Bar-Leve Schleider et al., 2019 ; Gulbransen et al., 2020 ; Sith et al., 2018 ).

Current barriers to prescribing

In the UK, despite the change in legislation there is ongoing controversy surrounding prescriptions. Medical cannabis is atypical in that its medical use preceded the demonstration of its efficacy in clinical trials, generally required for the marketing of modern pharmaceuticals D’Souza, 2019 ). Whilst on the one hand, there is strong patient demand for access to medical cannabis to treat chronic illnesses for which there are very few effective treatment alternatives, on the other hand there is only a limited placebo-controlled evidence base on whether and how to use cannabis for many of these conditions. Potential prescribers face a wide range of challenges, particularly as in the UK medical cannabis is regulated as an unlicensed medicine.

Lack of education

Doctors lack the knowledge of cannabis medicines to have the confidence to prescribe, especially off-license: they have not been trained in prescribing them and may not know the dosage etc. This barrier can be overcome by developing an educational programme, e.g. by Health Education England. A priority should be to provide a range of good quality teaching programmes. The Academy of Medical Cannabis ( http://taomc.org ) provides a free 12-module programme on the basics of cannabis which has now been used by about 1000 doctors. Drug Science launched a similar online resource ( https://mymedic.org.uk/ ), arranged a series of seminars for health-care professionals (HCPs), and developed a teaching module for medical students ( https://drugscience.org.uk/medical-cannabis-education-hub/ ). Further developments should include a diverse range of other teaching possibilities, especially accredited certificate course programmes.

Restrictive guidelines

In addition to the NICE guidelines, doctors are influenced by the guidelines produced by the Royal College of Physicians (2018) (for pain and nausea) and by the British Paediatric Neurology Association (2018) (for childhood epilepsy), which recommend the prescription of medical cannabis only as a last resort when conventional treatment has not been effective. In contrast, the Medical Cannabis Clinicians Society (MCCS) offer more balanced guidelines, proposing that for chronic pain for instance, cannabis medicine could be considered instead of opioids ( MCCS, 2019 ). The British Pain Society (2019) recently released a revised position statement considering the potential role of medical cannabis in pain management, while at the same time continuing to highlight the need for further high quality research, clinical surveillance and patient monitoring. By reference to all these guidelines a physician can now make a more informed decision on prescription in the best interests of their patient.

Fear of adverse effects, especially psychosis and dependence

Concerns about adverse mental health effects, especially psychosis and dependence, have been expressed ( Di Forti et al., 2009 ) but the recent data suggest that these are mainly the result of using street ‘skunk’ with high levels (>10%) of d9THC and negligible levels of CBD ( Di Forti et al., 2019 ). The large-scale database by Health Canada shows very few, if any, cases of psychosis with medicinal use. Surveys of people using medical cannabis revealed some patients with schizophrenia are using it to treat their symptoms and there are several studies providing experimental support for this application ( Leweke et al., 2012 ; McGuire et al., 2018 ).

Similarly, whilst the risk of dependence is around 9% for recreational users of street cannabis, it is more common with high potency THC strains with a low CBD content, large ‘doses’, high frequency use (heavy, daily) and starting use in adolescence ( Curran et al., 2016 ). Risk of dependence can therefore be mitigated with these factors in mind by giving harm-reduction advice. The Canadian database reveals that only about half of patients initiated on medical cannabis continue beyond six months, suggesting dependence liability is low. Moreover, the very easy access to street cannabis further argues that medical cannabis is unlikely to be sought for recreational purposes.

Still, regulations should mitigate against adolescent uptake and against the availability of high potency THC products lacking CBD. Additionally, in light of the recent outbreak in the USA of respiratory illness, including linked fatalities, associated with the vaping of black market (THC) cannabis oils ( Centres for Disease Control and Prevention (CDC), 2019 ), it is vital to further communicate with the public about related risks and to more effectively regulate products and routes of administration in order to limit illicit products.

It is a serious shortcoming of current research that adverse effects of cannabis have largely been studied in relation to recreational (i.e. non-medical) use, rather than medical use. This is complicated by recent findings indicating that a large proportion of medical cannabis users also report recreational use ( Han et al., 2018 ). Drug Science is currently reviewing existing research to discern if, how, and to what extent, adverse effects apply to prescribed medical use.

The cost of medical cannabis in the UK is currently high. Some families are forced to pay for private prescriptions, costing up to £40,000 a year, after their National Health Service (NHS) clinicians do not prescribe it ( Wickware, 2019 ). Yet medical cannabis is potentially cheap – saving money on conventional treatments as well as on opioid prescription costs ( Boehnke et al., 2016 ), anxiety prescriptions ( Baron et al., 2018 ) and hospital admissions, for example, epilepsy ( Bellnier et al., 2018 ). Medical cannabis could work out well economically, and a full health economics analysis is vital for conditions for which clinical efficacy has been shown.

Importation and supply chain issues

The high cost of private prescriptions is related to the import challenges of medical cannabis. It is difficult to get access to the right products in a timely manner. Licensing and imports generally are for one patient for one month at a time as bulk import is still limited ( Barnes, 2019 ). However, in March 2020, these restrictions were loosened and the UK government is now allowing bulk, non-patient specific, importation which should improve delivery time to the patient and begin to bring down costs. Current UK standards of regulation as well as of practice need to be fully developed and regularly revised, as is done, for example, by the Royal College of Physicians and Surgeons in Alberta/Canada in their ‘advice to the profession’ ( http://www.cpsa.ca/wp-content/uploads/2018/05/AP_Cannabis-for-Medical-Purposes.pdf ).

Ethical issues

The discordance between patient reports and prescribers’ confidence and reliance on clinical trial data supports the developing view that randomised controlled trials (RCTs) are not the only way to assess the efficacy of a spectrum of medical products that have subtly different effects and individual responses ( Barnes, 2018 ). Taking into account other evidence, such as observational trials, ‘experimental medicine’ studies and audits of patients already using the medicine would help to maximise research and patient benefit. Individual cases could be taken into account to build up to a pattern of evidence (indeed, in the case of childhood epilepsy, just two of these effectively changed UK law).

The concern that by using a broader evidence base for medical cannabis would lead to a lowering of scientific standards generally is understandable but misplaced. CBMPs are not the only medicine whereby non-RCT evidence was included – there are over 50 medicines or indications that have been licensed by FDA and/or EMA between 1999–2014 without RCT data ( Hatswell et al., 2016 ).

To include more ‘qualitative’ evidence is not to diminish the value of RCTs but rather to complement them and to serve as a precursor to later studies. If there is a sole focus on RCTs, it will take many years for results to be available and many disorders may never be studied – yet patients could benefit from the medicine now, making it essential to evaluate harm minimization against patient need.

Balancing patient need and potential for harm

Many patients who request cannabis have not responded to standard treatments and are desperate to find something that helps ease their symptoms. In such cases, the fact that other treatments might be statistically more effective may not be relevant as a contra-indication to use of cannabinoids ( Stockings et al., 2018 ). Now that cannabis substances have been legalised for medical uses, it is the duty of clinicians to assess the balance of legitimate patient need against potential harms as in any other area of medicine, particularly taking into account informed choice on behalf of the patient.

The ethical importance of autonomy interests in medical decision-making means that patients’ rights to information that enables them to properly weigh up potential goods and potential harms is paramount. When there is insufficient evidence and/or insufficient clinical understanding to adequately inform patients, patients are at risk of making bad decisions that can lead to harm. In the current context, most patients who use cannabis and their caregivers have decided to access cannabis without the benefit of clinical guidance or support. In so doing, patients are exercising autonomy and it would be excessively paternalistic to argue that such patients are intrinsically wrong in their actions. The desire for access to potentially beneficial treatments is certainly not wrong. Moreover, when a treatment is legally sanctioned by a national healthcare system for the application desired by the patient, then the patient has a right to access, within parameters. A healthcare system that legalises a treatment but then leaves patients to independently access and use those treatments because of a lack of evidence and clinical confidence, is arguably in danger of shirking its duty of care to vulnerable patients. At the same time, the challenges for prescribers have to be addressed as key gaps exist not only in the scientific evidence but also in the detailed information needed (but not yet available) about dosages, types, duration and formulations.

The development of the evidence base for medical cannabis needs to go hand in hand with the pursuit of clinicians’ education if the risk to patients of using cannabis from illicit sources is to be minimised. As evidence is being gathered, professional organisations must do what they can to educate clinicians. Given the problematics of clinical responsibility in an area where there is significant medical uncertainty and confusion ( Singh et al., 2017 ), the education process needs to engage explicitly with the ideal qualities of a practitioner. One such important quality is professional integrity, which may invite clinicians to acknowledge the limits of knowledge and confidence in this context, while still seeking to provide the best possible care and support for their patients. Physicians need to comply with the standards of practice, and develop a healthy physician-patient relationship, rather than simply being ‘prescribers employed by a cannabis clinic’. It is essential to develop the UK regulatory regime for medical cannabis so that it can allow for patient access while at the same time avoiding a ‘free for all’ scenario as in some US states ( Schlag, 2020 ).

Recommendations for best practice

Due to the scarcity of research, few clear and widely accepted standards exist to help guide patients and clinicians to make decisions of if, when and how to use cannabis safely and effectively. It is vital to develop strategies for best practice and ensure that global legislative changes are informed by neuroscience and public health.

Monitoring of prescriptions, patient outcomes and adverse effects

It is essential to monitor patient outcomes and adverse effects, as is already being done by Health Canada. In the UK, Drug Science launched Project Twenty21 in November 2019 to create Europe’s largest national medical cannabis database registry ( https://drugscience.org.uk/project-twenty21/ ). Continued monitoring and regulation can play a major role to mitigate risks and to collect and collate experimental and trial data. Efforts to collect valid ‘real world data’ in responsible and ethical ways need to be further improved. A ‘real world data’ approach, specifically promoting a digital solution to the multiple complexities of data, evidence, uses and formulations can offer a key resource. In the longer term, anonymous electronic patient records, such as Clinical Records Interactive Search (CRIS) can establish ‘real world’ data in large quantities.

When new compounds with misuse potential are licensed and deployed, the risks associated with misuse need to be mitigated so that patients are protected, but also so that the compound is not overused so widely that its use attracts stigma. A variety of elements to assure the safe use of such compounds can be instituted. In the UK, the packaging of opiates is to acquire warnings similar to those on cigarettes ( Gregory and Wheeler, 2019 ). In the USA, the use of Spravato, Janssen’s intranasal esketamine for depression, is conditional on patients confirming they understand the risks, and on doctors and pharmacies undergoing training ( Janssen Care Paths, 2019 ).

Registries, in which individual prescriptions or treatments are tracked, may offer a partial solution. At one end, the model of clozapine shows how a clear risk is mitigated by a pharmacist-operated algorithm based on a blood test result: no blood result, no dispensing. In some US and Australian jurisdictions, prescribers must check whether a patient is being prescribed an opiate elsewhere before writing the first prescription. In relation to medical cannabis, prescribers and regulators still need to develop and decide on the exact details of registry implementation.

Future progress – the next steps

Medical cannabis as a ‘last resort’ provision.

In the UK, medical cannabis at present is offered as a ‘last resort’, when other licensed medicines have been shown to be unsuccessful. It would be useful to develop a hierarchy of evidence to see where cannabis medicines sit, which likely would be indication-specific. However, this is a challenging task as cannabis is not one medicine but a whole family of medicines. They would come out poorly in a double-blind trial as, for example, in chronic pain some people might respond to a high CBD product, some to a high THC product and some to a product that combines both. As such, whilst the effect of a single cannabis product might lack statistical significance in a clinical trial, an analysis of different combinations of ‘cannabis’ could be statistically significant ( Namdar et al., 2019 ).

Comparing benefit-safety balances

Best-practice guidelines for prescribing medical cannabis could be informed by comparing its benefit-safety balance with those of drugs already in use. Multi-criteria decision analysis provides a well-demonstrated basis for making such comparisons based on available evidence and clinical practice ( Moore et al., 2017 ). For example, a multi-criteria decision analysis comparison of drugs for relapsing–remitting multiple sclerosis (RRMS) revealed very different benefit-safety profiles between drugs, which would enable prescribers to accurately select the most suitable drug for their patient ( Vermersch et al., 2019 ). Such an analysis could include options of alternative products, doses and timing in order to aid practitioners’ decision-making.

Coordinating a network for clinical studies

There is a need for collaboration between different stakeholders (including patients, prescribers, clinics and scientists), and to develop an overarching mechanism to convene different parties together. A network of clinical studies could report on clinical practice and monitor outcomes (both risks and benefits), to enable innovative use of medical cannabis with care, precaution and foresight. This network group could address particular diseases or more general controversies related to medical cannabis. All these concerns are part of society’s move towards increasingly personalised medicine.

Communicating with the public

The 2018 re-scheduling of medical cannabis has been rightly criticised by the public and media alike based on the misperception that these medicines would become freely available on the NHS. Public communication about medical cannabis needs to be much better. Whilst information is available on the NHS website for the public, communication efforts need to be increased. Accusing the public of not understanding is unhelpful and may lead to a lack of trust which is vital for the doctor-patient relationship. If a communication vacuum occurs, this will be filled by other interest groups, such as industry lobbying groups. Hereby, medical cannabis should not be presented as a panacea for all ailments – rather the public needs to understand that not all patients may benefit from the use of cannabis.

Conclusions

Today, medical cannabis policy and research is developing rapidly in line with shifting public attitudes. Yet the current UK procedures to access medical cannabis are not working. High hopes by patients have not been realised in practice.

The re-scheduling of cannabis from Schedule 1 to Schedule 2 should open up urgently needed research opportunities. For other drugs, research funding usually comes from the companies who will benefit financially, yet it remains to be seen if/what funding will be provided by the medical cannabis industry given the problems of patenting. Whilst awaiting RCTs, different methodologies can be applied to move the evidence base forward.

In addition to further scientific studies, the medical cannabis regulatory framework and its application in practice need to be clarified so that this framework can be responsive to patient need whilst adhering to medical practice and high ethical standards. Many questions remain unanswered: What medical cannabis products will be used exactly? How can governments permit the manufacturing and distribution of cannabis for medical purposes? Although these regulatory challenges highlight the complexity of decision-making about medical cannabis they have already been resolved in other jurisdictions, e.g. in the Netherlands.

Concerns by physicians when deciding if and how to prescribe medical cannabis need to be addressed. Because of concern about its recreational use and previous Schedule 1 status, there is still an emotional barrier to prescribing cannabis. It may take time to change doctors’ perceptions and to fill the knowledge gap. Hopefully, the various efforts to educate doctors and other HCPs will go some way in this task and the access to a standardised way of data collecting as in Project Twenty21 should help assuage prescribers’ anxieties. There is a need to maximise clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.

Author contributions: AKS developed the initial draft, wrote the sections on definitions, scientific evidence, future progress and conclusions and compiled and revised all authors’ contributions. DJN wrote the introduction and revised the manuscript. HVC wrote the section on cannabis and mental health. IS contributed the ethical sections. RMS wrote the section on registries, MB on barriers to prescribing, LP on comparing benefit-safety balances, SB on how to aid prescribers and decision makers, RC and DB contributed further references and revised the manuscript. All authors reviewed and accepted the article before submission.

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AKS is head of research at the charity Drug Science. DJN is chair of Drug Science. MB is chief medical officer of ECH and Sol Global Investments, chair of the Medical Cannabis Clinicians Society, and director of Maple Tree Consultants. None are employed positions and MB would not benefit from broader prescription of cannabis in any role. All other authors declare no competing interests.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article was produced with support from Drug Science (DrugScience.org.uk)

Germany decriminalised cannabis: why the UK should consider doing the same

Honorary Fellow, Department of Health Sciences, University of York

Professor in Criminology, Loughborough University

Disclosure statement

Mark Monaghan receives funding from UK Government, Cabinet Office and the ESRC. He has in the past received funding from the Nuffield Foundation.

Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

University of York and Loughborough University provide funding as members of The Conversation UK.

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The German government has approved new legislation which decriminalises cannabis.

This policy allows over-18s to possess a maximum of 25 grams of cannabis for personal use and grow up to three plants at home.

From July 2024, German residents will also be able to join not-for-profit cannabis social clubs or growers associations where plants are cultivated en masse for the benefit of members.

In the UK, on the other hand, the government continues to support prohibition , unlike many western countries – including Malta , Canada and several states in the US – which have opened up access to cannabis in recent years.

The UK government cites concerns about the risk to mental health associated with using cannabis as a justification for supporting prohibition.

Cannabis and mental health

There is extensive research exploring the relationship between cannabis and mental health problems, such as psychosis. However, no causal link has been established because to run such studies would be unethical.

There is, though, a significant association between cannabis and psychosis. The evidence suggests that some people may be more vulnerable than others to developing psychosis through cannabis use.

Although these health concerns are shared by some organisations in Germany, this has not prevented policy reform.

The German cannabis clubs will have quality control as part of their ethos, providing information about potency and any potential contaminants.

This is important as the evidence suggests there is a dose-response relationship – an association between the amount consumed and the incidence of effect – between the strength and frequency of cannabis use and the risk of developing problems such as psychosis.

Cannabis users who experience psychosis are very few when compared to the total number using the drug. One study estimated that to avoid one person developing psychosis, up to 10,000 men and 29,000 women aged 20-24 would need to be prevented from using cannabis.

The risk to mental health associated with cannabis, then, is relatively low.

Alcohol and tobacco: regulated but riskier

Unlike cannabis, alcohol is regulated in the UK. Although there are restrictions on its use, these have been loosened in recent years. As with cannabis, there are risks to mental health as a consequence of using alcohol.

The risk of developing depression among heavy alcohol use is significant: one in two will experience depression. So despite alcohol being regulated or legal, the risks to a person’s mental health are greater than those posed by cannabis.

A significant advantage of decriminalising cannabis would be the potential public health benefits. In the UK, most people using cannabis combine it with tobacco to smoke. The risks to health as a result of using tobacco are well documented and include a range of cancers as well as heart disease and stroke.

Although many young people consider themselves non-smokers they can be inadvertently introduced to tobacco when they smoke a cannabis joint. This creates not only a health risk but also the chance of becoming dependent on tobacco.

However, there is also evidence that cannabis used without tobacco may increase the risk of physical health problems. A recent study from the US, for example, where fewer people combine cannabis with tobacco, found a link between cannabis use and heart disease.

Because cannabis is prohibited, it is difficult for tax-funded organisations such as those promoting public health to intervene.

Public health

In contrast, German policy reform includes a public health education programme which aims to reduce the risks of using cannabis.

Under prohibition, there is no quality control or information about the potency of cannabis or which chemicals it contains. The lack of regulation leaves buyers at the mercy of the illicit market.

The Office for National Statistics estimates that 2.5 million people in England and Wales reported using cannabis in 2023.

Despite the relatively widespread use of cannabis in the UK, the major political parties, Labour and the Conservatives, show no sign of changing the legal status of cannabis. Perhaps influenced by polling suggesting support for the current policy approach.

We know from experience that governments don’t need to wait until there is public support to change their policy approach to drugs. In 2007, when the Labour government introduced a ban on smoking in public areas, this wasn’t supported by many people.

The risks to health from using cannabis, then, are relatively small compared to regulated drugs such as alcohol and tobacco. But even if the health argument isn’t enough to trigger a policy change, the economic case could be.

While decriminalising cannabis in the UK would save on criminal prosecution costs, going a step further and legalising cannabis could bring in significantly higher financial returns.

The estimated tax revenue that could be raised by the legalisation (rather than just the decriminalisation) of cannabis in Germany is €4.7 billion (£4 billion) annually. A regulated commercial market like Canada’s could create jobs as well as raise income from tax.

As the UK public finances continue to be squeezed, particularly around the NHS, persisting with the prohibition of cannabis is a missed opportunity for the nation’s health and a costly policy for its public services.

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Should the supply of cannabis be legalised now?

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• Peer review
• Molly Meacher , cross bench peer and co-chair of the All-Party Parliamentary Group for Drug Policy Reform 1 ,
• David Nutt , director, Neuropsychopharmacology Unit 2 ,
• Jonathan Liebling , director, Cannabis Patient Advocacy and Support Services 3 ,
• Robin M Murray , professor of psychiatric research 4 ,
• Adam Gridley , mental health writer and recovered cannabis user 5
• 1 House of Lords, London
• 2 Imperial College London
• 4 Institute of Psychiatry, King’s College, London
• Correspondence to: Molly Meacher meachermc{at}parliament.uk , R M Murray robin.murray{at}kcl.ac.uk

Strict regulation would allow for healthier cannabis consumption than the criminally controlled current supply can offer, say Molly Meacher , David Nutt , and Jonathan Liebling . But Robin Murray and Adam Gridley worry that legalisation could increase cannabis use and associated psychiatric disorders

Yes—Molly Meacher, David Nutt, Jonathan Liebling

Opponents of legalisation and regulation of the supply of cannabis raise legitimate fears that it could lead to more use and therefore increased mental health harms. However, recent research in the US, where some states have legalised cannabis supply for adult social use, suggests that cannabis consumption has increased irrespective of its legal status in each state. 1

Legalising and regulating cannabis confers many benefits over the current illegal and unregulated supply. Here we focus on benefits that directly affect mental and physical health.

Making consumption safer

The priority for drug policy must be to protect the mental and physical health of teenagers by discouraging cannabis use among this group and, in particular, consumption of cannabis with high concentrations of tetrahydrocannabinol (THC)—“skunk”—or contaminated products. We can expect that a proportion of teenagers who currently use skunk will access the regulated product, just as they access alcohol at present. A strong educational campaign will be important to warn of the risks associated with use. In US states with legal, regulated cannabis sales the number of teenagers taking cannabis has not risen, and in Colorado it has fallen. 2

States that legalise cannabis supply can provide a safer environment for young people, but this will depend on the regulatory environment. For example, smoking cannabis with tobacco should be discouraged, and vaping of cannabis should be encouraged to reduce lung damage.

A key health issue is the composition of cannabis products. The drug may contain as many as 140 different cannabinoids in varying proportions. The two main ones are THC—often called the active ingredient—and CBD (cannabidiol), a non-intoxicating, possibly antipsychotic cannabinoid. 3

A recent study has shown just how important the composition of cannabis products is in reducing health risks to the consumer. Cannabis supply remains illegal for social use in the UK, but cannabis is nevertheless used by an estimated 2.1 million people in England and Wales aged 16-59. 4 They buy it from drug dealers operating illegally, who want to maximise profits without concern for their customers’ health. Cannabis products with high THC concentrations yield the biggest profits and are therefore the dealers’ favoured offering.

Skunk is associated with psychotic episodes, particularly in young people with a family history of psychosis. It may also inhibit teenagers’ brain development.

The crucial question is whether low potency cannabis can be consumed safely. Di Forti and colleagues concluded that “individuals who mostly used low-potency (hash-like) cannabis occasionally, at weekends or daily had no increased likelihood of psychotic disorders compared with those who never used cannabis.” 5 On the other hand, people who used skunk daily were more than five times as likely to have a psychotic disorder diagnosed. 5

Benefits of a regulated market

Legalisation would enable the state to regulate the industry, with legal outlets supplying only herbal cannabis with balanced THC and CBD. Regulations would include an age threshold of 18 or 20 for cannabis purchase, and educational campaigns would have to clarify that, although such cannabis is much safer for adults than alcohol or tobacco, it may carry risks for young people whose brains are still developing.

A regulated market could have other health benefits when compared with the current situation. Regulation would ensure labelling: users would know the strength of the cannabis they were buying and could be sure that the product was free from adulterants, pesticides, and other harmful substances. Alcohol consumption would be likely to decline. 6

Currently, the only access to cannabis is through dealers operating illegally (apart from the few UK patients who have a private prescription for medical cannabis). Dealers also offer crack cocaine and heroin, risking a gateway effect between illegal cannabis use and the purchase of class A drugs. To maximise profits dealers promote these more dangerous and addictive drugs to children despite their health risks, 7 so legalisation of cannabis supply could well reduce the use of other, more harmful illegal drugs. We await research evidence that this logical benefit of cannabis legalisation has occurred in those states that have introduced reforms.

Finally, cannabis sale could be taxed and the income invested in the NHS, in treatment for drug disorders, and in drug education in schools. Rogeberg has shown that a state controlled regulated market gives the best overall outcomes. 8 State controlled regulated markets avoid the tendency among markets run for profit to incentivise increased use. Tighter controls than those for tobacco and alcohol regulation would be needed: for example, we would recommend a maximum THC limit and a minimum CBD limit in all legal products. Advertising would be banned.

In conclusion, legalisation and regulation of cannabis supply for adult social use would create a safer environment for children and young people and would reduce the health risks associated with cannabis.

No—Robin M Murray, Adam Gridley

A huge pharmacological experiment is currently under way with the brains of young Americans. It would be wise to watch how the results unfold before deciding whether to follow their example.

The UK’s legalisation of medicinal cannabis means that cannabis based products can be prescribed to some people who may benefit from them. Furthermore, recreational cannabis use has in practice been decriminalised in most areas of the UK. 9 But what would happen if recreational cannabis markets were legalised and the supply and sale of cannabis were legally regulated? This would take part of the trade out of the hands of some criminals—but not all, as no one is proposing to make cannabis available to 15 year olds, and experience in North America is that the illicit market continues to flourish.

Legalisation holds the promise of tax revenues, and it will certainly make investors rich. A recent report projected annual legal sales of cannabis at $66.3bn (£52.4bn; €58.4bn) by 2025. 10 Tobacco and alcohol companies are jumping on board. Altria, the owner of Marlboro cigarettes, bought a $1.8bn share in a Canadian cannabis company in 2018, 11 while Anheuser-Busch, the world’s largest beer company, is investing $50m in researching drinks infused with cannabis. 12

Increased risk of psychosis

Cannabis is reasonably safe in terms of physical health: smoking it can damage the lungs, but this is mostly a result of the tobacco it’s commonly mixed with. However, about one in 10 users becomes dependent, and numerous prospective studies have shown that cannabis use carries an increased risk of later, schizophrenia-like psychosis. In the heaviest users this risk increases by five 13 to nine times, 14 so 10% of heavy users of high potency cannabis are likely to develop psychosis. 14 Cannabis use also increases the risk of depression and suicide, although the effect is not as strong as that for psychosis. 15

The adverse effects of tobacco and alcohol track the extent of their use. Lung cancer reached epidemic proportions after cigarette smoking spread, and liver disease increases in proportion to alcohol consumption. Similarly, with cannabis, Di Forti and colleagues showed that the incidence of psychosis throughout 11 areas in Europe correlated highly (r=0.8) with the prevalence of daily cannabis use in the general population in the different sites. Indeed, if no one smoked high potency cannabis, 30% of cases of psychosis would be prevented in London, and 50% would be prevented in Amsterdam, where Nederhash—containing up to 60% tetrahydrocannabinol (THC) —can be lawfully smoked in “coffee” shops. 14

Throughout the US, cannabis use and dependence have both increased among adults in the states that have legalised cannabis for medicinal use. 16 These states also show higher rates of cannabis use disorders 17 and serious mental illness. 18 It’s too early to see the mental health effects of legalising recreational cannabis. However, Colorado, the first state to legalislate for recreational use, has five times as many “pot shops” as it has McDonald’s outlets, its use is 85% higher than in the rest of the US, 19 and potency has sky rocketed.

In the UK we consider skunk to be high potency, but on average it contains only 14% THC. In Colorado, “shatter” and “wax dabs” concentrates are widely available, containing as much as 90% THC. It’s clear that legalisation has driven up potency.

Cannabis related visits to the University of Colorado Hospital’s emergency department trebled in the five years after legalisation from under 250 to over 800, 20 and the share of drivers involved in fatal crashes who tested positive for cannabis increased from 11% in 2013 to 21% (n=139) in 2017. 21

It’s often said that alcohol and tobacco are more harmful to society than cannabis, but their heavy use is far more common because they are legal. Is it inevitable that legalisation in the UK would result in more dependence and psychosis? In theory it should be possible to legalise without an increase in use and potency, but the precedents from the US aren’t encouraging. In our opinion, the best option at present is to adopt the Portuguese model, where cannabis use is decriminalised but supply is not legalised, and the police refer persistent users to treatment.

Molly Meacher and Robin Murray were due to debate this question at the Royal College of Psychiatrists’ international congress in London on 2 July 2019.

Competing interests (Meacher et al): We have read and understood BMJ policy on declaration of interests and declare the following interests: MM is co-chair of the All Party Parliamentary Group for Drug Policy Reform. In this capacity MM has received grants from the Open Society Foundation for Drug Policy research and projects. OSF is a not-for-profit organisation.

DN sits on the advisory boards of several research and pharmaceutical companies, which have no connection to medical cannabis. DN has been paid to speak by several pharmaceutical companies that do not produce medical cannabis products. DN founded and chairs the charity DrugScience, which is funded by individual donations, a grant from Open Society Foundations, book sales, and companies that produce cannabis. DN’s company Alcarelle seeks to develop less harmful recreational alternatives to alcohol.

JL is employed as lead researcher by the not-for-profit Centre for Medicinal Cannabis and is cofounder and director of the not-for-profit Cannabis Patient Advocacy and Support Services. Both organisations exclusively focus on medicinal access for patients. Neither organisation is concerned with campaigning or lobbying for the legal regulation of cannabis for adult use.

Competing interests (Murray et al): We have read and understood BMJ policy on declaration of interests and have the following interests to declare: RM has received honorariums for giving lectures for Janssen, Otsuka, Lundbeck, and Sunovian. He has attended one meeting of Canopy Growth Health regarding CBD. He is a member of the Cannabis-Based Medicinal Products Panel, advising the Advisory Committee for Drug Misuse and the Home Office.

Provenance and peer review: Commissioned; not externally peer reviewed.

• ↵ Colorado’s teen marijuana usage dips after legalisation. Scientific American 2016. https://www.scientificamerican.com/article/colorado-s-teen-marijuana-usage-dips-after-legalization .
• ↵ NHS Digital. Statistics on drugs misuse: England, 2017. 28 Feb 2017. https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-drug-misuse/2017 .
• Di Forti M ,
• Quattrone D ,
• Freeman TP ,
• EU-GEI WP2 Group
• ↵ Kilmer B, Smart R. How will cannabis legalisation affect alcohol consumption? Rand Corp. 13 Feb 2018. https://www.rand.org/blog/2018/02/how-will-cannabis-legalization-affect-alcohol-consumption.html .
• Caulkins JP ,
• Kleiman MAR
• ↵ Rogeberg O, Bergsvika D, Phillips LD. A new approach to formulating and appraising drug policy. Int J Drug Pol 2018;56:144-52. www.sciencedirect.com/science/article/pii/S0955395918300264 .
• ↵ 420: Seven charts on how cannabis use has changed. BBC News 2019 Apr 20. https://www.bbc.co.uk/news/uk-47950785
• ↵ Grand View Research. Legal marijuana market by 2025. May 2019. https://www.grandviewresearch.com/press-release/global-legal-marijuana-market
• ↵ Brumpton H, Kumar US. Altria to marry pot with big tobacco in $1.8 billion Cronos deal. Reuters 2018 Dec 7. https://uk.reuters.com/article/us-cronos-group-m-a-altria-group/altria-to-marry-pot-with-big-tobacco-in-1-8-billion-cronos-deal-idUKKBN1O61BS
• ↵ Gray A, Bullock NAB. InBev in cannabis drinks tie-up. Financial Times 2018 Dec 19. https://www.ft.com/content/e3690ba2-03b7-11e9-9d01-cd4d49afbbe3
• Marconi A ,
• Murray RM ,
• Zytynski T ,
• Sarvet AL ,
• Arterberry BJ ,
• Treloar Padovano H ,
• Foster KT ,
• Zucker RA ,
• Parish WJ ,
• Gourdet CK ,
• ↵ Substance Abuse and Mental Health Services Administration. National survey on drug use and health. https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health .
• Shelton SK ,
• ↵ Colorado Department of Public Safety. Impacts of marijuana legalization in Colorado. Oct 2018. https://cdpsdocs.state.co.us/ors/docs/reports/2018-SB13-283_Rpt.pdf .

Why we need to legalise cannabis for medical use in the UK

As the Welsh Assembly votes in favour of asking the UK Government to reschedule medical cannabis to allow it to be prescribed and legally supplied, a long-standing member explains why redefining the drug as ‘therapeutic’ would decriminalise patients seeking pain relief.

George Mattei / Science Photo Library

“Fifty years of intelligent, pragmatic drugs policies of decriminalisation in The Netherlands have delivered a prison crisis. There are not enough prisoners to fill their prisons. Isn’t this a problem we would like to share?”

This seemed a reasonable question to ask the UK Government’s drugs minister, Sarah Newton, during a Commons debate in July 2017, but the antennae of the main British political parties have been insensitive to the current global disillusionment with drug prohibition laws.

Until 1973, tincture of cannabis had been medically available in the UK for over 100 years. It has been used as a medicine in its natural form across the continents for 5,000 years [1] . But in the 1960s, the UK was swept along with the international hysteria provoked by US President Nixon’s missionary zeal to eliminate the use of all illegal drugs.

UK’s progress lags behind

Increased drug use, and the monetary and human costs resulting from prohibition are now being recognised. Already, 29 of the 50 US states supply medicinal cannabis, and it has also been legalised in Canada. This side of the Atlantic, medicinal cannabis is produced in The Netherlands and is available in Italy, Finland, Switzerland and Germany.

But the UK’s stance has not yet changed. Public opinion is ahead of Parliament. In 1999, a jury empathised with a wheelchair-bound cannabis user and sought to disregard a law that they believed was unjust. The judge ruled that the decision lay with Parliament, and the accused was convicted. Parliament continues to deliver injustices as it dodges its responsibility and fails to reform.

Reclassifying medicinal cannabis

On 17 January 2018, Welsh Assembly Members voted in favour of a motion to reclassify medical cannabis .

My Bill,  Legalisation of Cannabis (Medicinal Purposes) Bill 2017–19 , scheduled for its second reading on Friday 23 February 2018, would move cannabis from a schedule that defines the drug as of no medicinal benefit to one that permits its use for therapeutic reasons.

My call for users of medicinal cannabis to break the law at Parliament was a final ploy. After 20 years of campaigning, impatience is now justified. That law is an ass. Could a day of civil disobedience shame a parliament into reform?

Elizabeth Brice, a television producer and a brilliant person, shared my anger. Brice was diagnosed with multiple sclerosis (MS) at just 26 years of age. She campaigned for the use of cannabis as medicines (under the pseudonym Clare Hodges), drank cannabis tea on the Commons terrace, and persuaded the Belgian Parliament to legalise medicinal cannabis in 2001. Sadly, she passed away in 2011 with so much more to have been achieved.

Current drugs law and strategy

The law on cannabis forces users to buy from the black market, where irresponsible dealers sell hazardous drug forms. One police officer forced into early retirement by MS turned to buying cannabis from the petty criminals she used to lock up, while others import seeds from Amsterdam and grow their own. UK law punishes by years of imprisonment for these victimless ‘crimes’. Police officers and prosecutors are doing Parliament’s job by turning a blind eye to this law, but the law is the law.

Combining previous failed policies creates failed policy

The ‘new’ drug strategy is a repeat of the lame cowardice that government has shown in the almost 50 years since the Misuse of Drugs Act 1971 was introduced, but it comes with ‘joined-up’ and ‘holistic’ window-dressing — meaningless adjectival jargon [2] . Combining previous failed policies creates failed policy, and there is no sign that the civil service or government has changed its thinking in response to the global disillusionment with drug law.

Decriminalising patients seeking relief

During my 30 years in parliament I have campaigned against the harm caused by the antidepressant paroxetine and the nonsteroidal anti-inflammatory drug rofecoxib; and I now chair a campaign opposed to the growing menace of opioid misuse. But cannabis is a drug that evidence suggests could provide unique relief for many who suffer from the cruel disease MS [3] , [4] . The law should not criminalise patients seeking relief from pain and spasm.

Legalising cannabis for medicinal use has shown reductions in criminal activity

Legalising cannabis for medicinal use has not previously shown spikes in cannabis use, and no increase in road fatalities [5] , [6] , [7] . But there have been reductions in criminal activity, and new taxes have contributed millions of dollars to the coffers of countries that have introduced new policy on medicinal cannabis.

The arguments are now irresistible. Recent parliamentary debates have been dominated by those who believe that prohibition has failed. I hope my party will be the first major one to adopt policies that are far removed from the evidence-free errors of the past 50 years. It is time to sweep aside those grievous errors and the waste of prohibition.

Paul Flynn is Labour MP for Newport West, Wales.

[1] Bridgeman MB and Abazia DT. Medicinal cannabis: history, pharmacology, and implications for the acute care setting. PT 2017;42(3):180–88. PMCID: PMC5312634

[2] HM Government. 2017 drug strategy. July 2017. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/628148/Drug_strategy_2017.PDF (accessed January 2018)

[3] National Multiple Sclerosis Society. Medical marijuana (cannabis). Available at: www.nationalmssociety.org/Treating-MS/Complementary-Alternative-Medicines/Marijuana#section-0 (accessed January 2018)

[4] Multiple Sclerosis Society. Cannabis and MS: the role of cannabis in treating MS symptoms. Available at: www.mssociety.org.uk/sites/default/files/Cannabis%20and%20MS%20Report%20July%202017.pdf (accessed January 2018)

[5] Hasin DS, Wall M, Keyes KM et al. Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated cross-sectional surveys. Lancet Psychiatry 2015;2:601–08. doi: 10.1016/S2215-0366(15)00217-5

[6] Anderson DM, Hansen B and Rees DI. Medical marijuana laws, traffic fatalities, and alcohol consumption. J Law Econ 2013 56;2:333–369. doi: 10.1086/668812

[7] Aydelotte JD, Brown LH, Luftman KM et al. Crash fatality rates after recreational marijuana legalisation in Washington and Colorado. Am J Public Health 2017;107;8:1329–1331. doi: 10.2105/AJPH.2017.303848

You may also be interested in

Medical Cannabis Clinicians’ Society publishes guidance for prescribers

Why patients are still being denied legalised medical cannabis

Novel psychoactive substances: understanding the new illegal drug market

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Like Germany, the UK should legalise weed – but I wish we could criminalise boring stoners

It’s gone from the mind-opening drug that inspired swathes of sixties music to being the least rebellious of substances. as cannabis becomes state-sanctioned in yet another country, former serial stoner oliver keens asks – what purpose does it really serve in modern life, article bookmarked.

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I n the early 1990s, Britain looked up to Germany like a young boy blindly following its smarter and more successful older sibling. Sure, on the surface we were still somewhat hostile and superior towards our then-partners in the European Union. But secretly we marvelled at the prudence of their politicians and their high growth, low inflation economy – and we copied it scrupulously until the economic crisis known as Black Wednesday in 1992 . Yet despite our history of discretely duplicating them, I privately hope we won’t be following Germany into legalising weed .

The currently class B drug was in my life for about 10 years, at various intensities – from a tiny bit to really quite a lot. I admit that spending half my adulthood smoking weed and the other half hating on it might cloud my credibility in thick plumes of hypocrisy. But if I’m trying to have my hash cake and eat it too, it’s for a good reason. If I can only convince you of one thing, it’s that the years I spent smoking weed were the most boring, unproductive and unadventurous of my life.

Looking back, I didn’t suspect when I took my first puff that there was any real downside. British culture has never updated its narrative on cannabis beyond the Swinging Sixties. “A bit of puff” is still widely seen as an aid to creativity, a mind-expanding pathway into huge swathes of popular culture: the music of The Beatles and Pink Floyd or the writing of Hunter S Thompson, for example. In excess, it might be a source of fun like the Camberwell carrot of Withnail and I , or a motif of an almost cartoonish weed advocate such as Snoop Dogg .

But we tend to dwell less on the fact that the thing that makes the sticky icky actually sticky might be toxic contaminants like hairspray or butane. We rarely acknowledge that modern forms of weed are of a vastly higher potency than our baby boomer forefathers could have handled. We swerve the proven links between extended cannabis use and psychosis , and bury our heads in the sand when it comes to the slavery and child exploitation that often goes hand in hand with modern selling.

For all these reasons and more, it’s a brave and principled decision (plus a lucrative one) when countries decide to bring marijuana under state control and legalise it – as Holland, Belgium, Canada, several American states and most recently Germany have done. It’s arguably the most sane and responsible choice.

Yet, at the same time, am I the only one who feels there’s something a bit galling about potentially having to spend a lot more time chatting to stoners? In an era when life can already seem flat and submerged in an uneasy torpor, the idea of adding in a drug that makes virtually nothing happen except a glazed insularity seems dangerously uninspiring. There’s nothing rebellious anymore about smoking weed – it’s a concept that’s as outdated as a Cypress Hill CD. In its place is almost the opposite, should weed ever be legalised: a state-sanctioned way to allay rebellion through sheer stoned inactivity.

Those seeking the mind-expanding Sixties dream have a plethora of more interesting drugs to choose from. Those wanting the more relaxing aspects have all manner of CBD products at their disposal. In the middle of those is weed, a drug that over time dramatically loses its ability to provide elation and spark. A drug that becomes to many – myself once included – a sludgy constant, a dreary crutch that inadvertently becomes part of your personality. Worse is the effect that sustained use can have on your relationships with other people. Weed can, quite frankly, make you become a really boring person, especially when the people in your life – partners, friends and family – aren’t as blaze-happy.

There’s also what we used to pejoratively refer to as a “geekiness” about weed – most commonly associated with a slightly righteous, know-it-all male energy. It’s why pretty much all the protagonists of hallmark stoner films, from Cheech and Chong to Harold and Kumar , comprise two guys: one to roll the joints, the other one to tell them they’re doing it all wrong (and share a hilarious anecdote about getting high with some other guy). Back in the day, weed bores would only have the product to be obsessive about. Like an illicit take on Gardeners’ World magazine, stoner bible High Times used to publish a glossy, poster-sized centrefold featuring huge aspirational buds of THC-coated green. But as time has gone on, weed bores have accumulated more paraphernalia than a pharaoh's tomb, the latest gadget being, of course, vapes .

It might seem absurd to bring this up now, just at a time when – say – a future Labour government might theoretically consider legalisation in the next few years. But all the same, it’s worth asking what place weed actually has in society anymore. Is it a drug of a bygone era? Is there an actual benefit that comes from it featuring in our lives (beyond legitimate medical grounds )? If so, I’d love more people to evangelise for it – beyond the tired idea of cannabis being a counter-cultural identifier.

Take it from someone who’s been there and done that – and slightly regrets the years of dull chats, dull lifestyles and a depressingly dull outlook on life – weed legalisation might make sense but it really isn’t something to get excited about. Quite the opposite.

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Germany decriminalized cannabis: Why the UK should consider doing the same

by Ian Hamilton and Mark Monaghan, The Conversation

The German government has approved new legislation that decriminalizes cannabis.

This policy allows over-18s to possess a maximum of 25 grams of cannabis for personal use and grow up to three plants at home.

From July 2024, German residents will also be able to join not-for-profit cannabis social clubs or growers associations where plants are cultivated en masse for the benefit of members.

In the UK, on the other hand, the government continues to support prohibition, unlike many western countries —including Malta , Canada and several states in the US—which have opened up access to cannabis in recent years.

The UK government cites concerns about the risk to mental health associated with using cannabis as a justification for supporting prohibition.

Cannabis and mental health

There is extensive research exploring the relationship between cannabis and mental health problems , such as psychosis. However, no causal link has been established because to run such studies would be unethical.

There is, though, a significant association between cannabis and psychosis. The evidence suggests that some people may be more vulnerable than others to developing psychosis through cannabis use.

Although these health concerns are shared by some organizations in Germany, this has not prevented policy reform.

The German cannabis clubs will have quality control as part of their ethos, providing information about potency and any potential contaminants.

This is important as the evidence suggests there is a dose-response relationship —an association between the amount consumed and the incidence of effect—between the strength and frequency of cannabis use and the risk of developing problems such as psychosis.

Cannabis users who experience psychosis are very few when compared to the total number using the drug. One study estimated that to avoid one person developing psychosis, up to 10,000 men and 29,000 women aged 20–24 would need to be prevented from using cannabis.

The risk to mental health associated with cannabis, then, is relatively low.

Alcohol and tobacco: Regulated but riskier

Unlike cannabis, alcohol is regulated in the UK. Although there are restrictions on its use, these have been loosened in recent years. As with cannabis, there are risks to mental health as a consequence of using alcohol.

The risk of developing depression among heavy alcohol use is significant: one in two will experience depression. So despite alcohol being regulated or legal, the risks to a person's mental health are greater than those posed by cannabis.

A significant advantage of decriminalizing cannabis would be the potential public health benefits. In the UK, most people using cannabis combine it with tobacco to smoke. The risks to health as a result of using tobacco are well documented and include a range of cancers as well as heart disease and stroke.

Although many young people consider themselves non-smokers they can be inadvertently introduced to tobacco when they smoke a cannabis joint. This creates not only a health risk but also the chance of becoming dependent on tobacco.

However, there is also evidence that cannabis used without tobacco may increase the risk of physical health problems. A recent study from the US, for example, where fewer people combine cannabis with tobacco, found a link between cannabis use and heart disease.

Because cannabis is prohibited, it is difficult for tax-funded organizations such as those promoting public health to intervene.

Public health

In contrast, German policy reform includes a public health education program which aims to reduce the risks of using cannabis.

Under prohibition, there is no quality control or information about the potency of cannabis or which chemicals it contains. The lack of regulation leaves buyers at the mercy of the illicit market.

The Office for National Statistics estimates that 2.5 million people in England and Wales reported using cannabis in 2023.

Despite the relatively widespread use of cannabis in the UK, the major political parties, Labor and the Conservatives, show no sign of changing the legal status of cannabis. Perhaps influenced by polling suggesting support for the current policy approach.

We know from experience that governments don't need to wait until there is public support to change their policy approach to drugs. In 2007, when the Labor government introduced a ban on smoking in public areas, this wasn't supported by many people.

The risks to health from using cannabis, then, are relatively small compared to regulated drugs such as alcohol and tobacco. But even if the health argument isn't enough to trigger a policy change, the economic case could be.

While decriminalizing cannabis in the UK would save on criminal prosecution costs, going a step further and legalizing cannabis could bring in significantly higher financial returns.

The estimated tax revenue that could be raised by the legalization (rather than just the decriminalization) of cannabis in Germany is €4.7 billion (£4 billion) annually. A regulated commercial market like Canada's could create jobs as well as raise income from tax.

As the UK public finances continue to be squeezed, particularly around the NHS, persisting with the prohibition of cannabis is a missed opportunity for the nation's health and a costly policy for its public services.

Provided by The Conversation

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• Should cannabis be legalised?

Cannabis is the world's most widely used illegal drug. British school children have the highest (around 40 percent) and adults the second highest use compared with the rest of Europe.[1] About one in five 16-29 year olds have used it in the last year, one in eight within the last month. The majority of young people believe it is safe and should be legalised or at least decriminalised. Only a third of adults believe cannabis to be harmful. The pro-cannabis lobby has attracted massive support from the public, media and even political parties such as the Liberal Democrats. Successive governments have however rejected such pleas. Recently, the Conservative Party's shadow home secretary announced their 'zero tolerance' policy for cannabis possession; and eight members of the shadow cabinet immediately confessed to having used it!

Although much is known about cannabis and its effects, arguments for and against its use are complex and cannot be resolved because we lack an adequate knowledge base. Many organisations have attempted to summarise the evidence impartially.[2,3,4,5,6] Given this level of interest, it is clearly important for Christians to know how to respond in order to be salt and light to the world.

Biological basis

Cannabis is derived from the hemp plant Cannabis Sativa . Used since antiquity, it was around in Jesus' day though not mentioned in the Bible. It contains over 400 chemical compounds (several thousand when smoked) including more than 60 cannabinoids -compounds unique to this plant genus. Cannabinoids interact with cannabis receptors in the body: like opiates, they substitute for endogenous compounds (eg anandamide) that interact with these receptors. Of all cannabinoids delta-9- tetrahydrocannabinol (THC) has the greatest effects on the brain.

It is illegal to grow, possess, produce, smoke or supply cannabis to another person; allowing your premises to be used for these purposes is also against the law. Cannabis and most cannabinoids are both Schedule 1 (absolutely prohibited from medical use) and Class B (attracting prison terms of up to five years for possession or 14 years for dealing). This consumes a lot of police time, accounting for three-quarters of all drug offences and seizures. As the police frequently use their discretion, a wide gap has opened up between law formulation and practice. The Police Foundation recently recommended that cannabis be reclassified as Schedule 2 (allowing medical use) and Class C (reducing the penalties involved). Indeed they stated: 'The evidence strongly indicates that the current law and its operation creates more harm than the drug itself'.[7]

Cannabinoids as medicines

We need to know if cannabis's potential benefits outweigh its risks. How does it compare with the alternative treatments available? The recent BMA review concluded: '...cannabis itself is unsuitable for medical use, (but) individual cannabinoids have a therapeutic potential in a number of medical conditions (see table) in which present drugs or other treatments are not fully adequate... present evidence indicates that they are remarkably safe drugs with a side-effect profile superior to many drugs used for the same indications'. They further stated that such therapeutic use should be confined to cannabinoids given as a tincture, oil or aerosol.[8] While two orally psychoactive cannabinoids (nabilone and dronabinol) can be prescribed legally in the UK, slow onsets of action and plasma level variability limit their therapeutic roles.

Evidence for effectiveness

Reasonable evidence Analgesic Antiemetic Appetite stimulant Muscle relaxant

Non-medical use of cannabis

Major obvious effects of cannabis.

The effects of cannabis depend on the amount and mode of use and the user's expectations and mood. When smoked the effects begin in a few minutes and last up to one hour with low doses or two to three hours with high doses. The most obvious effects of being 'stoned' are being relaxed, talkative and laughing easily (giggly and silly in naive users), followed by 'sleepiness' (folloed by sleepiness). Users may experience 'the munchies' (hunger) and heightened sensory perception (eg colours or music). Sometimes they have difficulty in thinking, problem solving, walking or remembering the immediate past. Some users also become anxious, suspicious or paranoid and panic attacks can be precipitated. At high doses hallucinations may occur. Chronic use leads to a prolongation of these effects, often in association with low energy and poor motivation, work or educational performance. Perhaps five to ten percent of regular users become addicted, finding it difficult to stop and experiencing a mild withdrawal syndrome when they do.

Comparison of cannabis with alcohol and cigarette smoking

Both alcohol and cannabis are often used for their intoxicating and euphorant effects. Both produce many similar effects on the brain although those due to cannabis are typically milder. Admittedly, chronic heavy cannabis use does not cause the range of problems that alcohol does (eg brain damage and liver cirrhosis). With the exception of nicotine and cannabinoids, cigarette and cannabis smoke contain the same toxic constituents. However, cannabis smoke contains a substantially higher proportion of particulate matter; more carcinogens and tar are inhaled longer and more deeply, causing increased daily cough, phlegm and wheezing, in addition to chronic respiratory disease such as chronic bronchitis. Tobacco smoking causes cancers and has toxic effects on the heart; as it is so similar, cannabis smoke probably also causes these. If the two are smoked together, the rate of damage is further accelerated.[10]

Cannabis is not a harmless drug. This is not disputed. Experts are also of the opinion that it is less harmful than the other main illicit drugs. 'When cannabis is systematically compared with other drugs against the main criteria of harm (mortality, morbidity, toxicity, addictiveness and relationship with crime), it is less harmful to the individual and society than any of the other major illicit drugs or than alcohol and tobacco.'[11] Overall these reports agree that cannabis or cannabinoids should be legalised for medical use and that there are strong arguments to reduce the penalties associated with its use. A recent internet survey of nearly 1,000 doctors found 54 percent thought the law on cannabis was too strict and only about 12 percent thought it was not strict enough.[12]

God gave us reward systems in our brains so that we could enjoy the good things in life. Drugs of abuse interact with these natural reward systems and addiction is a sign that they have been 'hijacked', resulting in reduced control over their use. As Christians we serve only one master and should seek help if another begins to gain control. We choose not to support the distribution of drugs by potentially violent criminal gangs and oppose the glamourisation of any drug of addiction. We are aware that our body is the temple of the Holy Spirit, to be kept pure and holy. The Bible advises against intoxication with alcohol[13] and no doubt the same should apply to cannabis. Furthermore, we must not do anything that might make our brother stumble, in order to reflect more fully the glory of Christ. Overall we need to support strategies which ensure that those patients who will benefit from cannabis's therapeutic properties can have access to it, whilst at the same time dispelling myths, increasing awareness of its harmful effects and actively discouraging its harmful use.

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• EMCDDA (European Monitoring Centre for Drugs and Drug Addiction). Annual report on the state of the drugs problem in the European Union . Luxembourg: Office for Official Publications of the European Communities, 1999
• BMA (British Medical Association). Therapeutic uses of cannabis . Amsterdam: Harwood Academic Publishers, 1997
• IOM (Institute of Medicine). Marijuana and medicine : assessing the science base. Washington DC: National Academy Press, 1999
• WHO (World Health Organisation). Cannabis: a health perspective and research agenda . Geneva: WHO, 1997
• House of Lords Select Committee on Science and Technology. Cannabis: the scientific and medical evidence . London: HMSO, 1998:151
• Police Foundation. Drugs and the Law: Report of the Independent Inquiry into the Misuse of Drugs Act 1971. London: The Police Foundation, 2000
• BMA. Op cit :77-78
• IOM. Op cit :101
• Hall W, Solowij N, Lemon J. The health and psychological consequences of cannabis use. National Drug Strategy Monograph Series No.25. Canberra: Australian Government Publishing Service, 1995
• Police Foundation. Op cit :103
• www.Medix-uk.com
• Proverbs 23:29-35; Ephesians 5:18; 1 Peter 4:3-4

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The Evidence—and Lack Thereof—About Cannabis

Research is still needed on cannabis’s risks and benefits. 

Lindsay Smith Rogers

Although the use and possession of cannabis is illegal under federal law, medicinal and recreational cannabis use has become increasingly widespread.

Thirty-eight states and Washington, D.C., have legalized medical cannabis, while 23 states and D.C. have legalized recreational use. Cannabis legalization has benefits, such as removing the product from the illegal market so it can be taxed and regulated, but science is still trying to catch up as social norms evolve and different products become available. 

In this Q&A, adapted from the August 25 episode of Public Health On Call , Lindsay Smith Rogers talks with Johannes Thrul, PhD, MS , associate professor of Mental Health , about cannabis as medicine, potential risks involved with its use, and what research is showing about its safety and efficacy. 

Do you think medicinal cannabis paved the way for legalization of recreational use?

The momentum has been clear for a few years now. California was the first to legalize it for medical reasons [in 1996]. Washington and Colorado were the first states to legalize recreational use back in 2012. You see one state after another changing their laws, and over time, you see a change in social norms. It's clear from the national surveys that people are becoming more and more in favor of cannabis legalization. That started with medical use, and has now continued into recreational use.

But there is a murky differentiation between medical and recreational cannabis. I think a lot of people are using cannabis to self-medicate. It's not like a medication you get prescribed for a very narrow symptom or a specific disease. Anyone with a medical cannabis prescription, or who meets the age limit for recreational cannabis, can purchase it. Then what they use it for is really all over the place—maybe because it makes them feel good, or because it helps them deal with certain symptoms, diseases, and disorders.

Does cannabis have viable medicinal uses?

The evidence is mixed at this point. There hasn’t been a lot of funding going into testing cannabis in a rigorous way. There is more evidence for certain indications than for others, like CBD for seizures—one of the first indications that cannabis was approved for. And THC has been used effectively for things like nausea and appetite for people with cancer.

There are other indications where the evidence is a lot more mixed. For example, pain—one of the main reasons that people report for using cannabis. When we talk to patients, they say cannabis improved their quality of life. In the big studies that have been done so far, there are some indications from animal models that cannabis might help [with pain]. When we look at human studies, it's very much a mixed bag. 

And, when we say cannabis, in a way it's a misnomer because cannabis is so many things. We have different cannabinoids and different concentrations of different cannabinoids. The main cannabinoids that are being studied are THC and CBD, but there are dozens of other minor cannabinoids and terpenes in cannabis products, all of varying concentrations. And then you also have a lot of different routes of administration available. You can smoke, vape, take edibles, use tinctures and topicals. When you think about the explosion of all of the different combinations of different products and different routes of administration, it tells you how complicated it gets to study this in a rigorous way. You almost need a randomized trial for every single one of those and then for every single indication.

What do we know about the risks of marijuana use?  

Cannabis use disorder is a legitimate disorder in the DSM. There are, unfortunately, a lot of people who develop a problematic use of cannabis. We know there are risks for mental health consequences. The evidence is probably the strongest that if you have a family history of psychosis or schizophrenia, using cannabis early in adolescence is not the best idea. We know cannabis can trigger psychotic symptoms and potentially longer lasting problems with psychosis and schizophrenia. 

It is hard to study, because you also don't know if people are medicating early negative symptoms of schizophrenia. They wouldn't necessarily have a diagnosis yet, but maybe cannabis helps them to deal with negative symptoms, and then they develop psychosis. There is also some evidence that there could be something going on with the impact of cannabis on the developing brain that could prime you to be at greater risk of using other substances later down the road, or finding the use of other substances more reinforcing. 

What benefits do you see to legalization?

When we look at the public health landscape and the effect of legislation, in this case legalization, one of the big benefits is taking cannabis out of the underground illegal market. Taking cannabis out of that particular space is a great idea. You're taking it out of the illegal market and giving it to legitimate businesses where there is going to be oversight and testing of products, so you know what you're getting. And these products undergo quality control and are labeled. Those labels so far are a bit variable, but at least we're getting there. If you're picking up cannabis at the street corner, you have no idea what's in it. 

And we know that drug laws in general have been used to criminalize communities of color and minorities. Legalizing cannabis [can help] reduce the overpolicing of these populations.

What big questions about cannabis would you most like to see answered?

We know there are certain, most-often-mentioned conditions that people are already using medical cannabis for: pain, insomnia, anxiety, and PTSD. We really need to improve the evidence base for those. I think clinical trials for different cannabis products for those conditions are warranted.

Another question is, now that the states are getting more tax revenue from cannabis sales, what are they doing with that money? If you look at tobacco legislation, for example, certain states have required that those funds get used for research on those particular issues. To me, that would be a very good use of the tax revenue that is now coming in. We know, for example, that there’s a lot more tax revenue now that Maryland has legalized recreational use. Maryland could really step up here and help provide some of that evidence.

Are there studies looking into the risks you mentioned?

Large national studies are done every year or every other year to collect data, so we already have a pretty good sense of the prevalence of cannabis use disorder. Obviously, we'll keep tracking that to see if those numbers increase, for example, in states that are legalizing. But, you wouldn't necessarily expect to see an uptick in cannabis use disorder a month after legalization. The evidence from states that have legalized it has not demonstrated that we might all of a sudden see an increase in psychosis or in cannabis use disorder. This happens slowly over time with a change in social norms and availability, and potentially also with a change in marketing. And, with increasing use of an addictive substance, you will see over time a potential increase in problematic use and then also an increase in use disorder.

If you're interested in seeing if cannabis is right for you, is this something you can talk to your doctor about?

I think your mileage may vary there with how much your doctor is comfortable and knows about it. It's still relatively fringe. That will very much depend on who you talk to. But I think as providers and professionals, everybody needs to learn more about this, because patients are going to ask no matter what.

Lindsay Smith Rogers, MA, is the producer of the Public Health On Call podcast , an editor for Expert Insights , and the director of content strategy for the Johns Hopkins Bloomberg School of Public Health.

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Should cannabis be legalised in the UK?

Should cannabis be legalised in the UK?                                                                       Clare Kelly

 This question has been asked for many years and still the government has not made a decision on whether cannabis should be legalised in the UK.

 Cannabis, weed, grass, hemp, shit, ganga, marijuana; they are all the same. Completely harmless, and completely misunderstood. 260 million people worldwide use it for its potential advantages. Those who don’t use it, in my opinion, are missing out. In 1973, the drug was banned from use in Britain, much to the dismay of its users. Since then up to now, people have fought for the right to use it as a drug, unsuccessfully.

 Many people believe that cannabis has a worse effect on the user than tobacco in cigarettes. This is untrue.

 One argument is that smoking cannabis when young can lead upto mental health problems such as schizophrenia, paranoia and depression. If it is smoked before the age of 14 it is more likely for the user to have these problems later in life. But shouldn’t this be upto the people who want to smoke cannabis? If they don’t mind taking a risk then I say let them. Just like when people smoke cigarettes they are taking the risk of getting lung cancer, but that choice is theirs and yet cigarettes are legal.

This is a preview of the whole essay

 However cannabis is definitely 10 times worse for the lungs when mixed with tobacco, but alone, cannabis is a lot less harmful. When smoking cigarettes you are getting tar and many of the other chemicals in your lungs, but when smoking cannabis you don’t get anywhere near as much chemicals in your body that will effect it in a bad way. Tobacco contains over 2000 other chemicals, such as tar and nicotine, which effect the body in negative ways. Alcohol is also worse for the body than cannabis but yet that has been made legal. Alcohol not only effects the body in the long term, but there is also the risk of drink driving. A lot more people die from drink driving and cigarettes, than from smoking cannabis. Another major point is that cigarettes and alcohol are addictive, whereas, it is impossible to become physically addicted to cannabis. You cannot over-dose on cannabis, and people who die after taking it, die from there own stupidity.

 One problem with legalising cannabis is that if it were legalised, the tobacco companies would jump at the chance to produce tobacco based reefers so they could get more young people addicted to smoking tobacco.

 However, if someone buys some cigarettes, they are buying them for the pleasurable effects that come with them. If they are buying cannabis, they are buying it for exactly the same reason. There would be no point for people to buy cigarettes that contained cannabis, as the cannabis can give them the same effects. I think that the customers would be drawn towards cannabis, as its effects are less harmful.

 Another argument against the legalisation of the drug is that users of cannabis would move on to using hard-core drugs instead. The government has done close to no research into whether cannabis users would move onto harder drugs such as heroine. The main reason people think this is because they believe that doing soft drugs, moves you onto hard drugs. Most heroine addicts smoked cannabis, therefore they think that most cannabis users will go on to use heroine. I don’t believe this at all. In some cases it may be true but if people are stupid enough to go on to do heroine then that is there own fault. Most people know the consequences of moving onto harder drugs and so I don’t think cannabis users would necessarily move onto it.

 Some people also believe that if cannabis was legalised the amount of violent crime in this country would rise. Alcohol is the country’s problem drug and is responsible for a large amount of violence. Most cannabis users drink little or no alcohol. For them, the drug is an alternative to alcohol, and not an addiction.

 If marijuana is not legalised for public use, then I believe doctors should be allowed to prescribe the drug to patients that really need it. I heard that it can be useful in the treatment of cancer, glaucoma, AIDS, multiple sclerosis, epilepsy and chronic pain. If this is true then it could save the NHS a fortune, if they were to allow doctors to prescribe reefers in the place of other painkillers.

 Arresting people for carrying the drug is stupid as far as I’m concerned. What good does imprisonment do to those people? It doesn’t teach them the mistake they made. Nor does it change the way they think. And it definitely doesn’t mean that when they leave prison they won’t smoke the drug again. Prisons are overcrowded as it is, without having more people squashed into them just because they were having a smoke.

 Keeping cannabis illegal is also endangering the lives of some of the people who want to smoke the drug. If people want the drug they have to take a risk. If cannabis was open to public use in the same way that tobacco is, the users would not be threatened by illegal suppliers. For example, the small amounts of people, who apparently die from the effects of cocaine are actually dead because they have snorted soap powder. Obviously this isn’t true for everyone but to some people it can happen. If cannabis was legalised not only would it give the public confidence to know that any cannabis available to them or their family was quality controlled, but also drawing the line between a soft drug like cannabis and a hard drug like Heroin would gain the authorities a lot more credibility with young people.

 Most importantly, unlike cigarettes, cannabis only endangers the user and not the ‘innocent’ public, so if someone wants to take the drug why should anyone else stop them? Legalising cannabis could mean more control over its use. Price, strength and quality could all be regulated.

 It is not the danger that makes cannabis illegal; it is the misinformed people who prevent it from being legalised.

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With Germany legalising cannabis, Europe is reaching a tipping point. Britain, take note

Regulating cannabis use is no longer radical but an increasingly normalised strategy. The ‘tough on drugs’ approach is archaic

G ermany’s cannabis reforms were approved this week, overcoming the final legislative hurdle when the Bundesrat, Germany’s upper house, voted through the bill that passed with a huge majority in the Bundestag (lower house) last month. Germany is a significant addition to the growing list of countries defecting from the drug war consensus that had held for more than half a century. More than half a billion people now live in jurisdictions establishing legal adult access to cannabis for recreational use.

When Germany’s new law comes into force on 1 April, it will decriminalise possession of up to 25g of cannabis for personal use (and up to 50g in the home), allow requests to remove criminal records for past possession offences, legalise home growing of up to three cannabis plants for personal use, and establish a regulatory framework for not-for-profit associations within which cannabis can be grown and supplied to members.

When the cannabis reforms were initially announced by Germany’s coalition government in 2021, the plan was for a regulated commercial market more like Canada’s, established in 2018. A study has suggested that such a commercial market could create 27,000 jobs in Germany, and be worth €4.7bn annually in tax revenue and criminal justice savings. But these aspirations had to be reined in when it became clear that the commercial market originally envisaged would probably breach legal obligations under the UN drug conventions, as well as EU law.

Instead, Germany has opted for a form of “legalisation-lite” that provides channels for legal access via home growing or not-for-profit associations while, it hopes, avoiding the minefield of international law that a commercial market would have led to. A similar retrenchment has occurred with reforms in the Czech Republic and Luxembourg . All three countries have moderated their plans and essentially copied Malta, Europe’s unlikely cannabis reform pioneer, whose groundbreaking non-commercial home-grow and cannabis association model passed in 2021, becoming the blueprint for the new wave of EU reforms.

But while Malta has made clear that its not-for-profit model is a deliberate harm-reduction strategy to avoid risks of “big alcohol”-style over-commercialisation and corporate monopolies, Germany and other EU countries have unambiguously positioned their new models as a transitional step to a future of commercial retail, albeit more responsibly regulated . Germany has already announced that it will proceed with phase two of its cannabis plan, in the form of a time-limited retail “pilot study” in a number of cities. Like similar “experiments” under way in the Netherlands and Switzerland , it hopes to finesse the constraints of international law under the banner of “scientific research”.

But as the debate about the merits of different cannabis policy models plays out in a globe-spanning natural experiment, from 24 US states, Canada and Uruguay to South Africa, Mexico and parts of Australia, Germany’s move feels particularly consequential. More than 100 times the population of Malta or Luxembourg, and sitting at the heart of the European establishment, Germany has the economic and political influence to significantly reorient laws and thinking about drug policy in the EU and the wider international stage.

This influence is inevitably being felt in the UK as well. As longstanding arguments for reform move from theory into reality in respected neighbour states, they become harder to ignore and increasingly permeate the national consciousness. Why continue to waste billions on failed enforcement when we could generate billions in tax revenue like Colorado? Why drive 100% of cannabis users towards organised crime groups and street dealers, when about 70% of cannabis users in Canada buy their cannabis from licensed stores? Why should people have to buy dodgy street cannabis of unknown potency, when they can join a legal association and buy quality controlled products with mandated information on contents and risks, as in Malta or Germany? Why maintain policies that disproportionately criminalise Black people and overload our creaking criminal justice system, when we could redirect enforcement spending and tax revenue into community programmes benefiting those most affected by the “war on drugs”, as they do in New Jersey or Massachusetts ?

Endorsement of responsible cannabis regulation is increasingly normalised and mainstream. It is no longer a radical position but a pragmatic one, with real-world examples to prove it. And while Labour and the Tories, with an election looming, lack the courage to move beyond tired “tough on drugs” posturing, public backing for legalisation continues its inexorable rise, with polling now indicating majority support . As support for a reform platform becomes a political asset rather than a political liability, positions long held in private by those in power will increasingly emerge in public.

With London’s support for cannabis legalisation topping 60% , for example, its mayor, Sadiq Khan, has started openly exploring reforms . In the absence of principled political leadership from the government, change may boil down to this cold political calculus. We are fast approaching the tipping point and Germany’s reforms can only add to the momentum.

Steve Rolles is the senior policy analyst for Transform Drug Policy Foundation .

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