A nation in pain

 
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On a cold April morning, six years ago, Victor Caprio stood at the summit of Mount Warning, northern NSW, throwing his father’s ashes over the lookout rails. Rumoured to be the first location on mainland Australia to see the sunrise, Caprio had carefully chosen this spot as his father’s final resting place.

“My dad was in excruciating back pain and all he wanted was some relief,” Caprio, 34, told me. “But when he asked his doctors for some medicinal cannabis to help with the pain, the doctors wouldn’t prescribe it. The doctors were like, ‘Have some opioids instead’.”

Caprio’s father was living in Canada when the forklift he was operating flipped over, causing a back injury that prevented him from returning to work.

“It was a downward spiral after that,” Caprio said. “He suffered terrible mood swings and had constant headaches and all he wanted to do was sit on the couch.”

Seeing how the increasingly large dosage of opioids that doctors were prescribing was adversely affecting him, one of Caprio’s father’s friends gave him some marijuana to try. “It really helped,” Caprio said. “He liked the fact it was a natural organic plant and, more importantly, he didn’t have to take as many painkillers.”

Caprio migrated from Canada to Australia and when his father died suddenly at the age of 50, Caprio had not seen him for over three years.

“There is no doubt in my mind that the opioids contributed to his death,” Caprio said. “My father was stressed out, depressed, and taking too many prescription medications.”

Since 1989 it has been technically possible in Australia to import and prescribe medicinal cannabis for individual patients; however, in practice this has been extremely rare. It wasn’t until 2008 that the first application to prescribe medicinal marijuana was approved in Australia, and over the proceeding eight years only three applications on average were approved nationwide per annum.

Things changed in February 2016 when the Federal Government, with bipartisan support, made amendments to the Narcotics Drug Act of 1967, allowing the Department of Health to regulate the cultivation of cannabis for medicinal and scientific use. The following month the Therapeutic Goods Order No. 93 came into effect, setting out the standards for medicinal marijuana and, in November 2016, the Therapeutic Goods Administration downgraded medicinal cannabis products from Schedule 9 (Prohibited Substance) to Schedule 8 (Controlled Drug).

These cumulative changes meant that, for the very first time, a legalised medicinal cannabis industry could be established in Australia.

By this stage, Caprio had built a successful career as a real estate agent in Surfers Paradise, Queensland. Nonetheless, recognising an opportunity, he quit his job, pooled his savings and founded PharmaCann, a biotech company whose aim is to produce and provide natural botanical cannabinoids for pain relief.

According to Pain Australia, pain is the number one reason people seek medical help[1]. Research has shown that an estimated 29 per cent of Australians suffer from chronic pain[2]. A widely used mainstay of treatment involves the prescription of opioids—Endone, OxyContin and the like—which act on the central nervous system to reduce pain impulses reaching the brain. However, these drugs can cause a number of side-effects including drowsiness, constipation, nausea, respiratory depression, mood changes and physical dependence. Following trends in the US, both Australia and New Zealand are seeing a worrying increase in prescription opioid addiction.

Figures from the Australian Bureau of Statistics show that opioids have been the leading cause of all drug-induced deaths in Australia, including those caused by alcohol, for the past 17 years[3]. In 2016 nearly three-quarters (1353 out of 1808) of drug-induced deaths involved the usage of opioids. And nearly three-quarters of these deaths involved prescription opioids rather than heroin, their illicit equivalent.

In comparison, the number of recorded people worldwide who have ever died of a marijuana overdose is zero[4].

A clinical review of medicinal marijuana published in the Journal of the American Medical Association found that “Use of marijuana for chronic pain . . . is supported by high quality evidence[5]” and a recent report by the National Academies of Sciences, Engineering and Medicine stated that “There is conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment of chronic pain in adults.[6]” In addition, research in the United States shows that the availability of medicinal cannabis can potentially reduce opioid overdose mortality rates[7].

Despite this, the use of medicinal cannabis, especially for chronic pain, remains a contentious issue within the medical community.

“There are those that feel medicinal cannabis is worse than the tobacco industry 50 years ago, and those who believe this is eventually going to be a science-led advancement of a molecule with clear physiological properties,” says anaesthetist and Director of Pain Services at Toronto General Hospital in Canada, Assistant Professor Hance Clarke. He believes medicinal cannabis can help with a number of conditions, including epilepsy, chronic pain, post-traumatic stress disorder and anxiety.

“For chronic inflammatory diseases such as psoriatic arthritis, medicinal cannabis has been an excellent choice over an opioid, without the dependence issues,” he says. “There is already data suggesting that patients are preferring to substitute prescription opioids with medicinal cannabis”.

Even with the recent legislative changes, the option of switching to medicinal cannabis remains limited in Australia, with a mere 266 individual patients being given approval to use medicinal cannabis as of September 2017. To obtain approval, the prescribing doctor has to submit a detailed report for each patient, outlining the condition being treated, previous medications used, why the practitioner believes the currently available medications are inadequate for the patient, and the proposed dose, strength and route of administration of the medicinal cannabis being applied for.

And that is before the individual state and territory barriers come into play, with each jurisdiction having their own individual requirements for approval.

In Queensland for example, an application for an individual patient must be made to Queensland Health by a specialist or, if by a GP, with a specialist’s written support. The applying medical practitioner must have participated in formal education on medicinal marijuana prescribing; they must have counselled and obtained the patient’s written consent about the potential risks and conditions of using medicinal cannabis, including the inability to drive; they must give details on the condition being treated, present therapies being tried and past therapies tried; they must give evidence for why they believe medicinal cannabis would be of benefit to the patient and their plans for ongoing monitoring. Approval, if given, is valid for only 12 months and the doctor is expected to review the patient at least once every three months.

Many doctors who work with chronic pain patients find these regulations excessive and cumbersome. Gold Coast-based general practitioner Dr Mark Jeffery has many chronic pain patients whom he is trying to wean off opioids and believes that Australia has an overly demanding process for prescribing cannabis.

“You can’t just tell someone in pain to go and do yoga,” said Jeffery. “I had a patient who broke his patella and required wires to be put in, who was in so much pain he was on 240 mg of OxyContin. He was dopey from the meds and ended up losing his job. He went back to Poland and sourced some hashish and he’s now down to 60 mg of OxyContin.”

However, not all doctors are supportive of medicinal marijuana.

“The trials that have been done suggest that any benefits in chronic pain would be very modest and likely to be outweighed by the harms,” Australian chronic pain specialist and Faculty of Pain Medicine Dean, Dr Chris Hayes, said when I spoke to him following his attendance at a Department of Health meeting on the use of cannabis for chronic pain. “More often treating chronic pain is about stopping medications, not adding medications,” he added.

Hayes estimates that about 20 per cent of patients in his own clinic are taking illicit cannabis for their pain; his clinical impression is that it works poorly.

“People take it in the hope that it might improve their pain or calm their mental health, but that’s offset by the fact that, from a mental health perspective, it might make things worse.”

Other doctors have a pragmatic perspective. Emergency medicine specialist and lecturer at the Australian National University’s medical school, Dr David Caldicott, teaches a course for doctors on medicinal cannabis. He says there is little point arguing whether cannabis can help with chronic pain.

“The more important point is that people are using it for pain,” he said. “There’s still an awful lot for us to know, but in the interim, it’s probably unethical and immoral of us to prevent it happening.”

For the foreseeable future, medicinal cannabis in Australia will not be subsidised under the Pharmaceutical Benefits Scheme, which means many Australians, even if they can be prescribed medicinal marijuana, may not be able to afford it. With this in mind, Caprio is founding a charitable organisation that will work to provide vulnerable patients with affordable medicinal cannabis.

“I got into this industry to make a difference,” he said. “I believe it is a human right to have access to a medicine that can help relieve a condition and it means the world to me to be able to support this cause.”

I asked Caprio if he thought his father would be proud of what he has done so far.

Caprio paused. Then smiled.

“Yes,” he said. “Yes he would.”

 

Suvi Mahonen is a writer and former News Corp journalist based in Surfers Paradise, Qld. This article first appeared in Australian Quarterly. Used with permission of the author.

 

[1] http://www.painaustralia.org.au/about-pain/painful-facts

[2] https://www.aipc.net.au/articles/chronic-pain-definition-statistics-and-causes/

[3]http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2016~Main%20Features~Drug%20Induced%20Deaths%20in%20Australia~6

[4] http://www.huffingtonpost.com.au/entry/marijuana-lethal-dose_us_58f4ec07e4b0b9e9848d6297

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

[6] https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state

[7] https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1898878