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Cannabis, Medical Research, and the Treatment of Pain in Canada

Cannabis, Medical Research, and the Treatment of Pain in Canada:
Some Historical Perspectives on a Drug that Never Became a Modern Medicine

Pierre Beaulieu, MD, PhD
Department of Pharmacology
Université de Montréal and Department of Anaesthesiology, CHUM,€“ Hí´tel-Dieu, Montréal

Laurence Monnais, PhD
Department of History, Canada Research Chair in Healthcare Pluralism, MEOS Team
Université de Montréal, Montréal

Correspondence to: Laurence Monnais, CETASE, Université de Montréal, C.P.6128 Succ. Centre-ville, MONTREAL, QC, CANADA H3C 3J7
Tel: (514) 343-6544 – Fax: (514) 343-7716
Email : laurence.monnais-rousselot@umontreal.ca

Abstract

Pain is still poorly treated, despite its emergence as a significant public health issue. Cannabis has a long history as a therapeutic substance, particularly for pain relief; yet its use remains both controversial and marginal despite recent data tending to show that it is not just promising but in certain circumstances truly effective in pain treatment. In fact, even further upstream, research on cannabis and on its therapeutic use remains fraught with difficulties. In Canada, the lack of funding for projects in this field is one of the clearest indicators of what appears to be a shared reluctance on the part of both public funding institutions and health professionals. By adopting a historical approach, we identify some of the obstacles that might account for the enduring roots of this double resistance. We will focus on thethree following factors that developed in the latter half of the 19th century: the dual construction of toxicity (in therapeutics) and of addiction (and of addictive drugs), the emergence of modern pharmaceuticals, and the development of a close relationship between the State and healthcare professionals. Because historical processes have made cannabis into a “non-medicine,”€ it is not currently considered to be a valid subject of clinical research, nor can it be medically prescribed in the vast majority of Western countries. Yet, in this era of evidence-based medicine,it is important to wait for well-conducted clinical studies and their results before knowing whether the therapeutic use of cannabis and its derivatives is possible or not.

Key Words: cannabis; pain; opioids; legislation; pharmaceuticals; Canada

Introduction

Pain, which is defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage€ (1), is currently the most frequently encountered clinical symptom; it has been found to be the reason for more than 40 million consultations per year in the United-States and for more than 50% of all medical emergency consultations (2). Canadian data, obtained from a sample of 2000 adult patients, indicate that non-cancerous chronic pain is reported by 29% of the population; in 80% of cases, this pain is judged to be moderate or severe (3).

Although pain has protective and warning functions that arecrucial for leading a “normal”€ life, persistent and poorly relieved pain is no longer considered to be a symptom but rather to be an illness in itself. Recent public declarations, such the following statement by Human Rights Watch (4), echo this recognition of pain as a major public health issue: €œAllowing millions of people to suffer unnecessarily when their pain can be effectively treated violates their right tothe best possible health.€ Chronic pain in particular is seen as a growing epidemic (5); meanwhile the World Health Organization (6) states that 80% of the world’€™s population does not have access to pain treatment. The study by Moulin et al. (3) thus shows that strong opioids are prescribed in fewer than 10% of pain cases. The authors not only reveal an inadequate treatment of pain, but point out its negative social impact, which they have found to significantly affect 50% of patients.

Besides, innovations in the treatment of pain result less from the discovery of new substances than, more often, from improvements in the use of available analgesics, through a better understanding of their mechanism of action and the emergence of a so-called multimodal approach consisting of the administration of a combination of analgesic agents. From this new perspective, the clinical use of cannabis seems particularly promising in offering a therapeutic option that might complement or even synergize current drug treatment protocols, but also in minimizing side effects associated with the most powerful drugs, i.e. opioids such as morphine. In this article, we intend to review the current status of cannabis as a pain medicine in Canada before putting it in a larger historical perspective of de-medicalization of cannabis worldwide in order to better apprehend what is at stake both locally and more globally speaking.

1. Cannabis, medicine and research

Cannabis: identity and challenges
Cannabis, or marijuana [Endnote A], is a plant with more than100 known varieties, but these all derive from the single Cannabis sativa species, described in 1753 by Carl von Linné. The earliest testimonies describing the use of the plant Cannabis sativa, also known as Indian hemp (Cannabis indica), date back to over 12,000 years ago; these concern the production of clothes and rope. Egyptian, Chinese (2,700 BC) and Assyrian (800 BC) sources also allow us to suppose that cannabis is probably one of the oldest medicines in human history. Over the centuries, it was prescribed for the treatment of pain, asthma and dysentery; it was also used to treat insomnia, nausea, migraine and vomiting, and recommended in cases of spasms and convulsions.

However, cannabis has only been known to Western medicine for a relatively short time. Actually, it is with the publication of a treaty in 1839 by W.B O’Shaughnessy, an Irish doctor serving in the British army in India, that cannabis made its entry into Western therapeutics (7). Having found cannabis to be effective but also remarkably safe in the treatment of wounded soldiers, O’€™Shaughnessy advocated its introduction in England and other European countries (8,9). Nevertheless, from the end of the 19th century, medical interest in cannabis seems to have started to decline, both in Europe and North America.

The isolation and the synthesis of cannabis’s main psychotropic component, Δ9-tetrahydrocannabinol (Δ9-THC) in 1964 (10) was the first major pharmacological breakthrough leading towards a modern understanding of the substance action and, eventually, its targeted therapeutic uses in the 20th century. About 60 related substances belonging to the cannabinoid family have since been described and other important steps have contributed to a better understanding of cannabis, notably the discovery of two cannabinoid receptor sub-types, CB1 and CB2, and of the existence of endogenous cannabinoids (or, endocannabinoids) which regulate many physiological systems in our organism (11,12). These advances, which revealed the substance’€™s great complexity but also its therapeutic potential, have, understandably, motivated researchers and clinicians to determine the specific role of cannabis in the treatment of various illnesses and symptoms, including pain. On the clinical level, many studies have focused on cannabis and synthetic cannabinoids in the treatment of various pain syndromes; the results have generally been encouraging (13).

In this era of evidence-based medicine, cannabis and cannabinoids must be subjected to a systematic research process to determine their efficacy and their lack of serious, undesirable effects. Focused on the field of pain, the current overview indicates that clinical studies on the analgesic properties of cannabis and its derivatives have only just begun. Numerous paths have yet to be explored.

Evidence-based medicine and adequate financing: the Canadian case
The actual focus on Canada is important because it is one of the rare countries in the world where medical cannabis has recently been allowed under certain circumstances. In doing so, Canada has indeed acted as an open and progressive country, encouraged in this scenario by many pressure groups and also political debates on this issue, not to mention the Nolin report published in 2002 (14). At the same time obstacles for the development and financing of medical cannabis, that are not specific to Canada but more global, are present. The problem of illegal drugs is central to the international legislation and it participates in health protection of individuals and populations. Furthermore, it is an ethical issue [Endnote B].

If we look at the Canadian example, it is clear that, in recent years, cannabis has not received a great amount of attention on the part of the scientific and medical research community. Even for the few researchers whose attitudes seem to have evolved, numerous barriers remain. For instance, any study including cannabis or its derivatives, whether it is clinical or fundamental, must be authorized by the government (15). Here, we clearly see the impact of issues arising in the case of medicines that are also defined as drugs by law, as well as, to some extent, in the minds of individuals. As noted by Gostin (16), “€œregulation of the use of marijuana for medical purposes is feasible and socially desirable, but it will require a different way of thinking about the problem. It requires viewing marijuana as a potential medication subjectto carefully controlled research, rather that as a drug of strict prohibition.”

If we look at the grants provided for clinical research on cannabis during the last decade or so, it may seem as if many large-scale projects have been launched across Canada. For example, in 1999, a research group in Toronto obtained a 2.5 million dollar grant to study the effects of cannabis on people with AIDS. In 2001, a Pan-Canadian research plan provided 7.5 million dollars of funding, over 5 years, to the Medical Marijuana Research Program (MMRP), supervised by the Canadian Institutes of Health Research (CIHR), in partnership with Health Canada. As this program has the particularity of funding only projects involving smoked cannabis, the company “Prairie Plant Systems Inc.” was conjointly mandated to provide the federal government with quality cannabis, through standardized production. In July 2001, 235,000 dollars were provided through the MMRP for a pilot study on the effects of smoked cannabis on chronicneuropathic pain. In January 2003, Health Canada launched the Marijuana Open Label Safety Initiative (MOLSI) aiming to encourage the long term follow-up of users of cannabis for medical purposes (17). Within this context, the multicentre COMPASS study, conducted in seven Canadian sites and led by Dr. Mark Ware at McGill University, received significant funding.

However, despite the theoretical availability of funds, as well as a seemingly favorable political climate -initially at least- and a real potential for the medical use of cannabinoids, disaffection and retractions soon jeopardized the fulfillment of these large-scale projects. Therefore, for example, the original grant to the Toronto research group was cut by more than half. A direct consequence of this was the resignation of Dr. Gregory Robinson, member of the Office of Cannabis Medical Access (OCMA), a decision he justified by denouncing the incoherence of a government that, on one hand, insisted on the importance of an evidence-based evaluation of the therapeutic use of cannabis, but which then obstructed the performance of the very clinical studies necessary for testing (18). In addition, the pilot study on smoked marijuana financed by the CIHR in 2001 experienced long delays in patient recruitment due to bureaucratic problems affecting access to the marijuana delivered by Health Canada. As for the COMPASS study, which has faced similar problems, it has barely begun despite the fact that its acceptance was granted in 2004.

What seems obvious right now is that the access to smoked marijuana that has been standardized primarilyfor research purposes is so restricted and problematic that few researchers are willing to persevere in this field. This loss of scientific motivation, directly related to obstacles that are institutional or even political and thus financial, was indeed pointed out in 2002 by the (summary) Report of the Senate special Committee on illegal drugs, also known as the Nolin Report: €”the current political and legal climate governing cannabis hampers thorough and objective studies”€ (14). The 8th and 10th recommendations of the Nolin Report, which capture the general tone of the document, did, however, suggest some possible solutions: “€œthat the Marijuana Medical Access Regulations be amended to provide new rules regarding eligibility, production and distribution with respect to cannabis for therapeutic purposes. In addition, research on cannabis for therapeutic purposes is essential; create a national fund for research on psychoactive substances and dependency to fund research on key issues,more particularly on various types of use, on the therapeutic applications of cannabis; the Government of Canada mandate the Canadian Centre; to co-ordinate national research and serve as a resource centre.”(14).

The Nolin Report was quickly forgotten. The first “death blow” for research on therapeutic cannabis came in June 2004 with the announcement by the CIHR that the MMRP would be suspended; the second onewould follow in September 2006 when the Conservative government was elected and decided to cut four million dollars from the same program. A strained assessment of this five-year period reveals that only two small pilot studies and one larger safety study have received financial support. Yet, data produced by such studies are needed to determine whether medical cannabis has a future or not (19). Beginning Phase III clinical studies (studies of efficacy) before conducting safety or dosage studies would be a lost cause from the start.

In addition, the lack of “€œreal research”€ threatens to further lower standards of evidence in discussions on the therapeutic potential of cannabis, as was demonstrated in the case of the so-called “€œsystematic” literature review on the use of cannabis in the treatment of pain published by the highly respected British Medical Journal in September 2001 (20). At the time, there were still very few available clinical studies with which to perform a meta-analysis on the subject, forcing the review’€™s authors to conduct a qualitative analysis instead of a quantitative one as had initially been planned. Recommendations were nevertheless provided on the role of cannabinoids in the treatment of chronic pain, even though the data were substantiated by only two studies, each one conducted with a single patient. Equally objectionable was the way in which the authors’€™ conclusions exceeded the data they analyzed, making definite assertions such as Cannabinoids are no more effective than codeine in controlling pain andhave depressant effects on the central nervous system that limit their use. Their widespread introduction into clinical practice for pain management is therefore undesirable. In acute postoperative pain they should not be used (20). The publication of this article provoked a strong reaction within the scientific community. In addition to comments on the inaccuracy of some of the collected data, criticism primarily pointed outthe lack of scientific relevance in conducting a systematic review on a subject for which there were so few randomized studies.

Our aim in this paper is to answer two related questions: first and foremost, why were so few studies finally conducted on the role of cannabinoids in the treatment of pain? And why was there such a quick reversal to an attitude of caution when it came to funding large-scale, well-planned and scientifically valid studies of a substance which is known to be potentially promising from a clinical point of view?

2. Identifying the obstacles, culturalroots and the historical lens

Current obstacles: are they new?
According to unofficial estimations, out of the nineteen grant applications submitted under the MMRP between 2001 and 2005, only one was accepted. As for immediate (seemingly, at least) obstacles, it must be pointed out that, for a long time, Health Canada stipulated that research grants be used for the study of smoked cannabis only, for the following reasons: (1) that it is the form commonly used by Canadians; and (2) that any form of cannabis other than smoked could (or should) fall under the responsibility of the pharmaceutical industry, and that the industry should therefore finance these clinical projects with its own research and development budgets. Therefore, in practice, neither public financing agencies nor any pharmaceutical company seem to have been willing to properly finance research on marijuana.

Accessibility to cannabis for research purposes and therapeutic consumption undoubtedly representsanother important barrier. In 1999, the judicial decision made in Ontario at the conclusion of a ground-breaking lawsuit recognized the right of a man affected by AIDS to consume cannabis for medical reasons (21). The Canadian government then recognized that users of cannabis for medical purposes should not be prosecuted. Thus, a clause of section 56 of the Controlled Drugs and Substances Act conferred the Federal Minister ofHealth the discretionary power to grant exemptions Health Canada 1999). On July 30th 2001, the “Marijuana Medical Access Regulations” (MMAR) guaranteed patients exemptions from prosecution for consumption of a controlled substance not authorized (whether in Canada or elsewhere else in the world) as a medicine, on the basis of the opinion of one or two physicians.

These new measures have nonetheless been deemed unsatisfactory by patients, physicians and professional medical organizations. Indeed, the issue of ensuring a supply of controlled, high-quality marijuana had not been considered. A large majority (86%) of the 200 patients with AIDS/HIV who participated in a recent survey used marijuana obtained from illegal sources, despite the existence of the MMAR. Among the reasons given for this choice were: a lack of information about the program, the poor quality of the products supplied by Health Canada, as well as the application process itself, described as expensive, confusing, intimidating and frequently associated with unexplained administrative delays (22). A survey conducted in 2004 by the Canadian Centre on Substance Abuse (CCSA) showed that 4% of Canadians aged 15 or over (about 1 million Canadians) had auto-prescribed themselves marijuana for medical reasons during the course of the year preceding the survey.

Yet, the medical community does not, in the end, really seem to react to these paradoxes. The silence observed by part of the medical community seems to echo an often divided and clearly prejudiced position that considers cannabis to be an embarrassing substance thatcannot be taken seriously. Thus, in national or international conferences on pain, it is not unusual to see participants, moderators and even speakers allow themselves to make subjective comments about cannabis, which are neither relevant nor substantiated by convincing data. Elsewhere, researchers are personally attacked for the obvious lack of significance of their choice of research subjects (pain and cannabis); this happens even on a national level, as part of the process for financing researchers’€™ salaries, or during research presentations within the context of formal academic evaluations.

How can we explain these attitudes, hesitations, and obstacles standing in the way of a medicalized access to cannabis, in Canada and elsewhere, when its efficacy, although modest, has been proven in particular for the treatment of chronic pain? We believe that, to understand this situation, we need not only to take the past, that is History, into account, but also to privilege a historical approach that would unveil the global construction, in the era of medicalization of cannabis as a non-medicine, a medicine that was enable to embody the modern healthcare systems’€™ model of the relation between illness and intervention. In other words, we do not limit ourselves to uncovering the historical trajectory of cannabis itself, but seek to identify broader factors and patterns that shaped both this trajectory and changing attitudes towards the use and study of cannabis and other therapeutic/recreational drugs. We are not the first to suggest this. What we would like to contribute to the discussion is an emphasis on a combination of three distinct but synchronous historical factors which played an important role in relegating cannabis to the rank of a “€œnon-medical”€ substance from the end of the 19th century: the dual construction of toxicity (in therapeutics) and of addiction (and of addictive drugs), the emergence of modern pharmaceuticals, and the development of a close relationship between the Stateand healthcare professionals leading to a strict regulation on a array of toxic substances. All three of these processes unfolded within the context of€“, and contributed to,€“ the assertion, from the end of the 19th century, of the biomedical model and healthcare systems as we know them today and of course of the identity of pharmaceuticals.

It is important to point out that the way in which these three significant factors interacted with and interpenetrated each other intensified their impact on current attitudes, particularly in terms of the refusal of health decision-makers,€“ and health care professionals with them, to launch a scientific, systematic and adequately financed research process aiming to guide decisions about the therapeutic uses and conditions of access to therapeutic cannabis. At the same time, these obstacles may not be the only ones: the poor funding of research on cannabis is also clearly a part of a global trend of inadequate pain research funding in Canada as recently reportedby Lynch et al. (5). These authors show in their survey that chronic pain funding in Canada is less than 1% of the total funding from the Canadian Institutes of Health Research and that it represents 0.25% of the total funding for health research. In fact, although analgesic drugs have been used for millennia [Endnote C] the excessive zeal in the control of analgesic substances (6) reveals an enduring biomedical and to a certain extent cultural- resistance to consider pain as a disease (23). But this history of resistance(s) is not the history we intend to unfold here.

The construction of a dangerous and illicit substance
The persistent confusion between the use of cannabis for medical purposes and the recreational use of an illicit substance has been identified by some researchers (19,24,25) as the key to understanding the current situation: Most cannabis research has been conducted under a paradigm of prohibition, and the study of risks is not yet balanced by much needed research on benefits. All drugs have risks. To reject the therapeutic potential of cannabis and cannabinoids on the grounds of toxicity and potential abuse is to throw the baby out with the bath water”(24). It follows that we should attempt to resituate this sense of uneasiness, in professional but also in some lay circles, €”towards cannabis within the historical construction of drugs, narcotics, but also, in parallel within the history of the international regulation of psychoactive substances, a history which will explain how its identity has become associated with social marginality, with the realms of recreation and addiction, and, of course, with the illicit. Such labels are unlikely to give or restore to cannabis a positive, much less constructive therapeutic status.

The history of narcotics regulation is relatively well known, particularly due to its significance in heralding the introduction of a series of regulations on the international scale in the spheres of public health and the management of social problems, while also highlighting the growing influence of the United States on the global scene of public health and morality. Indeed, the United States instigated the first important conference on the issue, specifically on the means of eradication of opium addiction, held in Shanghai in 1909, which was followed by another meeting in The Hague in 1912 before the League of Nations took over in 1921. The background of these meetings was a new awareness of drug addiction and its risks. Already, from the end of the 19th century, there was a shift in attitudes towards the consumption of opium or morphine which were no longer seen as romantic or forgivable. While not yet clearly defined as pathological, such practices were conjointly rejected in governmental and medical circles. Indeed, at the time, medical communities, including the Canadian one, were expressing strong opinions about the dangers of the lay consumption of all psychotropic and narcotic-containing products, including numerous secret remedies that were very popular at the time, especially for the relief of pain (26-28).

On the other hand, the emergence of prohibitive legislation towards narcotics was also a direct consequence of a condemnation, which was particularly vehement in some states and communities, of commercial and economic practices deemed to be beneath the civilizing West (and Japan), practices that were particularly exemplified by the existence of monopolies on the production and the distribution of opium. In the last quarter of the 19th century, opium was being associated with many forms of excess: colonial abuses through the development of these lucrative monopolies (29,30) and, by extension, the “intoxication”€ of populations, including colonized workers (31,32) but also White minorities working in the Tropics and prone to contamination through their physical proximity to the natives. At the time, opium had also become a symbol of depravity, the decadence of “€œthe Other”€ in various forms; an individual who chooses social marginality, the colonized native, whose uncontrolled consumption leads to death, hallucinations and suicide attempts and thus reveals his inferiority (33), or, of course, the immigrant, especially Chinese immigrants living in the United States and in Canada (34,35). This depravity was also seen as potentially contagious. Opium, and, by extension, narcotic drugs in general, a category that would soon be definedby law, thus became seen as a large-scale social threat to be combated in order to maintain national integrity and good health [Endnote D].

In this prohibitive context, underlying an inevitable moralization of modern societies (and the civilization of traditional ways of life in societies deemed inferior), cannabis was forced into a category of products which is a priori stigmatized and of which the consumption is both frowned upon and legally prohibited. This assimilation, in the case of cannabis, was an inappropriate one, in the sense that, being based on specific political intentions, it did not take into account actual patterns of consumption of the substance at the time. The Canadian Opium and Narcotic Drug Act (1920) placed within a few years strict control over opiates, marijuana, and cocaine whereas, as Carstairs writes (35), “€œthere was very little marijuana use in Canada from 1920 to 1961.”€ In 1907, colonial authorities in Cambodia and the South of Vietnam warned the French government in Hanoi about the substance’s harmful effects. From 1908 a text prohibited the consumption of cannabis in affected territories, while the importation and trade of the substance and its derivatives was limited exclusively to duly certified pharmacists,€“ traditional therapists were thus deprived of a substance which was part of their pharmacopoeia,€“ and for therapeutic use,€“ although cannabis was part of the local diet. Proponents of the ban admitted to not having evaluated the extent to which the substance was consumed locally and even to not knowing whether this consumption was “problematic”€ (33).

In 1925, cannabis was specifically added to the international list of dangerous and highly controlled narcotics despite the fact that, even then, no study had ever proved its harmfulness [Endnote E]. The tone had nevertheless been set. Thus, in 1937, the American Marihuana Tax Act clearly pointed out the risk of drug addiction associated with the consumption of cannabis and even went as far as to impose a tax on actors involved at every level of its circulation on the national scale: importers, producers, industrial users, commercial brokers but also prescribers such as physicians and dentists. By that time, it had already been about fifteen years since cannabis had already been added to drug legislation in Canada (1923), without any discussion or preliminary debate there either (35). The first United Nations Convention on narcotics of 1961, and the next one in 1971 stipulated that cannabis and its derivatives be added to the list of narcotics (Schedule 1), plainly indicating their potential dangerousness, even under medical supervision, as well as their high probability of being used as drugs of abuse. From 1961 marijuana in Canada was classified under the Narcotic Control Act which increased legal penalties for its possession, trafficking, exportation, importation, and cultivation (36).

On the national scale as well as the international one, cannabis clearly seems, as with other drugs – opiates in particular – to no longer have been considered in its actual or even potential therapeutic dimensions from the beginning of the 20th century. Such a total and systematic exclusion was deplored by some physicians. But they have remained few and far between. This was the case, for example, of the French physician Laurent Gaide who, after a long career in Asia, affirmed, in 1938 that, while he agreed that “it is long past the time when it was fashionable to praise drug devotees as sophisticated, delicate beings, the lovers of rare and sensual pleasures, eager for new, elegant and all exotically perfumed sensations,”€ he was opposed to the construction of an excessively negative image of opium as a substance that drives its consumers mad, causing them to commit suicide, murder or treason “without bothering to even remember that it is the most active and the most efficient medicine against physical pain and moral depression.€” He then reminds his readers ofopium’s extensive therapeutic indications “useful as a tranquilizer, antispasmodic drug, cardio-tonic stimulant, and sedative, specifically targeting anxiety” €”and that it is still widely used in therapeutics by the Chinese and Vietnamese as a tranquilizer and a prophylactic against all endemic conditions “against diarrhea, dysentery, cholera and especially malaria” (37). He also points out that this represents a multiform use which should not be rejected offhand. By that time, however, the construction of the “opium myth” was already solid and well-anchored, making opiates and other psychoactive substances classified with them considered to be inherently evil (38).

Cannabis as a “non-medicine”
In the specific case of cannabis however, we suggest that it was assimilated to other narcotics “€“instead of becoming a psychotropic medicine” because its therapeutic career in the West was short and controversial, and, perhaps more importantly, because it was not allowed to obtain the status of pharmaceutical in the modern sense. We also argue here that the double exclusion of cannabis (from the therapeutic field and from legal consumption) specifically can be understood in relation to the modern definition of medicines as pharmaceuticals, a historical process which is contemporary with that through which cannabis as a dangerous drug was defined.

Medicines as we know them today “as a product of the pharmaceutical and chemical industry, based on increasingly precise and reliable criteria of quality, safety and standardization, adopting new forms, the distribution of which was on increasingly massive but also increasingly controlled”€“ were born in the last quarter of the 19th century (39-41). It was with the introduction of the first effective drugs against infectious diseases, arsenobenzols in particular, in the 1910s that the rise of modern medicines was really established -dissolving physicians-€™ skepticism towards drug therapies and rapidly gaining popularity with patients, thus becoming a tool of medicalization valued by all (42,43).

In the context of this rise of modern medicines, cannabis suffered various drawbacks: none of its psychoactive principles could be isolated before the 1940s (9); and it is not very soluble and thus unusable by hypodermic administration, unlike morphine, for example. In addition, its foreign origins made it all the more mysterious, even dubious (and therefore dangerous); its Western therapeutic history was short, beginning only in the 1840s. Yet, at the same time, it was being used by “€œcharlatans”€ in their secret recipes as well as by various advocates of alternative methods of biomedicine, including homeopaths and mesmerists (9). It was considered to be both traditional and alternative, and therefore empirical, qualifiers with negative connotations that grew as the 20th century progressed. Finally, its brief use in Western therapeutics provoked numerous debates and dilemmas within the medical community.

During the period 1860-80, cannabis was used as an analgesic as well as antispasmodic; however, results of treatment reported by physicians were considered to be highly variable and especially unreliable. The range of therapeutic indications for which cannabis was recommended was surprisingly varied given the small scale on which it was being used at the time. The publication of Jacques-Joseph Moreau de Tours’ works in the 1840s, in particular Du hachisch et de l’€™aliénation mentale (1845), introduced and oriented its uses in the field of mental health. In North-America, Europe, and the colonies (8), it was soon used in psychiatry for various conditions: insomnia, delirium tremens, melancholia, neurasthenia, as well as addiction to different products including opium and chloral (44). These uses were controversial in a context of considerable debate, at the time, about the nature of, and ideal methods for “managing”€ mental illness, but also about drug addiction as a disease “or a form of social deviance. In this context, and especially in the years 1870-90, the status of cannabis, like that of other substances such as morphine, oscillated between therapeutic tool (to improve mental health and eventually to treat addiction) and consumer good that predisposed or aggravated mental problems (28). This situation, in the particular case of cannabis, hampered the substance from building a positive and durable therapeutic reputation.

Thus, cannabis quite rapidly disappeared from experiments, therapeutic trials, and scientific publications reporting on such trials. This absence was easily ascertained by reviewing the Canadian medical press during the period from 1870 to 1910. It was mentioned only twice in the Union Médicale du Canada (UMC) during this period, and both times described as ineffective. The first appearance was in 1872 €”the journal’€™s first volume €”in which a certain Dr. Desrosiers responded to a French article by describing hisown rather unsuccessful trials of the substance €”qualified as “exotic” €”in the treatment of menstrual problems, and the second in 1886, in which it was mentioned in passing as a hypnotic. There was another brief mention in the Canadian Medical and Surgical Journal (CMSJ) in 1881, as part of a list of hypotensive drugs.

The State and the physicians: for a total non-use
Can we assume from this observation that cannabis was also absent from day to day medical practices? Although the substance appeared many times in the therapeutic formularies of the UMC andthe CMSJ, it was much less visible than other psychoactive substances: it was indicated twelve times in the treatments proposed by the UMC, against 90 times for opium, 66 times for morphine, 19 times for cocaine, and 72 times for chloral hydrate. An analysis of the prescription book of one of Montreal’s most prominent pharmacists in the 2nd half of the 19th century, Henry Gray, does not find any medical prescriptions containing the substance (27). Our extensive research in the French colonial medical press (published in France and in the Far East in the years 1870-1940), but also in the monthly sanitary reports which colonial physicians, on duty in the region, sent to their superiors, again reveal its absence: there is no mention of its use, other than to denounce its misuse by some traditional healer or local quack or to remind that only doctors of medicine having graduated in France had the right to prescribe it because it was a toxic substance according to French and colonial law (45).

By the end of the19th century, the therapeutic career of cannabis was completely over before it had even begun. This reality has surely played a role in preventing it from ever “€œreemerging”€ in therapeutics; it never even had a place to maintain. From the outset, or almost, it was held back by a growing suspicion towards psychoactive substances and their potential toxicity, but also by medical debates surrounding the definition of drug addiction and mental illness. Nor should we forget the increasingly important and direct role that health care professionals sought to play in protecting the public, especially by multiplying discourses on hygienic, prophylactic, eugenic and moralizing themes. While addiction has truly been (re)defined as a disease, signaling the extensive reach of modern medicalization, cannabis has become a “€œnon-medicine”€, undergoing instead a process of de-medicalization over the course of the 20th century and relegated to the exclusive status of recreational drug.

Beyondits short therapeutic career and lack of “€œmodernity,”€ cannabis seems to have been a particularly undeserving victim of the medico-governmental attack on narcotics in that these legal restrictions were not adapted to its qualities as a mildly addictive product. Indeed, this “injustice”€ is perhaps particularly revealing of the collusion between the State and health care professionals that wasindeed also formalized in the second half of the 19th century in the Western world, thereby definitively sealing the relationship between knowledge and power in matters of healthcare (46). This collusion was underscored by shared interests and objectives, including in matters of public health protection and the definition of morally acceptable modes of access to healthcare. This is the context in which, as concerns about drug toxicity were resurfacing, physicians obtained the exclusive right to prescribe toxic substances and consequently a growing list of pharmaceuticals from their respectivegovernments.

The medical prescription profoundly modified the modern relation between patients, medicines, and physicians (47). Within the context of the emergence of the pharmaceutical industry, obtaining this exclusive right was also clearly for physicians an instrument of professionalization, by which they relegated self-medication practices, secret remedies, and unrecognized therapists to illegal sphere. It was also a means of confirming the scientific nature of medicine. Again, the goal was, perhaps especially in the case of Canada, to confirm the primacy of the role of physicians in the protection of society. As shown by Malleck (48), medical discourses with moralizing undertones were definitively established across the country in the first years of the 20th century with the Patent and Proprietary Act of 1908, a document demonstrating that medical perspectives were central to the conceptualization of opiate addiction as a social problem, and the regulation of the patent and proprietary medicine tradewas one outcome of the growing medical concerns over “€˜narcotic” drugs. Here, the physician is at the heart of a project to strengthen the nation; he is primarily the guarantor of public health, which is necessarily endangered by narcotics and secret remedies, and later on by recreational and psychotropic addictive drugs, even if the Canadian medical community was divided on the definition to give to “€œabuse”€ and “€œhealth risk”€ (36) for a long time and had very little interest in drug users as patients until quite recently (35).

In the case of the province of Québec, Denis Goulet (1997) has explained that the incorporation of the medical profession with the creation of the Collí¨ge des Médecins in 1847 was made possible by an existing collusion between the legislature and the provincial medical elite (49). From the outset, the incorporation charter addressed the issue of the population’s access to the best possible care. Indeed, the Collí¨ge was given a double mandate: to control medical practice and to protect public health; this set a precedent in North America. Although it was not until the 1870s (and in particular, with the 1876 law and the first professional code of ethics in 1878) that these ambitions were really concretized “with certified physicians obtaining a monopoly on medical acts [Endnote F] already, much earlier, a Quebec physician was expected to havea spotless reputation, to set an example, and to protect the sick, even from himself if necessary. The medical law of 1909 definitively confirmed a fundamental concept: that quality of care was closely linked to the recognition of medical doctors. One can now understand how cannabis, already defined as an illicit drug and “non-medecine,” was definitively discarded by physicians from their therapeutic and prescription practices.

4. Discussion

We would not necessarily go as far as arguing that cannabis would certainly be used in current therapeutic practice had it not been so strictly controlled, along with other narcotics, in the early 20th century. Yet, one can nonetheless consider excessive (for sufferers who claim access to the substance, and therefore its recognition as a therapeutic tool) the introduction of a law governing the uses of a substance that preceded its understanding and even its definition. Cannabis became legally dangerous before it had a chance to be recognized as a useful therapy. Medical doctors opted for a moral debate and, most of all, to take a stand “€œagainst”€ a drug, instead of positioning themselves “€œfor”€ the defense and investigation of a new medicine’€™s potential, while their exclusive right to prescribe any product defined as toxic protected this questionable position. The reasons accounting for the current lack of research on therapeutic cannabis therefore need to be replaced in the long term, in order to identify their multiple dimensions and linkages, and thus better understand the exaggerated cautiousness shared by the government and the medical world. This cautiousness is the product of a complex history, both of the specific trajectory of cannabis and, more broadly, of the rise of biomedicine as a process of professionalization, scientificization and public reassurance, that is of biopower (50) in a context of an increasing state interventionism in the field of population health.

It would be easy to apply to the present, to Canada’€™s current situation, the combined effects of cannabis’ difficult history by pointing out that, having been confined to a role as a recreational drug (in this respect, it seems clear that groups making demands for the broader legalization of cannabis do not help the cause of its therapeutic recognition), and potentially dangerous substance cannabis is not taken seriously when it comes to discussing or proving its therapeutic qualities. It cannot, in medical minds, be considered to be simultaneously an object of pleasure, addiction €“of marginality, and a tool of social protest as it was seen in the sixties, including in Canada (36) – and therapy. At least, health care professionals, and the government, cannot bring themselves to encourage this triple label.

In addition, cannabis probably remains, for some actors in healthcare, an exotic substance, propagated and consumed by the “€œOthers”€, including immigrants. In one of the reports written for the Senate Special Committee on Illegal Drugs in 2002, we notably find: “Although increasing acceptance of [recreational] marijuana use may be attributable to a number of factors, the 1990′s were described as the decade of immigration in Canada. Thus, once again, the increasingly permissive attitude of Canadians towards marijuana could potentially be linked to theories of transnational movements of cultural values, therefore leading Canadians to increased exposure and acceptance of different values of marijuana usage (51). Cannabis is also labeled “€œalternative,” a label which is indeed exploited by some of its users and proponents of its legalization to define it as natural and harmless. We should remember that homeopathy, as well as several traditional therapeutic systems, still uses it (52). This unconventional identity may further slow down the medicine integration into Canadian biomedical therapeutic research and practices.
Made into a “€œnon-medicine”€ by culture, cannabis cannotconstitute a valid and ethical clinical research subject, nor can it be prescribed or be included as part of a serious medical follow-up; at least for now. The inclusion of certain alternative practices in the biomedical field and the recent Canadian federal Natural Health Product Regulations (53), which together emphasize the influence of laypeople and patients, and of their expectations and health practices, on the evolution of options in health services and medical care, provide some hope for progress in this area. At the same time, in the era of evidence-based medicine, it seems reasonableto suppose that, in situations of conflict and disagreement (the individual versus the collective, physicians versus the sick, the State versus groups of patients and lobbies, etc.), the result of the studies now underway will provide tools to make more informed decisions.

Endnotes

A. “Marijuana”€ is the other term frequently used to designate cannabis. Its origins are Mexican, and it actually designates the leaves of cannabis.

B. We acknowledge that the commercialization of Sativex® in Canada in 2005 was important but contrary to smoked cannabis that contains more than 60 active compounds (cannabinoids), only THC and cannabidiol are present in the manufactured drug. Therefore, Sativex is not equivalent to therapeutic cannabis and it will not be discussed further.

C. Hippocrates can be credited for the first description of an analgesic, the Hippocratic Corpus, a multi-herbal source of pain relief; he also used salicin powder, made from the leaves and bark of thewillow tree, to treat headache, fever, and pain, as well as opium, the first narcotic used to treat pain. Edward Stone discovered in 1773 that extracts from the bark of white willow (Salix alba) could relieve the fever associated with the disease, without curing it. Starting at the beginning of the 19th century, experiments progressively led to more pure and potent extracts of white willow, culminating in 1838 with theisolation of a potent extract, named salicylic acid. By the 1850s, morphine had become standard treatment for preoperative and postoperative analgesia. Acetaminophen (paracetamol) was first synthesized in 1877. Most of the other classes of analgesics were developed in the first half of the 20th century.

D. It should be noted that opium was also seen in China and other Asian countries under Western influence at the time as a metaphor of national weakness, and anti-opium movements as a highly political instrument of Asian nationalism in the beginning of the 20th century. At the same time, even though it is a proof of acculturation in the new Western opinions towards addiction, it is also an answer to a public health problem which grew in proportion (37).

E. This inclusion was apparently made under pressure from the Egyptian delegation, thus manifesting its desire for political and economical independence from British influence.

F. When a first federal law in 1875 involved the distribution of medicines by establishing the basis for control over the falsification of nutritional substances, alcohol and drugs.

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