How is cannabis made medicinal in the UK?
Name: Christina Plowman Student ID: 12305316
Programme: MSc Medical Anthropology and Sociology University: University of Amsterdam
Supervisor: Dr Rene Gerrets 2nd Reader: Dr Eileen Moyer Date of Submission: 9th August 2019 Place of Submission: via email (as arranged)
Acknowledgements
My sincere thanks to my supervisor, Rene, who provided valuable support throughout my first foray into anthropological research. I always appreciated your insights and stories. It really was all good training.
I also would like to thank the people I met during this research, who shared their time, experiences and knowledge with me. I learnt a great deal that I will take with me.
To the UvA-MAS 2018-2019 students and staff for making this year so unique – Dank je wel!
Thanks to the friends and family for their encouragement
Summary
This thesis is centred on ‘how is cannabis made medicinal in the UK?’. In November 2018, the UK’s legislative change allowed specialist doctors to prescribe certain cannabis-based products (CBPs). This change largely symbolic, due to the infrastructural barriers that effectively maintain prohibition of medicinal CBPs. This has ethical issues: doctors
withholding prescriptions and knowingly letting their patients risk breaking the law and trying potentially unsafe products. However, there are many other practices of making cannabis medicinal that developed outside of biomedicine under prohibition of cannabis. The practices of making cannabis medicinal are highly individualised, context-specific and often draw on multiple modes of knowledge. The unique properties of cannabis its
complexity and instability allow it to fluidly adapt to these wide range practices. Cannabis’ fluidity is not inherently problematic is does underpin many other issues in this thesis. Namely, cannabis fluidity’ is incompatible with rigid and stabilising categories in science, which excluded valuable information about cannabis’ efficacy, such as pleasure. A related issue is the absence-presence of recreational cannabis in constructions of medicinal
cannabis. However medicinal cannabis is defined, there are struggles for authority over who got to claim what about making cannabis medicinal. Lastly, innovative collaborations and co-produced knowledge using technology to research medicinal cannabis use. Ultimately, the process of making cannabis medicinal foregrounds many taken-for-granted assumptions in contemporary medicine. The current biomedical knowledge paradigm has limited
applicability to cannabis’ fluidity and instability as such new forms of research are required to go beyond how cannabis is made medicinal and rather how medicine is made by
Table of Contents
Summary ... 2 Table of Figures ... 6 Table of Annexes ... 7 Glossary ... 8 Section 1 Introduction ... 9 1.1 Context ... 91.1.1 Positionality and Reflexivity ... 11
1.2 Literature review and research question ... 12
1.3 Thesis outline and Main Argument ... 13
1.4 Theoretical framing ... 14
1.5 Methodology ... 17
1.5.1 Data Analysis ... 19
1.5.2 Ethical considerations... 20
1.6 Summary... 20
Section 2: Competing Narratives ...21
2.1 Dominant narrative of drugs and prohibition of Cannabis ... 21
2.2 Counter narrative: re-making cannabis as medicinal ... 24
2.3 Absence/Presence of Recreational Cannabis ... 27
2.4 Conclusion ... 29
Section 3: Different ways of making certainty ...30
3.1 Complexity ... 30
3.2 Uncertainty ... 33
3.3 Sense making: Using the body as an instrument ... 34
3.3 Community produced knowledge ... 39
3.3.1 Underground expertise and the consumer-led industry ... 39
3.3.2 Online communities and fragmentation of information ... 41
3.4 Conclusion ... 43
Section 4 Evidence: hierarchies and alternatives ...44
4.1 Efficacy ... 44
4.1.1 Placebo ... 45
4.1.2 Pleasure ... 46
4.1.3 Miraculous example ... 47
4.1.4 Hierarchy of evidence ... 49
4.2 Who are the Gatekeepers? ... 51
4.2.1 Role of Doctors ... 51
4.2.2 Role of National Health System ... 54
4.3 Conclusion ... 58
Section 5 Interaction micro and macro ...59
5.1 Constructive interactions: changing public perception ... 59
5.2 Education for all: doctors, patients and public ... 63
5.3 Resistive interactions: power struggles ... 66
5.3.1 Breaking the law to change the law ... 67
5.3.2 Profit and Resistance ... 68
5.4 Conclusion ... 71
Section 6 Conclusion ...72
6.1 Discussion ... 72
Limitations of the study ... 73
6.2 Conclusion ... 75
Table of Figures
Figure 1 Geographic variability is symptomatic of two-fold problem: the classification of wide range CBPs under the one term: cannabis and the categories of classification: recreation (illegal or legal) (Nature, 2018). This is oversimplified and already out of date with countries like Thailand and South Africa liberalising their laws...9 Figure 2 This graphic shows key milestones in discovering the cannabinoids: THC and CBD as well as the endocannabinoid system (CB1 and CB2). It also shows the number of published randomised control trials on medicinal CBPs (Gibbs et al., 2018) ... 10 Figure 3 Timeline of history of cannabis in economic market forecast from Prohibition Partners European Cannabis Market Report 2019 ... 25 Figure 4 Figure to show the CANNtalks initiative to break stigma and taboo around cannabis by Curating A New Normal (Left). I was invited to speak during at an event ‘Medicine or Madness’ (Right). ... 26 Figure 5 Different types of cannabis posted by medicinal cannabis patient on social media (See Section 5). L: medically prescribed Bedrocan, R: recreationally bought Pink Kush in Canada. NB Pink Kush actually has a lower THC content ... 28 Figure 6 There are many points in cannabis life cycle where complexity can be amplified van der Geest et al.’s (1996) Biographical Approach to medicines. ... 31 Figure 7 (A) Poster at information small CBD business event detailing some of the conditions CBPs could treat and comparing that to medical pills (B) Slide from Centre for Medicinal Cannabis annual lecture 2019 detailing the proportion of wide range of conditions patients are prescribed medical CBPs in Australia, showing there is a wide range of conditions. ... 33 Figure 8 Left: without CBD, Right: with CBD. These two images show where Alice had similar lengths of sleep (9hr 51 min and 9hr 36min) but the quality of sleep was very different: 8% deep sleep without taking CBD oil at night and 25% with taking CBD oil at night. Obtained via personal correspondence. ... 37 Figure 9 Slide from CMC Annual lecture depicting Ananda Hemp’s ‘Bliss Intimacy oil’. Professor McGregor joked that the pharmaceutical industry would ‘explode’ if cannabis was marketed for improving quality of sex life. . 46 Figure 10 Hierarchy of Evidence included in BPNA’s written guidance for the use of CBPs in paediatric epilepsy (F. O’Sullivan 2019 p. 9). On personal note, this ‘hierarchy of evidence’ is deeply embedded in my perspective I have worked on several systematic reviews. ... 50 Figure 11 Refusal of doctors at Royal Derbyshire Hospital to engage with patients (pictured obtained via personal correspondence with patient activist) ... 53 Figure 12 Screenshot from the NICE (2014) website: the pharmaceutical Sativex (1:1 THC and CBD for Multiple Sclerosis) is not deemed cost effective ... 54 Figure 13 These screens of the Releaf App show how a session of medicinal cannabis can be documented by (i) choosing the strain, (ii) creative description of the immediate effects (iii) written review of session and (iv) the report produced from repeated documentation of sessions. (Releaf 2019) ... 62 Figure 14 Advert for TAoMC with the caption ‘Doctors, sometimes you have to unlearn in order to learn’. ... 64 Figure 15 Box from Rang & Dale's pharmacology showing Potential and Actual uses of cannabinoids (2018) p. 258 ... 65 Figure 16 Advertising of CBD-oil masquerading at education in a shop window ... 66 Figure 17 (a) Sunday Times report of ‘Ex-lecturer becomes first patient to be prescribed cannabis’ (Times 2018 my emphasis) (b) Carly on This Morning prime time TV after NHS failed to provide prescription like her private prescription ... 67 Figure 18 Prohibition Partners projection for Western Europe. The total market value for the UK medical and recreational market value forecast at £16.5 billion by 2028 ... 69 Figure 19 These arguments align with those of Sunder Rajan (2017) and Dumit (2012) but do not have the same authority ... 70
Table of Annexes
Annex 1.1: Interviews table with pseudonyms Annex 1.2: Interview themes
Annex 1.3: Interviewee roles Annex 1.4: Consent Form Annex 1.5: observation table Annex 2: List of Codes
Annex 3: Social Media Discussion of the Pechoti Method Annex 4: Press release from Project Twenty21
Glossary
ACMD Advisory Committee on Misuse of Drugs ADR Adverse drug reaction
BPNA British Paediatric Neurology Association CBD Cannabidiol
CBP Cannabis‐based product (includes synthetic cannabinoids) CBPM Cannabis‐based product for medicinal use (govt definition) CMC Centre for Medical Cannabis
CSC Cannabis Social Clubs CUD Cannabis Use Disorder EMA European Medicines Agency
EMCDDA European Monitoring Centre for Drugs and Drug Addiction GMC General Medical Council
GMP Good manufacturing practice GPs General Practitioners
HPRA Health Product Regulation Authority (of the Republic of Ireland) INCB International Narcotics Control Board
MCCS Medical Cannabis Clinicians Society
MHRA Medicines & Healthcare Products Regulatory Agency MRC Medical Research Council
NIMH National Institute of Mental Health NIHR National Institute of Health Regulation NICE National Institute of Clinical Excellence NHS National Health Service
RCT Randomised controlled trial RCP Royal College Physicians R2G Right to Grow
TAoMC The Academy of Medical Cannabis THC Tetrahydrocannabinol
UK United Kingdom of Great Britain and Northern Ireland UN United Nations
UPA United Patients Alliance WHO World Health Organisation
Section 1 Introduction
1.1 Context
The 1st November 2018 marked a historic moment for cannabis in the UK. A
legislative change allowed specialist doctors to prescribe certain cannabis-based products as medicines1 (ParliamentUK, 2018). There are high political, economic and social stakes2 complicating how cannabis is made medicinal. These stakes are heightened with the global liberalisation trend3 (Figure 1). In 2017, the patient-led movement to legalise medicinal cannabis 4 gained mainstream support5 through emotive media campaigns. These involved two epileptic children who were successfully treated abroad with CBPs which were
prohibited in the UK.
Figure 1 Geographic variability is symptomatic of two-fold problem: the classification of wide range CBPs under the one term: cannabis and the categories of classification: recreation (illegal or legal) (Nature, 2018). This is oversimplified and already out of date with countries like Thailand and South Africa liberalising their laws.
1 The 2018 regulations introduced a new definition ‘cannabis-based product for medicinal use in humans’ to distinguish what products in Schedule 1 (illegal) and Schedule 2 (medicinal on prescription) (Home Office 2018). I use cannabis-based products (CBPs) because it is more open to other medicinal or non-medicinal uses 2 Prohibition Partners (2019) reports on global trends towards liberalisation with intercontinental partnerships and huge economic forecasts for the global cannabis industry. The UK market could be £16.5bn by 2028 3 The variation in national legislation on cannabis is inconsistent with, if not contradictory to, the international scheduling of cannabis under UN Conventions. (Eliason and Howse, 2019) Indeed the UK’s rescheduling of cannabis no longer matches the 1961 UN Single Convention on Narcotic Substances.)
4 There are many different groups such; United Patients Alliance (UPA) and United Kingdom Cannabis Social Clubs (UKCSC) which have different agendas but advocating for compassionate use of cannabis.
5 Two surveys (YouGov, 2018 Volteface, 2019) showed strong support for legislation and access to medicinal cannabis and growing support for legalizing recreational cannabis
CBPs fall under many legal classifications, which sets boundaries on which are legal and illegal (Home Office 2018). Additionally, cannabis’ long history of prohibition
complicates boundary negotiation between recreational-medicinal and legitimate-illegitimate use. The legislative change is a milestone but remains largely symbolic. It
positions specialist doctors as the gatekeepers of medicinal CBPs. However, their prescribing ability is limited by infrastructural and bureaucratic barriers, which affects specialists in the UK’s National Health System (NHS) more significantly than in private healthcare (Gibbs et al., 2018). As such, patient-led movements continue campaigning and now can operate more openly with a diverse range of stakeholders in many sectors of the UK. The legal and biomedical systems of classification have powerful implications for the status of cannabis and shaping its historical trajectory such as the prohibition by law significantly impeded clinical research into cannabis and manifests in few licenced medicinal CBPs.6 (NASEM 2017, Chapter 15) (Figure 2).
Figure 2 This graphic shows key milestones in discovering the cannabinoids: THC and CBD as well as the endocannabinoid system (CB1 and CB2). It also shows the number of published randomised control trials on medicinal CBPs (Gibbs et al., 2018)
Cannabis is often problematised from a top-down biomedical and legal perspective, which is often a moralised issue because of cannabis’ recreational connotations. However, in this thesis I will foreground local ways of making cannabis medicinal outside of
conventional biomedicine methods. This is in respect to the patient-led movements, which
6 Drugs such as Sativex 1:1 CBD to THC might be licensed in the UK but are not recommended by NICE (2014) guidelines i.e. not first line treatments
catalysed legislative and clinical change. The terms ‘cannabis’ and ‘medicinal’ have broad meanings. I will look at how that meaning emerges in different practices situated in and specific to different social contexts and how medicinal use is often defined in opposition to recreational use.
1.1.1 Positionality and Reflexivity
I have a dual perspective as a medical student from London and a medical
anthropology student in Amsterdam. I returned to London to research an unfamiliar topic in a familiar context. I wanted to explore my insider-outsider dynamic but also because I had a well-established network of contacts there. My interlocutors liked the fact I was half-Dutch and coming from Amsterdam. This was often a useful conversation opener into cannabis. I thought studying in a familiar context might alleviate the ‘crisis of representation’ in
representing the ‘Other’ (Niewöhner and Lock, 2018, p. 690). However, if anything, this dual perspective highlighted the difficulties of representation in this topic. While my biomedical perspective enriched my understanding of the topic, it made me realise how deeply
ingrained my ‘medical gaze’ was. I will continually raise reflective points because the dynamic between my dual perspectives was integral to the research methods and analysis.
My research is situated in the aftermath of the legislation change and examines practices making cannabis medicinal outside, and in relation to, the biomedical process. This approach foregrounds issues of different knowledge production systems and differential authority levels and power in classifying cannabis. I will follow Nader’s (1972) concept of ‘studying up’ to reflect how patients lead the medical cannabis movement. As such, my ethnography looks up from the local (micro-level) practices of making cannabis medicinal. I will examine interactions between micro-level and macro-level stakeholders from this perspective.
1.2 Literature review and research question
My literature review continued throughout my research. My interlocuters
recommended papers for me as well as continuous publication of new papers and reports. From the outset, I found huge variation of academic disciplines publishing on medicinal cannabis. These ranged from historical texts7 to agricultural industry journals 8 to clinical and ethnopharmacology9 and drug policy10. There were also many government report11 and independent organisations. Furthermore, there huge amounts of information online12. This overwhelming volume and variation in the literature was a significant finding and expanded the scope and scale of the process of making cannabis medicinal.
In the medical literature, there seemed to more evidence supporting harm (Rabin, Zakzanis and George, 2011; Gage, Hickman and Zammit, 2016) or lack of benefit of cannabis (Whiting et al., 2015; NASEM, 2017). The variation in scientific evidence points to problems for evidence-based medicine, law and policy13 (Lancaster, 2014; Monaghan, 2014;
Lancaster, Treloar and Ritter, 2017). There were several further issues built up to the
research question. Firstly, despite international prohibition, cannabis use continues globally (UNODC 2016) 14 and the wider history of human cannabis use is relatively unknown to the public. Secondly, cannabis is generally seen as illicit drug in the UK, despite various CBPs ‘straddling’ standard categories of medicine, non-drug and illegal drug (RSPH, 2016, Tupper, 2012). Thirdly, the prohibition limited scientific research affecting the formation evidence-based policy and law (NASEM 2017; Taylor, 2010). Fourthly, related to the Prohibition, there is powerful moralising rhetoric demonising cannabis in the UK (Collins, 2011). This relates to
7 See J.H Mills (2003) Cannabis Britannica: Empire, Trade, and Prohibition, 1800-1928 and (2012) Cannabis Nation: Control and Consumption in Britain, 1928-2008
8 See Bernstein, Gorelick and Koch (2018) for a detailed account of how growing conditions affect chemical profile of cannabis.
9 See Bonini et al., (2018) Russo and Marcu, (2017) and Brezing and Levin, (2018) for various accounts of the pharmacology of cannabis and cannabinoids
10 International Journal of Drug Policy was useful to examine cannabis policy within the UK context (Klein and Potter, 2018) and those abroad (Zarhin et al., 2017) (Ritter, Lancaster and Diprose, 2018)
11 Excellently documented by (Taylor, 2010) PhD thesis on the (re)medicalization of cannabis.
12 The amount of information online is worth of its own research project: from specialised global sites such as Leafly.com to tight-knit online community groups.
13 It was beyond the scope of this project to look at the framing of cannabis within scientific research but it was often discussed in conversation.
14 The EMCDDA classes cannabis (along with ethanol and nicotine) as ‘one of the ‘big three’ of psychoactive substances in Europe (EMCDDA, 2008)
two-fold discreditation use of cannabis and classifying it as medicinal, which can have stigmatising effects. These four factors led to a two-part problem: what do the terms ‘cannabis’ and ‘medicinal’ mean and how does that meaning emerge. This informed the research question:
‘How is cannabis made medicinal in the UK?’
The question foregrounds the process(es) by which cannabis (in whatever form) transitions into a medicine (in whatever form), which encompass many yet highly context-dependent processes. In this way, my sub-questions are: is cannabis already medicinal (Section 2)? How do different people make cannabis medicinal (Section 3)? Who has the authority to decide how cannabis becomes medicinal (Section 4)? And lastly, how has legislative change affected interactions between different stakeholders (Section 5)? My aim is to foreground micro-level stakeholders and their local practices and how these relate with macro-level stakeholders, which is reflected in my thesis structure.
1.3 Thesis outline and Main Argument
My thesis structure reflects my research question and sub-questions outlined above. Later in this section, I will describe theoretical framing before outlining my research
methodology. In section 2, I will build on the context already outlined to examine the competing accounts of cannabis and their effects on practices of making (or re-making) cannabis medicinal. I will highlight how stigma associated with cannabis influences the categories of ‘medicinal’ and ‘recreational’ cannabis . In section 3, I will detail cannabis’ inherent complexity and emergent uncertainty. I use examples of stakeholders’ personal practices of making cannabis medicinal and how information is shared in local communities outside of biomedical practice. This points to a central issue: who gets to make claims about medicinal cannabis? In section 4, I will outline a few contested examples of efficacy and explain how the biomedical knowledge system excludes ‘evidence’. This shows how biomedicine’s authority shapes how cannabis becomes legitimately medicinal. I also
highlight how the infrastructure connects biomedicine, law and policy which self-reifies authority. In section 5, I will describe how legislation change enables interaction between micro-level and macro-level stakeholders and demonstrate how these can be constructive or resistive interactions. In the final section, I will discuss how cannabis’ fluidity underpins many of the issues outlined in this thesis. Namely how cannabis’ fluidity enables many alternative knowledge practices such as local practices of making cannabis medicinal. Yet, cannabis’ fluidity is incompatible with the rigidity of standards in ‘normal science’ (Kuhn 1962). These standards seek to stabilise objects through strict criteria research methods. Yet cannabis’ fluidity can lead to scientific uncertainty and problematisation of cannabis, which hinders cannabis becoming medicinal. However, I will flip this problematisation to show cannabis’ fluidity tests limits of normal science within a biomedical knowledge paradigm. As such, cannabis requires a creative if not ‘extraordinary approach’ (Kuhn 1962), which
embraces cannabis’ fluidity to expand cannabis’ medical potential. In this way, the paradigm shift could open up new ways of researching on other complex and hypervariable problems.
1.4 Theoretical framing
My key interest is in the tension between epistemology and ontology preceded this choice of topic. Yet making cannabis medicinal highlights this tension particularly in its potential to act on body and mind so that knowledge about cannabis shapes (and is shaped by) what cannabis is. My main theoretical influence is Science and Technology Studies (STS) to emphasise the materiality in practices of making cannabis medicinal. Cannabis is not merely a social construct; the material and social infrastructure shape the process of making cannabis medicinal and its interactions with the human mind and body. In this way, I’m influenced by Hardon & Sanabria’s (2017) Fluid Drugs approach, which outlines areas of flexibility of pharmaceutical drugs, particularly how cannabis becomes different types of ‘informed materials’ which change outside of laboratory conditions ‘in living labyrinths whose topology varies in time, where partial and circumstantial causalities are so
intertwined that they escape any a priori intelligibility’ (Bensaude-Vincent & Stengers 1996 in Hardon & Sanabria 2017). This points to different versions of medicinal CBPs emerging in different social and historical landscapes, outside of scientific disciplines. Yet I will outline
the significance of biomedicine’s ‘extreme insistence on materialism… [and] discomfort with dialectical modes of thought’ (Kleinman 1997 p. 29) has so far produced CBPs with limited use. The political economy of knowledge privileges the materialist biomedical knowledge systems at the expense of others. This can lead to clashing versions of CBPs which is why objectivity, impartiality and accountability are privileged in evidence-based medicine and policy (Monaghan, 2008; Taylor, 2016). This is significant because cannabis is a highly moralised topic, which makes scientific research socially situated. However, this moralised rhetoric increases the demand for a supposedly ‘objective’ approach where practitioners of biomedicine consider ‘their domain… distinct from morality and aesthetics, and from religion, politics, and social organization’ (Hahn & Kleinman 1983). However, I will emphasise how moralisation impacts on scientific research in cannabis and the subjectivities of the researchers, such as interpretation of evidence and particularly in doctors’ decision to prescribe medicinal cannabis or not.
Hardon and Sanabria’s (2017) term ‘fluid’ highlights how different versions of cannabis emerge through different practices. I build on this term because cannabis’ is unlike many other drugs. Part of cannabis’ fluidity lies in its polymolecularity, a key difference from other (plant-based) drugs (Section 3.1). The resulting in complexity which results in classification issues in what is meant by cannabis and in characterising CBPs’ therapeutic potential (Seddon, 2011; Tupper, 2012). Within this fluidity stakeholders ‘carry and carry out’ (Reckwitz p. 256) different practices of making cannabis medicinal. This is why I attend to the practices of cannabis medicines carried out by micro-level stakeholders. This includes routinized bodily, mental, intellectual and emotional activities involved in specific practices of making cannabis medicinal ‘contains specific forms of knowledge’ (Reckwitz 2002 p. 251 - 253). In cannabis’ case, there are many disparate or clashing forms of knowledge so
bracketing or ranking certain forms of knowledge above others is a key part of making cannabis medicinal.
While drawing on multiple or alternative forms of knowledge is acceptable on a local level, this is different within scientific communities. Gieryn (1983) proposes that ‘pursuit of epistemic authority’ leads to the ‘problem of demarcation’ between science and non-science (and pseudo-non-science). The process of demarcation results in ‘boundary-work’ to
separate and elevate scientific knowledge practices and reify differences from non-science and pseudo-science. Gieryn (1983) identifies several types of boundary work: expansion, monopolization and protection of authority, resource and autonomy. Indeed, these are typical features of processes of medicalisation and pharmaceuticalisation. However, non-scientific groups also exhibit processes of demarcation (Harambam and Aupers, 2015), this is important because the authority in patients’ expertise.
While boundary work foregrounds conflict, Star & Griesemer (1989) coined ‘boundary object’ to describe how boundaries can be sites of collaborative work. I conceptualise cannabis as a boundary object, which entails cannabis as a product of and producing ‘work arrangements that are at once material and processual’ (Star 2010 p. 604). In this way, considering CBPs as a boundary objects allows examination of how cannabis ‘maintain[s] coherence across intersecting social worlds’ (ibid p. 393). However, these ‘epistemic cultures’ (Knorr Cetina 1999) carry different levels of authority. For example, in the UK, evidence-based cannabis policy privileges of biomedical knowledge over lay knowledge. As such, following Star (2010), I separate two forms of the boundary object which stakeholders continually ‘tack back-and-forth’ between. The ill-structured, common form: cannabis and the well-structured local form: CBP which is specific to the social landscape. Cannabis’ fluidity can widen separation between these common and local forms. Star (2010) describes how regulatory agencies ‘try to control the tacking back-and-forth’ for standardisation purposes and this ‘collapse[s] the difference’ between the ill-structured common form, cannabis, and well-structured local form, CBP, (ibid p. 613-614). This is pertinent to both biomedical and legal classification seek to ‘stabilize pharmaceutical actions’ (Hardon and Sanabria, 2017) of CBPs. However, cannabis’ fluidity is incompatible with such rigid
standardisation and stabilisation methods thus causes problems for regulation and control.
As outlined in the introduction, there are high stakes here in terms of control over authority, power and profit which are powerful motivators of boundary work.
Pharmaceuticalisation (Williams, Martin and Gabe, 2011) of cannabis involves researching and developing pharmaceutically-approved CBPs that would fit into existing medicine frameworks. The gold standard of evidence is a double-blind randomised control trial (RCT). It is considered the most ‘objective’ and carries highest authority. Often, pharmaceutical
have the resources to run RCTs giving them the monopoly on providing approved-medicines. Pharmaceuticalisation has mixed reception in the cannabis industry, some critiques of the pharmaceutical industry align with sociological analyses such as the ‘appropriation by health by capital’ (Sunder Rajan, 2017 p. 7). Yet, many explain that cannabis’ complex properties resistance control. Such as its ability to be homegrown have the potential to circumvent both Big Pharma (difficult to patent) and the black market (self-grown). The resistance, symbolic or not, that cannabis presents to contemporary regulation and biomedical practice opens wider epistemological issues.
These analytical concepts within the STS framework, highlight the specific construction of knowledge from the material world is contingent on the context and the unique
properties cannabis presents can be analysed through Kuhn’s (1962) work on paradigms in science. In this way, I propose that the unusual properties of cannabis are incompatible with ‘normal science’. Normal science is situated within the dominant paradigm: biomedicine. In this case, the dominant paradigm has two meanings: firstly, a knowledge apparatus and infrastructure that is common throughout the biomedical community where knowledge can accumulate and progress across different disciplines. This is why rigid mechanisms of
standardisation are important for commensurability. Secondly, the biomedical paradigm itself signifies its epistemological tradition, which enables dismissal of anomalous
phenomena that are incompatible with this paradigm. For example, cannabis’ contest effects could be dismissed as anomalous, but there are many ‘anomalous’ cases. Kuhn (1962) initial stages of paradigm shifts are key: firstly, cannabis’ fluidity and success throw normal science into crisis, that elicits mixed responses in the biomedical community (Section 4). Some innovative research groups carry out ‘extraordinary research’ to break-through the boundaries of ‘normal science’ (Section 5.1) due to its limited applicability to cannabis.
1.5 Methodology
I completed my fieldwork between 21st February - 3rd May. My main research activities were interviews and observations and netnography (Kozinets et al. 2018) as a minor method. I found contacts and events online and also used a snowballing method to
find further interviewees or events. My interlocutors were often helpful and invited me to join closed online groups or events. Some also suggested collaborating on research with them and I received a PhD offer a few times(!) Many people also recommended articles and I helped in setting up open systematic review project with the Medical Cannabis Clinicians Society (MCCS). I was pleasantly surprised by the openness of my interlocutors because I was expecting the industry to be more closed.
In total, I conducted 29 interviews with 32 people, which averaged 72min (range: 40min - 125min) (see Annex 1.1). In the UK, cannabis is a polarising issue because of prohibitive legislation and moralised social rhetoric15. Thus, cannabis is a highly sensitive topic where disclosure of illegal activity can lead to punitive consequences. This was a limiting factor in recorded interviews. Often unrecorded or informal side conversations with were more important for finding out about illicit activity or deviations from acceptable views. My interviews and observations were largely unstructured because I wanted to limit the extent of my framing of the research on my interlocutors’ responses. This did not always work such as my early preoccupation with how CBPs worked jarred with many interlocutors concern that CBPs worked for them. I had some basic interview themes in my research proposal (see Annex 1.2) as prompts but often interviews were conversational. I completed 23 unstructured observations at a wide range of events mainly in London but also in other parts of the UK (see Annex 2).
I used different methods to find events and interviewees, but many interlocutors were connected or knew each other well and repeatedly commented ‘it [UK’s medical cannabis industry] is a small world’. I was concerned with confirmation bias, so I sought out points or cases of contradiction to triangulate my findings. The interconnectedness was symptomatic of the emerging industry, particularly as it moves from underground to legitimate spaces. Often my interlocuters held multiple roles and navigated multiple levels in the medical cannabis industry which affected what they said in different contexts (see Annex 1.3).
15 Indeed, many of my friends and family in the medical world cautioned me against this topic or publishing because of the negative consequences for my medical career if I am associated with cannabis.
As a minor method, I used netnography (Kozinets et al. 2018) using my personal social media account to join cannabis user groups. This was essential because my interlocuters often referred to social media demarcating themselves from extreme examples. These comparisons were often humorous and broke the taboo on cannabis. I observed what the language and information used in social media groups familiarise with recurring issues as well as specific humour and linguistic conventions. This enriched my ability to navigate the ‘small world’ of the medical cannabis industry. I copied using extreme online examples as conversational springboards towards controversial issues that were sometimes difficult to talk about without conveying judgement from a biomedical
perspective. Throughout my research, I juggled my medical anthropological and biomedical approaches. My medical gaze influenced my problematisation of practices of making
cannabis medicinal. Despite my attempt to foreground local practices, I devoted a large part of this research to the biomedical approach to cannabis in the UK. The iterative nature of my research and going back to the data itself helped to restructure the thesis to foreground local practices.
1.5.1 Data Analysis
In light of my biomedical perspective, I wanted to open up the process of how cannabis is made medicinal to my different interlocuters, so I took an iterative approach to content thematic analysis (Green and Thorogood, 2004, p. 177). I completed several rounds of open coding using Atlas.ti ‘to generate ideas from the data itself’ (Green and Thorogood, 2004, p. 185). From here, I established themes from the codes (see Annex 1.3). I kept analytical memos as a ‘pivotal intermediate step between coding and writing’ (Charmaz, 1999). I also highlighted deviant or contradicting views which were essential for
1.5.2 Ethical considerations
I used the Health Research Authority16 to register my project but I didn’t need further formal ethical approval. However, my research involved examining practices making cannabis medicinal which were often the law and I encountered varying degrees of illegal activities. I recognise that I do not have legal defence for source protection, and I will use pseudonyms to anonymise my informants, except where I have permission and my
interlocutors are in the public domain. Where pseudonyms fail to adequately anonymise my interlocuters, I exclude distinctive quotes to protect them. The ethical implications extend beyond spoken interviews because my interlocuters’ words might relate to their online profiles and lead to identification. I put together a consent form (Annex 1.4) however when it was not possible to get signed consent, I got verbal consent, emphasising that I would stop the recording or not record at their request. I offered to send transcripts to my interviewees, but this was rarely taken up and never remarked on.
1.6 Summary
The UK’s legislative change on cannabis opened up a tension between different ways of making cannabis medicinal. I will use an STS approach to analyse making cannabis
medicinal and link this to the high stakes of authority, legitimacy and profit involved. In outline the key historic tensions which raise these stakes. I use the term ‘fluidity’ (Hardon and Sanabria, 2017) foreground complexity at different processual stages of making cannabis medicinal. I will use analytical concepts of boundary work (Gieryn 1983) to highlight struggles for ‘epistemic authority’. I contrast this with cannabis as a ‘boundary object’ (Star & Griesemer 1989) to emphasise the aspects of cannabis as a collaborative working arrangement, despite the lack of consensus, between stakeholder groups. However, I argue the many practices making cannabis medicinal is incompatible with ‘normal science’ (Kuhn 1962) within the dominant biomedical paradigm and that extraordinary research on cannabis is necessary to surpass these issues.
Section 2: Competing Narratives
In this section, I will examine whether cannabis is already medicinal. I will outline the competing dominant and counter- narratives to show how they situate different practices of making cannabis medicinal in tension with cannabis’ recreational aspect. This highlights issues of stigma and legitimacy in practices involving cannabis. I will outline how the dominant narrative situates cannabis in the ‘drug war paradigm’ (Tupper, 2012) which has lasting prohibitive effects. The counter narrative argues that cannabis was already medicinal until the prohibitive legislation unmade cannabis medicinal such that now cannabis is actually being remade medicinal. Then I detail the construction of medicinal uses of cannabis in opposition to recreational. These narratives have bearing on issues outlined in subsequent sections.
2.1 Dominant narrative of drugs and prohibition of Cannabis
The dominant narrative justifies the prohibition on cannabis by depicting it as dangerous and a gateway drug which are deeply ingrained in society. The ‘fear driven rhetoric on cannabis’ (Emma, a patient advocate) is a barrier to legitimately making
cannabis medicinal. The dominant narrative’s historical starting point lies in the 20th century (Mills 2005, 2012) 17, where there was increasing availability and use of different types of drugs, including medicines and psychoactive substances. This necessitated international cooperation and control mechanisms, such as the UN Single Convention on Narcotic Drugs (1961) and The Convention on Psychotropic Substances of (1971). Yet, the dominant version of cannabis as illicit solidified during the War on Drugs era. Derek, a drugs policy researcher remarked ‘history of the war on drugs […] and drug laws has been one of competing
ideologies’. Derek further explains that the debates ‘use the same sets of facts and cherry-pick the ones that support their argument’. Cannabis falls within the ‘drug war paradigm’
17 Cannabis’ history in Britain and the British Empire before the prohibition is largely unknown. Mills (2005) Cannabis Britannica: Empire, Trade, and Prohibition 1800-1928 and Mills (2012) Cannabis Nation Control and Consumption in Britain, 1928-2008
(Tupper, 2012, p. 462) 18 and its classic categories of drug (illegal), non-drugs (legal but regulated) and medicine (legal and restricted) (ibid). Despite various forms of CBPs falling into each of these categories, cannabis is predominantly depicted as harmful and justifiably illicit. This account is supported by a powerful infrastructure in law and biomedicine, such as the UK’s Misuse of Drugs Act 1971. Despite the legislative change allowing prescription of some CBPs as medicines, the illicit ‘drug’ imagery prevails.
This inhibits ways of making cannabis medicinal and influences how legitimate or creditable the label ‘medicinal’ label. Ungerleider and Andrysiak (1981) warned of the War on Drug’s moralising impact in scientific research and its supporting infrastructure which was echoed in more recent studies with real impacts on clinical research (Gibbs et al., 2018, Figure 2). Zach, a patient advocate, commented that despite ‘since the ‘60s the West poured money into studies to prove [cannabis] is harmful[…] and failed. Repeatedly.’ This was supported by Andy, a CBD businessman, who pointed out the ‘data is completely skewed’ against medical benefits because most studies focused on ‘recreational use […] or pseudo-medical formats’ which uses different methodology from clinical research. This has the effect that the bulk of scientific evidence links cannabis to harm. Indeed, a recent meta-review devoted a chapter to ‘challenges and barriers in conducting cannabis research’ (NASEM (2017), chapter 15) and emphasised historic and contemporary issues preventing research from regulatory, access and funding barriers19. This is problematic because there becomes a self-reifying cycle in interrelated evidence-based medicine, law and policy (Monaghan, 2014; Lancaster et al. 2017). In the UK context, several studies shown that ‘evidence-based’ policy-making on cannabis is situated within the dominant narrative of prohibition (Bennett and Holloway, 2010; Taylor, 2010, 2016) despite contradicting evidence (Nutt et al 2010).
Several interlocuters referred to common scaremongering tropes moralising propaganda on cannabis such as: ‘Reefer Madness’ and other forms of ‘racial prejudice -
18 See the Global Commission on Drug report ‘Classification of psychoactive substances: when science was left behind’ for details on ‘biased historical classification’ on the UN conventions contributed to the global drug problem
19 A recent audit by the National Institute of Health in the USA showed that within studies on cannabis, only a minority of funding supports studies framed to investigate therapeutic benefits (rather than harms) of cannabinoids. (NASEM 2017)
even the word “marijuana” has negative connotations about South America’ (Rob, CBD business owner) and associations with ‘black Jazz’ (La Barre, 1977; Bender, 2016). Indeed, early investigation into the ‘misuse of cannabis’ propagated these stereotypes such as the Wootton Report (ACDD, 1969). Liam, a medical cannabis user, and Larry, a prominent patient advocate, noted the negative framing of the Wootton report set the status quo in British politics and media. This is problematic because any nuance with cannabis ‘get collapsed down to skunk – psychosis’ (Zach, CBD shop-owner). Emma, a patient advocate, uses a debate in the House of Lords debate20 to show how misrepresent medicinal cannabis in politics. Emma detailed how ‘Baroness Blackwood said, “there is no problem with
accessing medicinal cannabis” […] which is a complete disgrace’ . Furthermore, Lord West said cannabis ‘ “causes violent crime” ’, which Emma deemed ‘completely inappropriate [because] there is actually no data to back that up […] and it has nothing to do with
medicinal cannabis’. However, oversimplifying something like crime or mental health issue to a single factor ‘so it’s difficult to draw direct conclusions [and] to have discussion about mental health issues. It’s easier to blame scary cannabis than accept other issues’ (Ollie, analyst at cannabis start-up). This demonstrates moralising rhetoric at the political level hinders cannabis becoming medicinal.
The moralising force of the prohibition can lead to illegitimacy of medicinal cannabis use and stigmatisation of cannabis users. Many interlocutors face social consequences of their medicinal use of cannabis: Sally hides her cannabis use from her work; Beth lost relationships with disapproving relatives and Liam served a prison sentence for his cannabis use. If medicinal cannabis use is not socially legitimate then both the use of cannabis and claims of its medicinal properties are discreditable behaviour, which can lead to
stigmatisation of cannabis users (Goffman, 1963; Balneaves et al., 2013). The moral
dimension heightens the stakes of boundary work to demarcate creditable and discreditable behaviour21 is important for making cannabis legitimately medicinal. This is why the
counternarrative is important for showing how the prohibition itself is problematic.
20 This clip from a debate in the House of Lords shows how negative stereotypes of cannabis enter a debate centred on cannabis-based medicinal products: https://www.youtube.com/watch?v=2rSdq1TgAZ4 . I watched it on Emma’s recommendation and her comments are completely accurate.
21 Also moralised political rhetoric shapes and is shaped by media rhetoric (Collins, 2011). For example, the claims by Lord West echoes arguments proposed from a prominent opponent of cannabis, the journalist Peter
2.2 Counter narrative: re-making cannabis as medicinal
The counternarrative broadens the history of cannabis outlined above and includes its ancient and pre-prohibition medicinal uses. The counternarrative problematises the prohibitive dominant narrative22 and reframes the problem: re-making cannabis medicinal after the prohibition unmade cannabis medicinal. At many events, people re-framed cannabis’ history to legitimise cannabis as a medicine. This had a dual purpose of firstly, legitimising cannabis as a medicine, by illegitimating the prohibition and secondly, to show that cannabis requires new classification and research methods i.e. beyond the drugs war paradigm. Below, I will outline a typical account23 of the counternarrative :
Cannabis sativa is highly adaptable plant that differs across the world and has various uses. Cannabis was used medicinally24 for millennia in ancient Egypt and China. The UK has laws promoting hemp cultivation from the 16th Century. Cannabis indica (higher THC variant) was
(re)discovered in 1830s by Irish Dr William O'Shaughnessy. He learnt about its uses in India as an antiemetic, anticonvulsant, analgesic and brought it to Britain where it was widely used – even by Queen Victoria 25 - until the discovery of opium and syringes.
Cannabis became the target of prohibition after the alcohol prohibition in the USA. Propaganda, like the Reefer Madness film, used sexuality and race to denigrate cannabis use. This was solidified
internationally with the UN classing cannabis as having no medical benefit, which the UK copied into its legislation. This hampered clinical research resulting in the endocannabinoid system remains the most
under-Hitchens ( https://www.dailymail.co.uk/news/article-6791067/PETER-HITCHENS-real-cause-knife-crime-hidden-fog-cannabis-smoke.html )
22 See (see GDC 2019)
23 Note the counternarrative is also a selective retelling, which merges fact and fiction.
24 What was also not acknowledge was that concepts of a medicine have changed immensely especially ancient/eastern medicines include practices of freedom and spirituality (Bonini et al., 2018).
25 Often the source of humour because of the highest authority in the land using a stigmatized substance in a medicinal way – evidence of past legitimacy and credibility
researched in the body and rarely taught at medical schools. The
prohibition forces patients to resort to use illegally sourced cannabis but self-experimentation gives them more expertise than the doctors.
The UK lags slightly behind in the liberalisation trend and legislative change in 2018 was a necessary but insufficient strep. Yet restrictions prevent patient access to legal medicinal CBPs in the UK. More research of a different type has to be done because the full-spectrum of chemicals in cannabis act in the body would take centuries to be medically validated through the usual pharmaceutical route: randomised control trials will take too long, be too expensive and won’t work for cannabis. A new paradigm is required26.
Figure 3 Timeline of history of cannabis in economic market forecast from Prohibition Partners European Cannabis Market Report 2019
There are variations on this typical (re)framing of making cannabis medicinal that crop up in scientific literature (Russo, 2014, 2016), economic reports (Fig 3, Prohibition Partners 2019) and policy recommendations (Barnes and Barnes, 2016; MCCS&APPG, 2019). This typical account provides a counternarrative which is ‘a positional category, in tension with another category’ (Bamberg & Andrews 2004 p. x). It was a declarative start in public
26 The conclusion that a new paradigm is required for cannabis research was the underlying message at the Drug Science Symposium 2019 but echoed in my interlocutors’ calls for more research needed.
presentations countering the dominant narrative from the outset to set a legitimising tone for event. The counternarrative breaks down aspects of prohibition: it undermines undoes legitimacy prohibition morality-based rather than fact-based but the prohibition’s influence biased scientific research such that the Prohibition became evidence-based. As such, both the counternarrative renders the prohibition and its supporting biomedical and legal infrastructure illegitimate and portrays medical cannabis patients as victims of an unjust system rather than perpetrators of a crime.
Figure 4 Figure to show the CANNtalks initiative to break stigma and taboo around cannabis by Curating A New Normal (Left). I was invited to speak during at an event ‘Medicine or Madness’ (Right).
I found that re-framing of cannabis in a such positive light restricted critical discussion (Figure 4). It almost became taboo to mention dangerous CBPs e.g. synthetic cannabinoids like Spice. Despite this, I was struck by both the history (which I was unaware of) and its mobilisation as a legitimising force in (re)making cannabis medicinal. This
alternative narrative of cannabis is similar to a genealogy of cannabis. When speakers give a brief introduction to medical cannabis, it is more than just a history. Firstly, the telling of the ‘history of the present’ (Foucault 1977 p. 31) is a critique of dominant narrative setting historical conditions which determine contemporary taken-for-granted assumptions and practices. Secondly, the re-telling of an alternative history is legitimising i.e. the
counternarrative discredits the dominant narrative and demonstrates how the present could be other.
However, the counternarrative is not neutral and situated within the agenda of legitimising medicinal cannabis use. These narratives shape the ill-structured form of cannabis and specific medicinal CBPs stakeholders ‘tack back-and-forth’ (Star, 2010). The
importance of this lies in the making cannabis medicinal is often in opposition to its ‘recreational’ side. Ochs & Capps (1996) describe narrative resistance as ‘to-and-fro of challenges and counterchallenge’ (p.36) in scientists, politicians and artists as a key part in evolving paradigms.
2.3 Absence/Presence of Recreational Cannabis
Medicinal and recreational are functional descriptions the emerge through practices of cannabis’ use. Since the prohibition powerfully constructed cannabis as recreational and illicit, ‘medicinal cannabis’ relies on the ‘absent-presence’ of ‘recreational cannabis’
(Lancaster et al., 2017; Zarhin et al., 2018). This explains why reference to danger or
‘recreational’ uses of cannabis was almost taboo. While cannabis is polymolecular, two well-known compounds are key in tension recreational-medicinal. Tetrahydrocannabinol (THC) and Cannabidiol (CBD) are both cannabinoids but THC is psychoactive and causes the ‘high’27 whereas CBD has holistic effects in the body. Jill, a medicinal CBP user, said she wanted ‘the health not the high’ which was important for her because she faced
stigmatising encounters such as in a doctor’s appointment, she saw a warning triangle sign on my file […] it had me down as a cannabis abuser’. As such, demarcating between
legitimate medicinal use versus illegitimate was important to reject accusations of drug-abuse or diverting medicinal cannabis for recreational purposes.
This boundary work is material and symbolic (Lamont and Molnár, 2002) because symbolic demarcation affects the materiality of medicinal CBPs. Derek, a drugs policy research explains, ‘the medical arguments are […] morally acceptable whatever your
starting point is ideologically’ which rests on the idea that ‘drugs are bad because hedonism is bad […] except for when they [drugs] are medical’. Some interlocuters pointed to
recreational and medical CBPs as an artificial divide which is far messier in reality (Figure 5). For example, the medicinal emphasis on ‘health not the high’ (Jill), excludes the ‘THC’ from legitimate medicinal CBPs. However, the psychoactive effects are important for its beneficial
effect28 (Section 3). In a separate critique, the demarcation of medicinal from recreational could reify the stigma associated with cannabis as a whole. Sally, a biomedical researcher, explained that fear of diverting medicinal CBPs for recreational purposes stemmed from the illicit association with recreational cannabis . This fear ignores the in-between uses of cannabis: ‘redical’ for cannabis that was neither ‘not recreational or medical’. Jill, a patient advocate, proposed many people ‘self-medicate without knowing it’ implying that people who used recreationally might also have a medicinal purpose.
Figure 5 Different types of cannabis posted by medicinal cannabis patient on social media (See Section 5). L: medically prescribed Bedrocan, R: recreationally bought Pink Kush in Canada. NB Pink Kush actually has a lower THC content
Figure 5 shows two different forms of herbal CBPs obtained by Carly Barton, a medicinal CBP patient and advocate, for her condition (see Section 5.3.1). The ‘medicinal’ form (left), prescribed by a doctor in the UK, contains higher THC-levels than the
‘recreational’ form (right), bought in a Canadian dispensary. These two CBPs are defined by their context, how they were obtained, rather than content, what they contain. This legal and biomedical classifications disregards Carly’s intended, and actual, use of both her condition. This example highlights the problems in separating medical and recreational cannabis.
My perception of these labels also influenced my research. Henry, an employee in cannabis biotech company, pointed out my research question ‘assumes that cannabis isn’t a medicine already… you mean: it is not a regulated medicine so how do we make it such’.
28 This medicinal criteria excludes subtle effects like well-being (Subritzky, 2018) or stronger effects like pleasure (See Section 4.1). See also: Race (2009) explores how medical discourse moralises healthy and risky drug-taking behaviours use and notions of hedonism restrict potential medicinal uses of currently illicit drugs
Henry questions the authority to decide what is and isn’t a medicine (section 4). This
emphasised my position as a researcher in ‘making cannabis medicinal’ and whose authority I appeal to for my medicinal-recreational . In Section 3, I will outline local practices of
making cannabis medicinal which highlight how ‘regulation’ is not the ultimate factor arbitrating whether cannabis is a medicine or not.
2.4 Conclusion
This section provided further historical context and examined whether cannabis is already medicinal. Currently, the dominant narrative taints cannabis with recreational and/or illicit connotations which is a barrier in legitimately making cannabis medicinal. Cannabis’ complex history loses nuance in political and media and often the prevailing illicit depiction is propagated. Contrastingly, the counternarrative provides a compelling
refutation by providing evidence of legitimate cannabis use for medicinal purposes by problematising the prohibition’s foundations. However, the reactionary nature of the counternarrative results in a constant struggle with dominant tropes, particularly the absence-presence of ‘recreational cannabis’. The competing narratives are key in shaping cannabis trajectory in the UK. The following section will detail outline how cannabis’s unusual properties resist the classic categories of drug, non-drug and medicinal categories and require a new conceptualisation.
Section 3: Different ways of making certainty
The previous section examined how competing narratives frame ways of making cannabis medicinal. The terms ‘cannabis’ and ‘medicinal’ are broad and how they
specifically relation to each other emerges in different practices. This section will outline how cannabis’ fluidity results in highly individualised practices of how cannabis is made medicinal. I begin by explaining how cannabis’ fluidity, namely its botanical versatility and chemical polymolecularity, make it unlike other medicines (or drugs). I will then outline how cannabis’ fluidity enables a range of practices of making cannabis medicinal, which vary at the individual and community-level. I argue this adds to cannabis’ fluidity such that cannabis resists classic categorisation, which make problematic to control and research. I show how this leads to huge variation in evidence which leads to difficulties in trying to accumulate knowledge which underpins authority issues and also hinders progress in making cannabis medicinal beyond the practices of micro-level stakeholders.
3.1 Complexity
I will first outline how complexity is amplified in making cannabis medicinal and how this relates to uncertainty. These are subjective and dependent on the scope and scale of process making cannabis medicinal. For example, different interlocutors highlighted on different stages of complexity which were significant to them. In Figure 6 which I have made a simple schematic of these stages. While the law and biomedicine have interrelated and overlapping effects on this cycle, the fluidity of cannabis allows for ‘interpretive flexibility’ (Star and Griesemer, 1989). The lack of enforcement of the law29 enables variation in practices making cannabis medicinal through illegal (or extra-legal30) means.
29 Many Police constabularies in the UK have said they will not prosecute small-scale cannabis users. 30 Extra-legal in terms of activities beyond the scope of the law. Activity might be technically illegal but not enforced due to sentencing guidelines or variable police enforcement [footnote 29]
Figure 6 There are many points in cannabis life cycle where complexity can be amplified van der Geest et al.’s (1996) Biographical Approach to medicines.
Whilst complexity alone is not a problem for medicines per se, I suggest that complexity amplifies at each stage. Cannabis’ versatility as a plant means it is easy and cheap to grow but difficult and expensive to standardise. There are many different sub-species known as cultivars (Lewis et al. 2017). As such, there is a vast difference CBPs produced through the micro-level and macro-level processes, such as homemade and pharmaceutical-grade CBPs. Instability is another challenge because cannabis plants’ chemical profiles are hypersensitive to growing conditions31 which causes differences between genetic clones and even the same plant (Bernstein et al 2018). Zach, a patient advocate explained, ‘with cannabis we are looking at the whole plant’ and outlined stages in the process making it medicinal such as ‘harvesting’, ‘drying’, ‘curing’ and ‘heating for activation of the cannabinoids’. However, Zach also said that there is a ‘whole process before that is really affects it [cannabis] having its full effect’ which referring to the interrelated processes of actualising the efficacy-potential in the plant.
Cannabis’ chemical profile, polymolecularity, contains over 400 active chemicals which include 70-90 cannabinoids, such as CBD and THC32. The pharmacological explanation of how CBD and THC works outlines their mechanisms of action but are limited in explaining ‘how cannabis works’. It is difficult to measure subtle33 effects of other chemical families,
31Sally, a biomedical researcher, linked the prohibition to the development of the hydroponic industry, from which technology and knowledge are used in legitimate industry today for in optimal growth conditions such as which ‘nutrients increase which secondary metabolites’
32 These numbers vary depending on the information source see (Russo, 2014)
33 The cannabinoid THC has the strongest effect and often the defining marker in law and social understanding because of its. It is classed as the psychoactive component and associated with the recreational ‘high’ of cannabis (Ford et al., 2017; Freeman et al., 2018).
such as terpenes and flavonoids, or the effect of multiple variables such as ‘CBD and THC don’t bind in the same way but they do mess around with the same protein [receptor]’ (Helen, a biomedical researcher). This makes it difficult to test claims that cannabis’ polymolecularity has an ‘entourage effect’ makes full-spectrum CBPs ‘more effective that having this one single active compound on its own’ (Sally, medicinal CBP patient). Cannabis’ polymolecularity is variable and is used for a diverse variety of symptoms and illnesses (see Figure 7a). This contrasts with the a legally protected term ‘medicine’34 where conventional medical drugs are often unimolecular targeting a single symptom or disease.
Arguably, cannabis’ fluidity is incompatible with the conventional biomedical and legal classifications which have stable categories. Emma, a patient advocate, argued for ‘a separate classification – not the drug scheduling [because] It’s not a singular compound […] It’s not like any other pharmaceutical drug so it shouldn’t be in the medical scheduling either’. However, cannabis’ fluidity and variation of CBPs would be difficult to categorise individually – and even then, it might not be a solution with too many categories. The fluidity of cannabis manifests in different ways with different effects. The physical
complexities of the plant are often invisible. This is because cannabis’ versatility materialises at the chemical level while the visible appearance (or smell) of cannabis is conserved. This allows the cannabis to operate as ‘boundary object’ (Star & Griesemer 1989) across many disparate groups. However, this leads to linguistic complexities with the polysemic word cannabis collapses the many and varied CBPs into a single term. This is problematic because there is a large distance between the ill-structured common form of cannabis compared to a well-structured CBP that emerges from local practices CBPs. It is hard for stabilising or standardising mechanisms collapse this distance and effectively categorise cannabis and CBPs, which can lead to uncertainty.
34 The UK’s Medicines Health and Regulation Authority heavily regulates this process and even places restrictions on advertising and presentation
3.2 Uncertainty
In a similar way to complexity, uncertainty also depends on the level and orientation of analysis. The ambiguity of cannabis relates to its contested history and fluidity which makes it difficult to categorise cannabis because ‘it doesn’t fit into a neat box’ (Emma, patient advocate). It is difficult to build on knowledge and communicate about cannabis’ effects, particularly since they are wide-ranging (Figure 7a).
Figure 7 (A) Poster at information small CBD business event detailing some of the conditions CBPs could treat and comparing that to medical pills (B) Slide from Centre for Medicinal Cannabis annual lecture 2019 detailing the proportion of wide range of conditions patients are prescribed medical CBPs in Australia, showing there is a wide range of conditions.
I showed Figure 7 (a) to a group of fellow medical students, we all found it funny but ‘ridiculous’ because ‘one thing can’t do that much’. A few weeks later, I attended a lecture, given by an Australian specialist in medicinal cannabis, where he described the range of patients currently prescribed medical CBPs (Figure 7b). While there is significant overlap significantly with the poster (Figure 7a), I was more accepting of the information from the lecture than from the poster. My instant judgements, finding one amusing and the other impressive, highlights how I evaluate information and privilege biomedical authority in the face of uncertainty (Section 4).
Within biomedicine, there is another dimension of uncertainty concerning the endocannabinoid system (ECS). A doctor in the MCCS, described it as ‘unique’ across different bodies in different states of health. This means different products work for different people, so it is important to ‘start low, go slow’ and experiment (doctor from the MCCS). There are complex interactions between polymolecular cannabis and highly individualised ECSs. The fluidity and instability resist conventional methods of ‘certainty-making’ such as RCTs. Sally explains, ‘you’re told, as a scientist, to only change one variable at a time. The standardised methodology for doing clinical trials favours isolates [single compounds] but cannabis is doesn’t work like that’. While uncertainty is part of how science problematises cannabis however I propose that uncertainty is an emergent attribute. Cannabis’ fluidity resists stabilising effect of contemporary standards of research. This leads to uncertainty because current measures of cannabis’ effects (for benefits or harm) have limited predictivity. However, the uncertainty here emerges specifically from the limitation ‘normal science’ to account for cannabis’ fluidity within the current biomedical ‘paradigm’ (Kuhn 1962). I argue ‘extraordinary research’ is necessary to breakthrough boundaries of normal science but this would need more than a separate classification system.
I have so far problematised complexity and uncertainty, but they are not always a problem. Uncertainty can promise untapped medical potential (Figure 7a) and can allow patients and communities to actively make sense their experiences which I will detail in the next sub-section.
3.3 Sense making: Using the body as an instrument
Both complexity and uncertainty are subjective and depend on the breadth and depth of individual perspectives. There are many sense-making practices which simplify the complexity surrounding cannabis. These perspectives use different modes of knowledge to in their practices of making cannabis medicinal, privileging bodily experience. Some
interviewees even saw simplicity in cannabis as something-that-works highlighting complexity and uncertainty are context-dependent. However, the range of knowledge
practices results in vast amounts of information which is not standardised or regulated which can cause problems especially online.
My interlocuters’ sense-making practices varied considerably and often depended on what their goal. This was a highly individualised process and I will briefly outline examples of Hakim, Alice, Beth and Liam to show how they privileged their bodily experience and bracketed forms of complexity and uncertainty. Patients had learnt to actively evaluate how CBPs worked for them as a medicine for their ailment and heightened awareness of symptoms and effects, for example by logging of different dosages, strains and delivery modes and experimentation with and without CBPs to see the difference to
concretise the effects.
The first two examples include CBD-oil, a form of CBP officially categorised as a food supplement i.e. non-drug, which highlights the tension between recreational and medical usage. Hakim is in his early-30s and has long-term mental health issues35. He previously used cannabis as a ‘mood stabiliser’. He found it difficult to control fluctuating THC-levels which led to some bad experiences. He stopped cannabis altogether, but his mental health worsened. A friend suggested CBD oil,36 which he doubted initially but after a few days of trying he realised it helped him. Then he heard that CBD and THC work synergistically, he began using CBD in another way: to balance the effects of THC37. Hakim carried his ‘Holland and Barret’ 38 bottle around with him – just in case he ‘needed his medicine’. This sits between recreational and medicinal usage of cannabis. Hakim obtained the illicit drug cannabis from a drug dealer, with no control over THC-level and the non-drug, CBD oil from a health and wellness retailer. He found a process that worked for him and was
unconcerned about how it worked and seemed surprised by my preoccupation with it.
35 Hakim did not want to be recorded because of he was worried disclosing his recreational cannabis use would lead to ‘trouble with the police’.
36 CBD oil is technically a food supplement (MHRA, 2016, FSA 2019)
37 I heard many of such accounts of this non-supplemental usage of CBD. One study investigates how cannabis users tinker with levels of CBD and THC (Freeman et al., 2014) but it would be interesting to replicate this with medical cannabis users
38 Holland and Barret was often used as a legitimising force because it is a well-established Health & Wellness shop. Simultaneously, it was also critiqued for poor quality CBD-oil
Contrastingly, Alice in her early-20s is a long-term sufferer of chronic fatigue syndrome (CFS), said she would ‘never take drugs like cannabis’ because she doesn’t want to risk the ‘mental health issues’. She started taking CBD oil on a recommendation from a family member to help with anxiety and sleep but without many expectations.
