WHEN THE DRUGS DO WORK

The drug Nabilone offers great pain relief, but is not freely available.
Why? Because it is synthetic cannabis, says Dr COLIN BREWER.

Even over the telephone, you can tell that Walter Dale probably never smoked
cannabis as a teenager. Not the type. Not the age-group. His teens were the
early Fifties when cannabis simply wasn't around, unless you were a Jamaican
saxophonist.

By the time it appeared in the mid-Sixties, Walter was married, running a
successful business and collecting old Jowett cars. If he wanted to adjust
his brain, he used alcohol.

Until his late-50s, he was fit and healthy, but ageing humans, like ageing
Jowetts, give trouble sooner or later. In 1995, he slipped a disc. After an
operation (courtesy of Bupa, so no delay), there was some residual pain.

The surgeons said a little injection near the spine should do the trick. It
probably does for 99 per cent of patients but Walter's legs were numb and
paralysed the next day.

Movement and feeling returned, but he was left with increasingly severe pain
and weakness.

Soon, he had to use two walking sticks and neither his GP nor the local pain
specialists had an answer.

Strong opiates didn't help and, in any case, he feared becoming addicted to
them.

A few months ago, he read that cannabis sometimes relieved intractable pain.
Overcoming his law-abiding habits, Walter obtained some. He wasn't very
hopeful but five minutes after the first lungful, the pain was enormously
better.

Subsequent cannabis joints were equally effective.

He told his GP who was, as always, sympathetic but couldn't legalise Water's
successful self-medication with cannabis.

Walter contacted Release, who normally advise youngsters arrested for
possessing illicit drugs. Release referred him to me, though I specialise in
addiction, not pain.

As I understood the legal situation, I could prescribe heroin for Walter but
not cannabis, though it might become possible when planned clinical trials
had been completed in a year or two.

Of course, I'm all in favour of objective scientific trials, but I also
believe that one of the primary duties of doctors is to relieve pain and
that there's an important but unfashionable entity called "the art of
medicine".

In the absence of scientific evidence, I'm willing to use cautious
empiricism to help my patients. Although I had never prescribed it, I knew
of a synthetic cannabis preparation called Nabilone, used to control the
severe nausea and vomiting which complicates some types of chemotherapy for
cancer.

I checked it out. It wasn't even listed in the current MIMS (the
pharmaceutical industry's monthly guide). The National Formulary mentioned
it but warned that it was for hospital use only.

The makers, Cambridge Laboratories (based, confusingly, in Tyneside), were
very helpful and told me that in addition to its official, licensed use by
hospital cancer specialists, any doctor could prescribe Nabilone for other
purposes, provided the patient knows the drug is being used "off label", as
the Americans say.

This is not unique to Nabilone. Many drugs are prescribed "off label"
because medical practice advances more quickly than medical bureaucracy.

Prescribing "off label" exposes both patient and doctor to possible risks,
and it must be done responsibly.

But it is common in most areas of medicine.

Nabilone isn't a "controlled drug" like morphine or dexamphetamine. It is
actually in much the same legal category as many other drugs used to treat
cancer.

I gave the good news to Walter's GP. He was afraid to prescribe it, so I
referred Walter to an allegedly sympathetic pain specialist. He was
sympathetic, but not enough to prescribe it.

It seemed I would have to prescribe it myself. I took a history and examined
him. He was clearly quite handicapped and there was obvious wasting of the
leg muscles.

After intoning the official "off label" warnings, I gave him a prescription.
Two chemists then refused to dispense it, apparently on the grounds that
anything involving cannabis was dodgy. After two weeks, one relented, though
Nabilone cost Walter much more than his illicit cannabis. He had to pay
UKP117 for 20 capsules.

They worked just as well, though the onset of relief was naturally slower
than with smoking.

One capsule a day is usually sufficient.

He still walks slowly, sometimes even without sticks or pain, and the only
side-effect is slight nausea.

Naturally, I have asked myself whether this is simply a placebo effect. It
could be but the benefit has now lasted for over a month.

We could easily give him some dummy capsules and see if he can tell the
difference.

The GP is impressed and accepts that he won't be dragged before the General
Medical Council if he gives Walter an NHS prescription, but he still won't
prescribe Nabilone because it costs so much and might be needed for several
years.

Walter is 61 and married for a second time with three teenage children. He
has had to retire from his business because of his disability, but at least
he can live free of pain with Nabilone.

What are we to make of this crazy situation?

The official position (that we can't prescribe cannabis until trials have
been done, and maybe not even then) is obviously incorrect.

Nabilone is tetrahydrocannabinol (THC) - probably the main active
constituent of cannabis. As with many new or under-researched treatments
(especially drugs for Aids), clinical trials can be done in parallel with
empirical use.

Cannabis isn't a new drug and clearly has relatively low toxicity. It
shouldn't be dished out like Smarties (nor should Valium), but it shouldn't
be denied to deserving cases like Walter just because of the USA's
ineffective worldwide "war on drugs" during the last 80 years.

I don't easily believe in conspiracy theories but I do suspect that the
government is terrified of offending the US and that there's at least a
mini-conspiracy to pretend that Nabilone doesn't really exist. Or
alternatively, to pretend that it can only be prescribed by cancer
specialists for in-patients.

I don't say that it should be prescribed (especially on the NHS) to people
who just want to get stoned, but it seems that most regular cannabis users
prefer the real thing.

I hope to get Walter enrolled in one of the trials expected to start soon,
so that he won't have to pay about UKP6 a day for a legal supply of a drug
which, in a sensible world, he could grow at home for a few pennies.

Dr Colin Brewer is medical director of the Stapleford Centre in London,
which specialises in addiction.