Medicine, Education, and Cannabis Policy in Switzerland

Translated from the website Health Europa

Professor Rudolf Brenneisen from the Swiss Cannabis Society in Medicine discusses medicinal Cannabis in Switzerland.

The Swiss Cannabis Society in Medicine (SSCM), the Swiss ambassador organization of the International Association for Cannabinoid Medicines, aims to see Cannabis recognized and regulated as a legitimate form of medicine in Switzerland. MCN talks with Professor Rudolf Brenneisen, chief editor of the specialized journal Medical Cannabis and Cannabinoids of SSCM, about medicinal Cannabis and cannabinoids in Switzerland.

What are the main benefits of Cannabis in medical treatment?

Cannabis can have a multitude of effects - although this does not mean it is a panacea. It can have therapeutic benefits in a broad spectrum of indications, including chronic and neuropathic pain; nausea, vomiting, and loss of appetite; neurological conditions; chronic inflammation; and more. Marijuana and cannabinoids - mainly THC and CBD - have a wide therapeutic window: this means they carry only a marginal risk of physical or organ toxicity, and the risk of possible psychological side effects is low to moderate and dose-dependent. The typical psychotropic side effects of THC can be improved by combining it with a dose of CBD.

Are there any specific challenges or side effects of Cannabis as a medicine?

A really challenging aspect of Cannabis is evaluating all the different forms of application to determine which is ideal for medicinal use. The selection of the type of medication should ideally be based on the patient and the indication, although some producers claim to offer between 1,000 and 2,000 individual types and chemovarieties, it is still essentially impossible to provide Cannabis-based treatment that is 'individualized' uniquely for the patient.

Marijuana and its extracts may be available in the form of single isolated substances, such as THC or CBD; standardized extracts like Sativex®; and full-spectrum preparations, such as marijuana flowers.

The predominant application forms are:

• Oral preparations, such as capsules and teas: they are easy to use, with high patient adherence, but the low bioavailability in orally administered products means that up to 85% of the cannabinoids they contain are deactivated in the digestive process;
• Smoked Cannabis in the form of joints is the most popular application form for self-treatment, but it is prohibited in clinical trials as it is harmful to the airways and lungs. Additionally, street or homegrown marijuana is not quality-controlled, meaning dosing is trial and error;
• Vaporized marijuana instead of pyrolyzed for inhalation is highly recommended: it is efficient, easy to titrate and calculate dosages by microprocessor-controlled devices, and less stressful on the lungs; and
• Oromucosal preparations, such as sublingual oils or sprays, are easy to apply and avoid some of the deactivation that occurs in hepatic metabolism. Sativex, the only Cannabis-based medicine approved in Switzerland, is an ethanolic extract of Cannabis, which means it irritates the mucosa; and therefore, is not allowed for pediatric treatment.

Another very challenging factor is the combination of the complex pharmacokinetics (what the body does with the drug) and pharmacodynamics (the effects the drug has on the body) of cannabinoids. THC and CBD are multitarget modulators and interfere with the endocannabinoid system in various pharmacological ways: therefore, it is not easy for the physician to understand or predict the full range of effects.

What is the current status of medicinal Cannabis in Switzerland?

Currently, any therapeutic application of THC and Cannabis preparations containing more than 1% THC requires a special permit from the Swiss Federal Office of Public Health. THC-rich Cannabis is prohibited. CBD-rich Cannabis and CBD itself are not scheduled but are not freely available as medication in pharmacies without a prescription. CBD-enriched products are freely available as dietary supplements, tobacco substitutes, and lifestyle medications; as long as they are officially quality-controlled.

Switzerland's drug law is currently under review, which means that by around 2022, it may be possible to prescribe THC-rich flowers and preparations without the need for a special permit, as is required today for each patient and indication. So far, the oromucosal spray Sativex - a standardized THC-CBD extract - is the only approved formulation in Switzerland with a significant THC content.

Is knowledge exchange and continuous education important to ensure a broader evidence base for the medical application of Cannabis?

It is essential and mandatory to enhance the specific expertise of physicians, pharmacists, and healthcare professionals. Scientific information should be provided by professional organizations such as the International Association for Cannabinoid Medicines (IACM); the Swiss Cannabis Society in Medicine, the Swiss branch of IACM; the International Cannabinoid Research Society (ICRS); CannX; and many more national and local organizations. Due to restrictions imposed as a result of the coronavirus pandemic, continuous education is currently largely conducted virtually, through online seminars: it seems likely to continue until 2021. A Zoom conference reaches more people, facilitates scheduling, convinces more top speakers to contribute, and reduces organizational costs; however, the classic physical conference should be reactivated as soon as the pandemic allows.

Interdisciplinary education and training in medicinal Cannabis should be integrated into the curriculum of medical and pharmaceutical studies: SSCM has a program planned to be launched in the near future at the University of Bern. Research data - including basic, clinical, and case reports - should be more widely shared within the scientific community and among professional therapists; but also more broadly, to the public and media. The recently founded open-access journal Medical Cannabis and Cannabinoids, the official journal of SSCM, is one of the few peer-reviewed journals dedicated to this particular plant, its amazing components, and the cannabinoid target system present in all mammals.

Do you see medicinal Cannabis gaining broader legal acceptance throughout the EU in the future?

The increase in clinical evidence, positive patient reports, and media coverage are contributing to the ongoing destigmatization of Cannabis: this, in turn, leads to greater acceptance in policy and legislation; and thus facilitates the increased medicalization of marijuana and cannabinoids. On the other hand, recreational use is still very common, often in many quite problematic ways; and therefore, in most European countries, recreational Cannabis use is prohibited - as in Switzerland - or only tolerated. SSCM emphasizes the need for definitive separation and separate regulation of the medical and non-medical use of Cannabis and cannabinoids.