Doctors need to participate in the debate on legalisation and regulation of illegal substances, because this topic is within their area of responsibility. The debate is not only about the introduction of legal, regulated outlets or prescribing of such substances by doctors. Some factors are directly related to the role of doctors in society, as well as to their relationship to patients who are using illegal substances.
Medical practitioners are responsible for providing unbiased information on the positive and negative effects of illegal substances. This is needed to improve the information on illegal substances in our society. The prevailing climate of prohibition policies has caused what I consider pseudo-medical, unbalanced information on the harmful effects of these substances to be supplied to the public by the police, by prohibitionist activists with no medical background, by the medical community and the politicians. This happens not only through media coverage of issues related to illegal substances in general, but lately also as part of the debate on legalisation and regulation itself.
As a reaction to this scaremongering, the legalisation movement has voiced a response. Occasionally, this movement promotes arguments on the positive effects of these substances that are just as pseudo-medical as those voiced within the prohibitionist regime on their negative effects. Medical practitioners must and should have the primary responsibility for correcting the myths that prevail, precisely because the substances are illegal and because in a prohibitionist mindset, morality often takes precedence over medical knowledge.
In an article in the Journal of the Norwegian Medical Association, Dr. Jørgen G. Bramness concludes: «A liberalisation or legalisation of cannabis is often linked to a desire for regulation through state-run schemes. There is a call for sales to be undertaken through a regulated monopoly for recreational drugs. If legalisation is chosen, I believe that such a development makes sense. I do not believe, however, that doctors should have a role in the important, preventive element of such a future arrangement» (1). Nevertheless, Bramness deserves credit for starting to take responsibility with regard to cannabis in particular, and for giving unbiased, sound information on the medical effects of the substances and the current state of research.
Doctors face illegal substances
Doctors must relate to how the use of illegal substances has positive or negative effects on the patient and the fact that treatment opportunities in some contexts are restricted because the drugs are illegal. Doctors with patients in opioid maintenance treatment (OMT) programmes are affected by the issues involved in legalisation, since the prohibitionist policies force them to implement control measures that engender distrust, such as urine testing and strict regulation of dispensing.
At the same time, doctors often need to make decisions on the basis of guidelines that have been established with a view not only to what is medically acceptable, but also in light of societal concerns, such as prevention of ‘leakage’ of OMT drugs. They also face restrictions in their prescribing of some medications because they are encompassed by anti-drug laws. Against this background, some doctors suffer medical pangs of conscience, and those who circumvent the guidelines may be stripped of their prescribing rights.
In the city of Bergen, when arrested for use and possession of small amounts of illegal substances, mainly cannabis, young people under the age of 25 whom the Hordaland county police refer to as resourceful, are offered participation in the programme «Tidlig ute» (Early start) as an alternative to other penalties. The programme refers them for health assistance and follow-up, including urine-sample monitoring. Such referral for health assistance of resourceful young people who violate the anti-drug laws may possibly come into conflict with the right to prioritised health assistance laid down in the Patient Rights Act – because non-criminal young people who have a greater need for help than those caught for smoking cannabis are pushed backwards in the queue. This could, for example, include young people who are in the process of developing an alcohol problem.
Doctors should realise that the anti-drug policies themselves have an impact on treatment and thus may have negative health effects for the patients. Recent research shows that GPs and doctors in the specialist health services have a strong tendency not to enquire about somatic illness in patients with known addiction disorders (2). Somatic diseases therefore remain untreated. I believe that this may be a result of a traditional, stigmatising prohibitionist mindset with zero tolerance for illegal substances – the doctor’s attention is deflected from physical and mental ailments and directed towards the elimination of substance use (3).
Doctors also need to relate to patients who engage in self-medication with illegal substances. These substances have medical as well as adverse effects that may interact with medications prescribed by a doctor. The patient may have medically valid grounds for his or her use of them.
A content declaration may prevent deaths
Although doctors may relate only to approved drugs when prescribing, they will need to take into account the patient’s use of natural remedies or synthetic drugs such as MDMA (ecstasy). In the event of legalisation, it would therefore be in the doctors’ interests that strict demands for content declarations and the best possible overview of active ingredients be set. If mild drugs such as cannabis and MDMA are legalised, such content declarations might reduce the problems faced by doctors in knowing what sort of substances the patient has taken – which may involve overdosing or coordination with medications to be prescribed. I am of the opinion that through regulation, we cannot exclude the possibility that naturally occurring cannabis or synthetic drugs with medical effects can be supplied with sufficiently accurate content descriptions to permit approval for medical use.
Doctors have a key role in the preventive efforts that the legalisation and regulation of illegal substances represent. Content declarations may prevent deaths and promote a better control of the medical treatment provided to substance users. Against this background, the debate on cannabis is a key concern for health personnel.