On Monday and Tuesday, doctors, researchers, government officials, entrepreneurs will gather at the Aotea Centre for the first MedCan summit, which is also the first big gathering for the sector since the introduction of regulations allowing for cannabis medicines to be legally produced and more easily prescribed in New Zealand. But by no means everyone there will be working under the new law.
When the officials and regulators take their seats for the summit's main event – a video keynote from Professor Raphael Mechoulam, the 90-year-old Israeli researcher who first isolated THC and CBD from cannabis, and the totemic figure of medical research around the plant – they will be alongside people who are, officially speaking, drug criminals.
It's a measure of the complicated state of medicinal cannabis in New Zealand that the illicit sector currently accounts for the overwhelming majority of therapeutic cannabis use – and that, at least for now, its providers and have more and better products than the doctors do.
"Whether we like the idea of it or not, and personally I'm quite comfortable with it, that is a big part of our industry," says Paul Manning, chief executive of the summit's foundation sponsor, Helius. "The question is how do we bring those people and those organisations along on the journey, so one day they can be part of a regulated space where they aren't forced to operate underground?"
The answer is much less clear since the narrow failure of the "Yes" vote in this year's cannabis referendum. Although the referendum bill was officially only about legalising and controlling "recreational" use, it would have offered a way forward for an illicit therapeutic community that touches the lives of tens of thousands of people, yet can't even get its products tested.
You may have seen "Sam" and "Rico". They featured in this year's third episode of Patrick Gower on Weed, as the Dab Chemists, a pair of masked yahoos making scarily strong THC extracts. Then-Justice minister Andrew Little was ambushed in the programme with the test results on their concentrate "diamonds", which turned out to be 71 per cent THC. They were horrified.
"What the documentary didn't show is that my extraction processes and techniques are being used mostly for CBD products and a lot of people are benefiting from the healing properties of what I'm able to make," Rico wrote in an impassioned email to the minister after the programme aired. "I want you to know that I am in no way involved with any gangs nor other drugs manufacturing and my passion lies in helping people and making use of this incredible plant."
He didn't have $150,000 for a licence. How, he asked, could he follow his passion, and use his scientific background, legally? After a week, the minister replied with a long and sympathetic email advising them to keep their noses clean and suggesting ways the cannabis legalisation bill could work for the pair – if it passed the referendum.
The cost of a typical set for licences for a smaller venture would actually be more like $20,000, but the cost of licensing is just a start for any green fairies hoping to go legit, says Shane Le Brun, the former spokesman for the patient advocacy group MCANZ: "The medicinal law, because it's pharmaceutical grade or bust if they actually want to make their own products, it's $10 million or go away. Which is pretty disheartening for them."
Meanwhile, Sam and Rico embody the growing sophistication of the illicit sector. Although their full-spectrum pure CBD oil is imported – a breach of the Medicines Act rather than the Misuse of Drugs Act – they have the equipment to extract both THC and CBD cleanly from cannabis flower and offer extraction as a service to green fairy growers, promising a more palatable product than the traditional bitter cannabis oil. They sell oils and pre-loaded vapourisers for medicinal use and can mix products to order. Their latest investment is a batch of nebuliser-style devices for patients who can't use oils or vapes.
By contrast, all that doctors can readily prescribe as yet is a small range of CBD isolates and one product containing THC, GW Pharma's Sativex, which was approved in 2010 but can now be prescribed for any purpose by GPs. THC products from the Canadian firm Tilray are not approved but can be prescribed by specialists.
On the other side of the line there's Auckland medical herbalist Erin Hudson, who does not supply but "facilitates access" for clients to products from Sam and Rico and the Northland green fairy Gandalf. She requires a phone, Zoom or in-person consultation to do so. One client, who has suffered pain for osteoarthritis for two decades, told the Weekend Herald he had a 45-minute phone consultation with Hudson and described her as "genuinely empathetic and interested". The THC product he subsequently obtained worked well, he said: "I've been on anti-inflammatory and painkilling drugs for years and I honestly don't feel like I need any right now. It's mind-boggling."
Hudson says she discusses safety with clients, sometimes advising them to only dose at the weekend and telling naive users in particular to start on a very low dose. In some cases, she may recommend raw cannabis smoothies ("It's as much a food as it is a medicine"), which isn't as daft as it sounds. The raw, acidic forms of the two main cannabinoids, THCA and CBDA, are not psychoactive and research by Professor Mechoulam and others suggests they have more therapeutic potential than THC and CBD, if they can be made stable enough for production as medicines. But even though you can't get high by eating raw weed, possession of any part of the plant is a criminal offence.
Sam and Rico use their own products. Sam, who puffs occasionally on a THC vapouriser as we talk, had spinal fusion surgery last year and came off a 300mg a day codeine prescription. He says it's the first time in 15 years ("and I'm not yet 30") that he has not been taking prescription opiates. Rico says he gave up his antidepressant medication after he began making his own CBD products.
Although the efficacy of cannabis for pain relief is still not clearly established – in part because of the difficulty of conducting research with a controlled drug – this pattern of being able to reduce or stop use of sometimes onerous prescription medicines came up strongly in a patient survey conducted last year for MCANZ.
"It's often dismissed as anecdotal," says the University of Otago's Dr Geoff Noller, who directed the MCANZ survey. "But if that's the case, how can it be that people are able to give up these powerful analgesics through the use of cannabis as a medicine? I'm not a clinician, so I can't make any clinical claims, but it's hard to ignore the data."
Noller has just completed a paper for an American journal on the use of cannabis for endometriosis pain. Ten per cent of his sample reported an endometriosis diagnosis and two-thirds said they'd given up other pain medication in favour of cannabis.
Noller's results were echoed in a similar study by Massey University researchers, which found that 95 per cent of patients who used opioids reported reducing their use with cannabis. The class of prescription drugs most frequently stopped was gabapentinoids, which can have unpleasant and occasionally dangerous side-effects. Although these people overwhelmingly did not get their cannabis from their doctors, they did generally continue to see those doctors.
Dr Graham Gulbransen, one of about a dozen doctors nationwide who regularly prescribe cannabis products, is looking forward to having a wider range of products to dispense as the new regime matures. For now, he largely prescribes CBD, sometimes for children suffering seizures or with anxiety related to autism. He acknowledges that his prescribing makes him one of the doctors most trusted by the cannabis community.
"It's great to be able to talk to those who are risking prosecution by being out there," he says.
Le Brun, who has advised Rua Bioscience, is now working with another local company, Medleaf, which has contracts to import cannabis products from more mature markets. He says the thicket of regulations under the new scheme means it will not be until the middle of next year that products from a cluster of local producers become available. He expects the locals to deliver both oils and raw cannabis flower (which is permitted under our regulations) before trying to differentiate themselves with particular products and delivery devices.
The pharmaceutical-grade standards open up export markets for them, but also hamper them. The regulations cite the EU Pharmacopoeia, which means that balms or ointments containing local ingredients such as kawakawa or horopito are not allowed. Meanwhile, locally blended cannabis balms and hemp oils are migrating from under the table at farmers markets to open display. And even as the nascent industry gets up and running, it's possible that green fairy products will be more attractive to many people than the official ones.
"That's already the case," says Le Brun. "'Made in a kitchen with tender living care' has a certain appeal to people and the green fairies are often local heroes. I'm not saying their products are better or worse. For the most part I suspect they're better than the isolate products that are available now. On the pharmaceutical side it's going to be much easier, at least early on, to cobble together some isolate products – while patients want broad-spectrum products that should have more effect."
It amounts to a difficult situation for police, who are required to apply the law, but presumably mindful that there are patients who rely on the illicit therapeutic networks.
This week, Erin Hudson and her colleagues will be attending MedCan as guests of Manning and Helius. The Government may need to find a way for their respective groups to live together – perhaps, as Hudson proposes, a formal green fairy amnesty to provide some breathing space.
Whatever happens, it may be that Andrew Little, who seemed so keen to put the referendum to bed as Minister of Justice last week, will find that the issues it was meant to address have followed him to his new portfolio in Health.
When the results speak for themselves
Sirene Gill turned 6 years old last month. It was not a birthday she was expected to reach.
After spending most of 2019 in treatment – including a bone marrow transplant – for acute myeloid leukaemia, she went into remission in December. But in June this year, the cancer returned and she was back at Starship. Her prospects were very bleak.
"They gave her a 16 per cent chance of survival with treatment," recalls her mother, Marama Gill. "They told me that without treatment, she would die within months. She went straight into another round of chemotherapy – and on her second day into her first cycle of chemotherapy, she ended up in paediatric ICU. She was just really unwell and the doctors told us to call our family up to come and say their goodbyes. It happened very, very quickly."
Had the situation not been quite so hopeless, Gill might not have bowed to the urgings of her father and begun supplementing her daughter's treatment with oral drops of cannabis oil, hiding it from the nurse stationed to her daughter's bedside.
"The morning after I started her on the cannabis drops she was transferred out of ICU and back up to the oncology ward. She no longer needed to be in ICU. She also began eating again, overnight. And she was tolerating her chemo better."
During her 2019 treatments, Sirene had stopped eating for months and became immobile.
"But what I noticed with the drops was that none of those things were happening. She still had a healthy appetite. This time around she coped with everything so much better. When they found out what I was doing, I went through multiple whanau meetings with the doctors, who all came together to tell me what I was doing was wrong. But the results I was seeing were what drove me to continue."
"They were quite ostracised in the hospital," says Erin Hudson, the Auckland medical herbalist who worked with the family. "To start with, they're a young Māori family, so they were shy, but they didn't have any doctors' visits, the entire team would walk past their room every day. A junior doctor would just come and check if there was anything they needed. Their nurses were always moved off after one shift – they never had the same nurse twice. It appeared to them that if the nurse showed any interest they were moved on."
Gill admits she was wary when her father first urged her to try the high-THC oil and spent "probably 14 hours straight" reading research on her phone at her daughter's bedside before concluding that "if it didn't work for her there was also no harm in trying. She couldn't overdose on it."
The first bottle of oil, made by the well-known Northland "green fairy" Gandalf, was brought to her by Brad Rapira, who her father had contacted after seeing a Marae TV report on Rapira's own daughter, 2-year-old Ahurewa, also a leukaemia patient, being given cannabis oil alongside her conventional treatment. Ahu, who had been given a 50 per cent chance of living before chemo began, is now also at home and apparently healthy. And Rapira, who has worked for 18 years as a clinical social worker, has become an unabashed activist.
Like Sirene, Ahu began on Gandalf oils before also receiving a prescription for CBD oil – to help ease the side-effects of her treatment – from Auckland GP Dr Graham Gulbransen. Starship doctors agreed to the prescription after a Zoom call with Gulbransen in which he assured them CBD would not interact badly with the chemo.
Rapira says she tested clear of leukaemia after her first chemo treatment, but he and his wife agreed to a full three rounds, requesting only that one chemo drug, etoposide, be removed from the third round on grounds of recent research suggesting it is associated with an elevated risk of secondary cancer, especially in young patients.
Hudson supported them in the decision: "I'm not an oncologist," she says, "and never, ever do we tell anyone to not take their medication."
Ahu's patient notes simply observe that she "responds well to chemotherapy" and it cannot be stated that the cannabis oil even helped. It's also not absurd to speculate that it could have.
A study published in the International Journal of Oncology in 2017 found that CBD and THC killed leukaemia cells and that cannabinoids in combination with chemo were more effective than either taken alone. It confirmed multiple other pre-clinical studies showing similar cytotoxic effects. But all these are in the lab. A proven clinical treatment is a long way off, assuming it ever comes.
At least one New Zealand child has actually been prescribed a THC cannabis product. In 2016, Elyse Johnson was prescribed Sativex, the only approved medicine containing THC. Officially, the prescription was to ease the side-effects of conventional treatment for a form of the aggressive and incurable brain cancer glioma. But she has lived far beyond her nine-month prognosis and her parents believe Sativex – which is unsubsidised and costs them up to $3500 a month – has helped her regain mobility. GW Pharma, which manufactures Sativex, has reported positive results for glioma in Phase II clinical trials. In one trial, the one-year survival rate was 56 per cent greater among patients who received Sativex than those who did not.
Dr Gulbransen can't discuss Ahu's case and is at pains to emphasise he does not prescribe CBD products as a cancer treatment, only for symptom relief, but adds "I'm aware of the powerful medicines that the doctors are giving. These are strong drugs with known side-effects that really do mess up these children. In terms of cannabis, I'm not aware that adverse effects are likely be anywhere near as strong as that. My legal advice is to say I can't recommend illegal remedies, but I can understand why you might take them."
As one of the doctors who enjoys the trust of the illicit therapeutic community, he would like to see "green fairies" given access to product testing.
"Like I am, they're dealing with intractable conditions. For people who are not responding to standard treatment, everyone should have the opportunity of trying cannabis – preferably knowing what's in it and what the ingredients are. I think it would be wonderful for these people to not have to guess about the ingredients."