Cannabis medicine, education, and policy in Switzerland

Professor Rudolf Brenneisen of the Swiss Society of Cannabis in Medicine tells us about medical cannabis in Switzerland.

The Swiss Society of Cannabis in Medicine (SSCM), the Swiss ambassador organisation of the International Association for Cannabinoid Medicines, aims to see cannabis recognised and regulated as a legitimate form of medicine in Switzerland. MCN speaks with Professor Rudolf Brenneisen, Editor-in-Chief of the SSCM’s peer-reviewed trade journal Medical Cannabis and Cannabinoids, about medical cannabis and cannabinoids in Switzerland.

What are the key benefits of cannabis in medical treatment?

Cannabis can have a plethora of effects – although this does not mean it is a panacea. It can have therapeutic benefits across a broad spectrum of indications, including chronic and neuropathic pain; nausea, vomiting and appetite loss; neurological conditions; chronic inflammation; and more. Cannabis and cannabinoids – primarily THC and CBD – have a broad therapeutic window: this means that they only carry a very marginal risk of physical or organ toxicity, and the risk of potential psychological side effects is low to medium and dependent on the dose. The typical psychotropic side effects of THC may be ameliorated by combining it with a dose of CBD.

Are there challenges or side effects specific to cannabis as a medicinal product?

One really challenging aspect of cannabis is evaluating all the different application forms in order to determine which is optimal for medicinal use. The selection of the medication type must ideally be based on patient and indication, though as some producers claim to offer between 1,000 and 2,000 individual types and chemovarieties, it is still essentially impossible to deliver cannabis-based treatment which is uniquely ‘individualised’ for the patient.

Cannabis and its extracts can be available in the form of isolated single substances, such as THC or CBD; standardised extracts like Sativex®; and full spectrum preparations, such as cannabis flowers. The predominant application forms are:

Oral preparations such as capsules and teas: these are easy to use, with high patient compliance, but 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 a no-go in clinical trials, as it is harmful to the airways and lungs. In addition, street or home-grown cannabis is not quality controlled, meaning dosing is reliant on trial and error; Cannabis which is vaporised rather than pyrolised for inhalation is highly recommended: it is efficient, easy to titrate and calculate dosages via microprocessor-controlled devices, and less stressful for the lungs; and Oromucosal preparations, such as sublingual oils or sprays, are easy to apply and avoid some of the deactivation which occurs in the liver metabolism. Sativex, the only cannabis-based medication to be approved in Switzerland, is an ethanolic cannabis extract, meaning that it irritates the mucosa; and is therefore not permitted for use in paediatric treatment.

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

What is the current status of medical cannabis in Switzerland?

Nowadays, every therapeutic application of THC and cannabis preparations containing more than 1% THC require a special permit from the Swiss Federal Office of Public Health. THC-rich cannabis is prohibited. CBD and CBD-rich cannabis are not scheduled, but are not freely available as a medicine in pharmacies without a prescription. CBD-enriched products are freely available as food supplements, tobacco replacements, and lifestyle drugs; provided they are officially quality controlled.

Swiss narcotic law is currently undergoing revision, meaning that by around 2022 it may be possible to prescribe THC-rich cannabis flowers and preparations without the need for a special permit, as is required today for every single patient and indication. So far, the oromucosal spray Sativex – a standardised THC-CBD extract – is the only approved formulation in Switzerland with a significant THC content.

Are knowledge exchange and continuing education important to ensure a broader evidence base for the medical application of cannabis?

It is both essential and mandatory to improve the specific expertise of physicians, pharmacists, and caregivers. Scientific information must be provided by professional organisations, such as the International Association for Cannabinoid Medicines (IACM); the Swiss Society of Cannabis in Medicine, the Swiss arm of IACM; the International Cannabinoid Research Society (ICRS); CannX; and many more national and local organisations. Due to restrictions imposed as a result of the coronavirus pandemic, continuing education is currently largely conducted virtually, through the medium of webinars: this appears likely to continue into 2021. A Zoom conference reaches more people, facilitates programming, convinces more top speakers to contribute, and reduces organisation costs; however, the classic physical conference should be reactivated as soon as pandemic allows.

Interdisciplinary education and training on medical cannabis must be integrated in the medical and pharmaceutical study curriculum: SSCM has a programme planned to launch in the near future at the university of Bern. Research data – including basic, clinical, and case reports – should be more widely shared in 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 periodical of SSCM, is one of the very few peer reviewed journals dedicated to this particular plant, its amazing constituents, and the body cannabinoid target system present in all mammals.

Do you see medical cannabis gaining wider legal acceptance throughout the EU in the future?

Increasing clinical evidence, positive patient reports and media coverage are contributing to the ongoing destigmatisation of cannabis: this in turn leads to higher acceptance in politics and lawmaking; and therefore facilitates the wider medicalisation of cannabis and cannabinoids. On the other hand, recreational use is still very common, often in many ways quite problematic; and therefore in most European countries recreational cannabis use is forbidden – as in Switzerland – or only tolerated. The SSCM emphasises the need for the definitive separation, and the separate regulation, of the medical and non-medical use of cannabis and cannabinoids.