In Kuala Lumpur, Malaysia, a 29-year-old man was recently sentenced to death for selling cannabis oil to cancer patients. In the courtrooms of Thailand, lawmakers made a decision to legalise medical marijuana. In a laboratory in Australia, naturopaths and oncologists are conducting a major study on the effectiveness of liquid cannabis in the treatment of brain tumours.

Medical marijuana has entered mainstream discourse in recent years. But while many Western countries are aligned with regards to its efficacy, its adoption in Asia has been more complicated. Caught in a complex maze of limitations, the psychoactive plant is colliding with legal, religious, scientific and economic factors that have restricted its wider adoption, casting lingering doubts on its acceptance as a medical palliative, let alone a cure.

Proponents of the drug’s medicinal properties argue that cannabis is a vital tool when it comes to cancer care and treatment; some oncologists prescribe cannabinoids – the chemical compounds that naturally occur in cannabis – to manage the side effects of chemotherapy, such as pain, nausea and anxiety.

Of the 113 cannabinoids secreted by the cannabis flower, the most commonly discussed compounds are tetrahydrocannabinol (THC), the principal psychoactive ingredient of cannabis, and cannabidiol (CBD). THC is known to prevent nausea, vomiting and loss of appetite caused by chemotherapy, while CBD alleviates pain. Cannabis has also been successfully used to treat and alleviate the symptoms of Parkinson’s, epilepsy, and multiple sclerosis. Doctors typically recommend ingesting cannabis oils containing a combination of compounds, rather than smoking it, as the effects last longer.

Cannabis oils have enjoyed widespread support since the production and distribution of Rick Simpson Oil (RSO), the brainchild of a Canadian medical marijuana activist of the same name. Simpson created the oils – which are similar in structure to full extract cannabis oils, or FECO – in 2003 after he was diagnosed with a form of skin cancer known as basal cell carcinoma. When he applied an ointment containing high levels of THC extracted from the cannabis indica strain to the affected area, Simpson reported himself cured.

While no figures exist to prove how effectively marijuana reduces nausea, vomiting and loss of appetite in cancer patients, a recent survey of American oncologists published by the Journal of Clinical Oncology states that “80 per cent of the [country’s] oncologists had discussed medical marijuana with patients and nearly half recommended use of the agent clinically. And yet, less than 30 per cent actually consider themselves knowledgeable enough to make such recommendations.”

 Another cohort of doctors strongly believe that cannabinoids like THC and CBD can actually reduce the size of tumours and should be an integral part of cancer treatment earlier on in the diagnosis, and a team at Endeavour College of Natural Health in Australia is currently in the process of testing this on patients diagnosed with glioblastoma multiforme (GBM), a highly aggressive form of brain tumour.

But surrounding these medical approaches, a web of legal and scientific challenges is stalling the wider adoption of cannabis as a resource for cancer patients in Asia. As Yuuki Setsuna, an advocate at the Malaysia Awareness Society (MASA), puts it: “People with cancer are waiting and are ready for medical marijuana. It is the [laws in] countries that are slowing things down.”

RETHINKING CANNABIS IN MALAYSIA

Ashfaq* never thought he would try cannabis. The 42-year-old electrician, who lives in Kuala Lumpur, was diagnosed with leukemia last year; when he learned that his disease had progressed to stage 3, he felt hopeless.

After he started chemotherapy, Ashfaq looked for ways to alleviate his physical and emotional pain. A friend suffering from thalassemia (a blood disorder caused by abnormal hemoglobin production) had used cannabis to reduce fatigue and suggested Ashfaq give it a try.

After some initial skepticism, Ashfaq began smoking marijuana and ingesting cannabis oil last May. “The first time I used [marijuana], the smell was so strong. I couldn’t bear it. But I got used to it. Whenever I go for chemotherapy, it seems like I’m losing a bit more of myself. The cannabis helps in dealing with the pain and nausea,” he says.

But then Ashfaq lost access. In August 2018, authorities sentenced his supplier, Muhammad Lukman Mohamad, to death for possessing, processing, and distributing marijuana in the form of oils. Lukman admitted to selling cannabis but claimed that his clients were cancer patients who were using it for medicinal purposes.

“I tried to get it through other channels, but it’s hard to find a reliable person in Malaysia,” Ashfaq says.

That’s because selling cannabis in any form has long been punishable by death in Malaysia (although the policy is currently under government review). According to Lukman’s lawyer, Farhan Maaruf, the reason for the draconian law is, in part, due to religion. Roughly 60 per cent of the population identifies as Muslim, a religion that takes a conservative view of intoxicating substances.

 The harsh sentence sparked a sharp reaction in the country: MASA has been advocating on Lukman’s behalf, and a group of patients who found relief through cannabis he supplied started a petition calling for his freedom. To date, more than 70,000 people have signed the petition, prompting the Malaysian government to review the case.

In October 2018, the government announced plans to end capital punishment. There is currently a moratorium on all death sentences, including Muhammad Lukman’s, in the interim. The Malaysian government has also promised to re-examine the use of cannabis in the context of local research, education, and medication.

Setsuna of MASA believes that equating small-scale drug trafficking with crimes such as murder, treason, and waging war against the king is an “outdated and extreme step.” She is also of the firm belief that medical marijuana should be fully legalised.

“Most Malaysians understand that cannabis is widely used as medicine in other countries. There is a lot of awareness of the benefits from cannabinoids,” she explains. “Lukman’s case is proof that when people fall sick and modern medicine seems to fail, they will look for alternatives. Sooner or later more Malaysians are going to try to find [alternative] cures. Some [in dire situations] will try cannabis.”

 That might mean seeking out cannabis through illegal means or turning away from Malaysia’s medical system altogether – but that’s a move not many people can afford, says Setsuna. Those with financial flexibility might turn to neighbouring Thailand.

In December 2018, Thailand became only the second country in Asia to legalise medical marijuana after South Korea legalised it in November 2018. According to a new amendment in Thailand’s Narcotics Act, the drug is no longer considered to be Category 5 narcotic (ie “any form of chemicals or substances which… causes physiological or mental effects”). Cannabis can now be used for the purpose of medical research and care under the control of medical practitioners.

EXPLORING NEW THERAPIES

While countries like Malaysia and Thailand grapple with its legality, researchers in Australia have begun testing one of the sector’s most burning questions: Can medical cannabis treat cancer?

Dr Janet Schloss, a naturopath in Brisbane, Australia, first began entertaining the idea in 2015 after meeting renowned neurologist Dr Charlie Teo at the Australasian Integrative Medicine Association (AIMA) conference.

Three years later, in November 2018, Schloss launched a phase 2 clinical trial to investigate the effects of cannabis on malignant brain tumours, specifically glioblastoma multiforme. Earlier studies had investigated the drug’s ability to reduce symptoms and side effects, but this particular trial explores cannabis’ performance as a companion treatment to standard chemotherapy, radiation, and surgery.

“Oncologists can prescribe cannabis for chemotherapy, nausea and pain in countries where medical marijuana is legal, but not for the cancer itself,” says Dr Schloss. Her research, conducted at the Endeavour College of Natural Health in collaboration with Dr Teo and his team, aims to change that. 

Designed as a double-blind, randomised trial, the trial administers two different ratios of THC and CBD to 82 cancer patients, with each patient receiving treatment for a 12-week period. At the end of the study, the researchers will compare the two groups and see whether the drug compounds have had any effects. There is no placebo, meaning neither group has been given an identical dummy treatment to control for bias. Instead, the study’s design incorporates what is called a retrospective control group: a group of monitored cancer patients who are not administered the combination.

As of March 2019, 80 of the 82 patients have started the trial. After their 12-week course of treatments, the patients may choose to continue using cannabis at their own cost. The research team will continue to monitor patients each month in conjunction with their standard medical team for up to two years. If successful, Schloss will then begin another research trial to pinpoint the optimal stage to incorporate cannabinoids within the cancer treatment cycle.

“[Medical marijuana] may be better for people who are less progressed than those who are further along in the disease,” Dr Schloss says. The other thing she’ll look at will be dosage – what type of ratio works most effectively. “We’ll also monitor whether it’s just THC or CBD or their combination [to produce results], and what kind of combination works for each particular type of cancer. That’s where a lot of research is still needed.”

UNANSWERED QUESTIONS

The gaps in cannabis research for cancer treatments reflect the varying degrees of openness across countries and cultures. While Germany, Israel, Australia and the UK are currently running trials on cannabis and cancer, others, such as the United States, Switzerland and the Netherlands, have focused their trials on symptomatology and palliative care. Fewer studies thus far have explored the plant’s ability to inhibit tumour growth or “treat cancer.” 

Because of that, it’s difficult for researchers to reach a general consensus on a universal dosage regime and prescription, and for unified regulations to follow. It also means that as a cancer patient your options are defined and limited by the country that you are in – a multiple sclerosis patient in Germany might have access to more types of pain reduction alternatives than those in Malaysia. 

Even in countries where research is more common, many in the medical field tend to shy away from discussing cannabis and cancer. Due to the lack of universal recognition, researchers and practitioners are skeptical about appearing as ambassadors for cannabis as a cure. When invited for an interview, one American oncologist declined, responding: “I believe that there are still too many unanswered questions on this topic.”

Despite a wealth of literature on the recreational and therapeutic use of the herb throughout millennia, the full extent of its effects on the brain and the body’s nervous system remains unknown. The physical and psychological risks involved in its prolonged use as a psychoactive “high” are relatively well documented, but clinical investigations in the medical setting are less clear-cut.

When it comes to medical marijuana, the issues are two-fold. The first concerns the use of cannabis as a replacement for commonly accepted cancer treatments such as chemotherapy, radiation, or surgery; the American Cancer Society has warned against patients “relying on marijuana alone as treatment while avoiding or delaying conventional medical care” as it could lead to “serious health consequences.”

The second concerns the potential toxic side effects of the drug, especially in patients with undiagnosed or underlying mental health issues. Paradoxically, many believe that cannabis wards off depression, anxiety disorders, and insomnia. Others view it as a trigger for these very diseases; it is also known to cause paranoia, delusions, disorientation, tachycardia, dry mouth, diminished concentration and motor skills, and increased dependency. In an age when the drug’s potency has exploded as a result of specialised farming and intensive cultivation, these are factors that cannot be ignored.

In the absence of clear-cut guidance, patients may turn to unchecked channels. For instance, home remedies or faith healers, neither of which are regulated, provide an array of services like supplying cannabis oil and recommending allied therapies (such as homeopathy), often advertising in online forums such as Facebook.

On social media, a number of groups act as resources on the use of CBD and THC in conjunction with chemotherapy, providing unfounded claims and promises of a cure. “There’s a lot of information out there, but there’s no concrete evidence to say what the right type of ratio for this [or that] type of disease is, because each cancer is its own disease,” says Dr Schloss. With few legitimate resources, people are then susceptible to bad information. “Doctors need training, so they know what they are dealing with.”

The chemical constitution of cannabis is highly complex, as is the drug’s varied effects on individuals. Until quite recently, marijuana was generally considered to be a drug that people smoked, often with tobacco, a highly carcinogenic substance that causes lung cancer and emphysema. Cannabis smoked pure doesn’t fare much better. But with the introduction of vaporisers, oils, edibles, tinctures, and sprays, credible alternatives now exist that are safer and more palatable for both the mind and body. And perhaps one of the most under-appreciated aspects in this debate is the fact that many patients believe medical marijuana offers them what they value most when it comes to their illness and treatment: control.

Even for the converted, however – from doctors to advocates – it is hard to be sure of how effective the drug really is. “Those who claim they have been cured by cannabis… I don’t know how much of that’s true,” says Kitty Chopaka, a medical marijuana advocate at Highland, a Thai organisation that fought for the change in legislation through public awareness and education. “Legalisation and regulation would mean that these drugs are used the right way [with a prescribed dosage tailored to each case].”

With or without legislation, many cancer patients in the region haven’t lost hope. “Even though chemotherapy is supposed to be the ultimate remedy, I hope the day comes when everyone can choose to opt for marijuana along with it,” says Ashfaq. “While we wait for the law to catch up, I wonder if suffering so much when there are ways to reduce the pain is worth it.”

Additional reporting by Oliver Clasper

*Name has been changed due to potential legal action.