Medicinal Cannabis and Endometriosis - hashing out the evidence.

By Dr Mike Armour and Justin Sinclair from NICM Health Research Institute at Western Sydney University.





Is cannabis legal for medical purposes in Australia?


Yes, it is. Amendments to the Narcotic Drugs Act in 2016, along with other revisions to existing regulatory frameworks, now allows for medicinal cannabis to be cultivated, manufactured and prescribed by medical practitioners in Australia. This being said, it is not as simple as going to your medical doctor for a prescription. Currently, medicinal cannabis products are accessed predominantly through the Special Access Scheme (SAS) Category B and Authorised Prescriber Schemes due to the majority of available products being classified as unapproved medicines. These schemes involve slightly more paperwork for your medical doctor, and a Federal and State approval process. Whilst this sounds a little daunting, the process has become much more streamlined over the years and approvals are obtained relatively quickly. As of late August 2020, over 61,000 SAS Category B applications have been approved across Australia for a wide range of different clinical indications, including chronic pain...and yes, we are aware of patients that have been approved for endometriosis.


How is medicinal cannabis classified in Australia?


This is dependent on what is contained within the medicinal cannabis product your medical doctor may prescribe you. Should you be prescribed a Cannabidiol (CBD) dominant medicine, this is classified as a Schedule 4 drug (Prescription Only Medicine), whereas if you are prescribed a product with higher levels of delta-9 tetrahydrocannabinol (THC) in it, that is classified as a Schedule 8 (Controlled Drug). Please note that both of these schedules can only be prescribed by authorised medical doctors – so it’s not currently legal to buy CBD oil from a health food shop or over the internet...and don’t worry, we will explain what these two chemicals are shortly.


What exactly is medicinal cannabis? How does it differ from cannabis obtained from illicit sources?


This is a very commonly asked question and an important one to address. Cannabis has long been used as a medicine by our ancestors and is comprised of hundreds of different chemicals, many of which have pharmacological activity. At the moment, a particular class of chemicals known as cannabinoids is attracting a great deal of research interest, with over 140 different cannabinoids being identified within the Cannabis genus. Of these, THC and CBD have received the most research attention and are currently the main cannabinoids standardised in medicinal cannabis products in Australia. The term standardisation simply means that the levels of these cannabinoids are tested to be within very strict and consistent amounts in every single batch of medicinal product produced, whether that be an oral oil, capsule or dried Cannabis flower. Think of this like going to take Panadol for a headache – each tablet has 500mg of paracetamol per tablet, and is tested rigorously to ensure this is the case from batch to batch.


Medicinal cannabis and illicit cannabis come from the Cannabis plant, but that is where most similarities end. It is the difference in their cultivation and manufacture, and the fact that one is legal and one is not, that separates the two. Medicinal cannabis is grown to very strict quality assurance standards and must comply with specific regulatory guidelines to be free from microbial contamination, pesticide residues, aflatoxins and heavy metals. Medicinal cannabis plants are grown in highly controlled environments so that variability in their chemical composition is minimised, allowing for reproducible levels of THC, CBD and other chemicals dependent on the chemovar (chemical variety) of cannabis grown. The products that are manufactured from these plants must comply with Good Manufacturing Practice (GMP) to ensure quality and safety for end users.


Lastly, and perhaps most importantly, is that medicinal cannabis is prescribed, and your condition monitored, by a medical doctor...an important consideration to ensure you have the right product for your condition and you can be monitored for side effects or potential drug interactions with other medications you may be taking.


On the other hand, illicit cannabis does not necessarily comply with any of these quality requirements, so the chance of obtaining consistency, standardised levels of cannabinoids or being sure it is free from adulteration or contamination is simply unknown. Furthermore, most illicit cannabis used for recreational purposes is grown to be high in THC, the chemical most responsible for the feeling of being high, with minimal amounts of other cannabinoids typically present. Whilst illicit cannabis is being used for therapeutic purposes in Australia and numerous other countries, most people prefer to know exactly what is in their medicine. The cost of illicit cannabis is also notably cheaper than legal medicinal products, but this will likely change as more legal medicinal cannabis companies come online and scale up the size of their cultivation facilities.


I want to know more about THC and CBD – what do they do?


As previously mentioned, THC is the main cannabinoid responsible for the feeling of being “high”. However, it is incorrect to think that THC does not exert important pharmacological activities and is only used recreationally. THC binds to specific cannabinoid receptors throughout the body to produce its therapeutic effects. In fact, it was studies into cannabis which identified an entire neuromodulatory system that we knew nothing about – the endocannabinoid system - which is integral for controlling homeostasis across many body systems. We produce our own cannabinoids in the body which bind to the same receptors that certain cannabinoids like THC interact with. Studies have shown THC plays an important role in pain management through its analgesic and anti-inflammatory activity. Furthermore, studies have also demonstrated that THC exerts antioxidant, antiemetic (reducing nausea and vomiting) and sedative actions. Not surprisingly, THC is found in many medicinal cannabis products in Australia and around the world, either alone or with defined amounts of CBD, to manage chronic pain and other conditions.


Unlike THC, CBD does not cause any noted intoxicating effects, and is perhaps best known for assisting certain patients in reducing seizures observed in intractable epileptic conditions. That being said, CBD has noted analgesic, anti-inflammatory and antiemetic activity also, along with recent research highlighting its ability to reduce anxiety and ease depression via working on serotonin receptors (5HT1A).


These are just two of over 140 different cannabinoids that have been identified in cannabis, and researchers from around the world are busy investigating the therapeutic potential of many others at the moment.


So what is the difference between hemp oil and CBD oil?


The quick answer to this is that the former is regulated as a food, and the latter as a medicine. A major review by Food Standards Australia and New Zealand (FSANZ) in November 2017 led to changes in legislation to allow hemp to be allowed in foods. Whilst a little confusing, hemp is a term given to a Cannabis plant that is bred to contain very low levels of THC, and is used mostly for industrial purposes, such as using its fibre for making clothes and ropes, or for seed oil production. As such, most hemp products for food focus on the very nutritional oil (rich in omega fatty acids...a lovely addition to salads), or the very respectable levels of protein it can provide. Hemp oil is obtained from the seeds of various Cannabis chemovars, whereas CBD (and all other cannabinoids) are obtained within hair-like structures on the flower known as glandular trichomes, and is strictly regulated as a medicine in Australia. So...by all means enjoy hemp oil for its nutritional benefits, but do not equate this to being CBD oil, which has noted pharmacological activity and is a regulated medicine.


Is there any evidence cannabis can help my endometriosis symptoms?


Based on preliminary survey evidence conducted by our research team from Western Sydney University and colleagues at the University of New South Wales, findings would suggest that cannabis may be of benefit. Our published research has shown that Australian women who used illicit cannabis for management of their endometriosis self-reported it being effective for pain, as well as other associated symptoms such as poor mental health (anxiety and depression), sleep, gastrointestinal upset and nausea and vomiting. Results from a yet to be published New Zealand survey show similar findings.


Our research team will be conducting a clinical trial investigating the safety, tolerability and effectiveness of medicinal cannabis for endometriosis in late 2021, so watch this space for further details.





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