Personal views: Extra pharmacopoeia
Authors: Steven Ford
Journal: BMJ (2001)

I am not now nor have I ever been nor do I have any intention of becoming a user of illicit drugs. I routinely advise against the use of LSD, amphetamines, Ecstasy, cocaine, and the like. However . . .


I have no doubt that I could secure any drug within minutes of leaving my computer keyboard, although the last cannabis I handled came from a uniformed police officer. The use of illicit drugs is now ubiquitous and inextricably woven into society's fabric. My son, aged 12, has a computer game in which the player takes the part of a machinegun toting and energetically toking Rasta protecting his ganja patch from the marauding Drug Enforcement Agency which appears in Hueys, on parachutes, and, implausibly, in Fairchild A10s and Red Baron biplanes. 


How much evidence must there be before it is acknowledged that prohibition does not work?



Routinely, patients raise the use of illicit drugs and, while presenting a mask of imperturbability, I find it unsettling conducting a consultation potentially open to damaging interpretation by an ambitious silk.

A woman in her mid-50s with multiple sclerosis came with her husband to discuss her medication. Beta interferon has been left in abeyance for now; she has gained fleeting benefit from high dose methylprednisolone. Analgesics, antispasticity drugs, antidepressants, benzodiazepines, and gabapentin, among others, have been tried without benefit. She asks about cannabis. She is impressed by the anecdotal evidence and I cannot do other than agree that a trial would be entirely rational. The drawback is that her most likely source of supply is her son who already has a criminal record for drug use. So we address the issue not only of whether she should use cannabis but also of whether she should call upon her son for help, knowing that if he acted to relieve her suffering he would risk further prosecution. She tells me today that she has contacted an underground cannabis chocolate factory—yum.

A man in his late 40s is days away from death from a disseminated malignancy. He is fully in command of his faculties but dreadfully nauseated, conventional medications by syringe driver having had little effect. He is a lifelong cannabis user who has not stopped merely because of illness. He reports dramatic benefits to his overall condition, confirmed by his wife, from the use of twice or thrice daily cannabis. We discuss his hope of building a greenhouse to grow his own; he discourses knowledgeably on the relative merits of the varieties he will cultivate.

Many years ago an elderly man dying of malignancy impressed me with his terminal temerity. Within yards of a densely trafficked trunk road, in full view of passing police vehicles, he grew a magnificent profusion of head high (sic) cannabis plants. The produce of his garden he consumed in a meerschaum of Brobdingnagian proportions. His suffering was limited.

Our two HIV positive patients have taken between them a wider variety of drugs than either could raise the energy to shake a stick at. They are now occasional users of cannabis and other materials. The one is on methadone maintenance in a dosage that has been stable for years. The other (whose HIV positive spouse died in disturbing circumstances in hospital) is now on methadone too, but only after a series of events that finally ripped away any shreds of credibility behind which the medical profession, politicians, and the Home Office may ever have hoped to hide the present policy debacle.

This patient was on a steady dose of diamorphine tablets from the local drug unit for a long time, but these were withdrawn when there was, ostensibly, an interruption in supply. Though suspecting a ruse de guerre, the proffered methadone was accepted with good grace. Requests for assurance that the supply of diamorphine would be resumed in due course were met with manifest evasion. Needless to say, when the supply was re-established further prescriptions were refused and contact with the drug unit effectively withdrawn on the flimsiest of pretexts. I am vexed that the unit has demonstrated neither the grace nor stature nor intellectual rigour to respond to questions that I posed in a letter. When these patients are actively dying and requiring diamorphine to help them do so I understand that I can prescribe it, but will prescriptions from me invite unwelcome Home Office attention?

These patients' situations had been under control but are now threatened with renewed ill health, and the potential for chaos and illegality should they seek alternative supplies. To withdraw treatment from people who are effectively terminally ill may make the Home Office figures neat and tidy but it is unacceptably inhumane.

How much greater does the evidence base have to be before it is formally acknowledged that prohibition does not work and may, by promoting criminality, do harm? When will effective management of the situation, by legalisation of cannabis and well funded and organised legitimate supplies of other materials, replace the current blanket oppression of an already oppressed group?