Patients fearing worst ahead of government medical marijuana reforms

With Israel’s medical marijuana reform on the way, patients see things getting worse before they get better.

cannabis plant 298.88 (photo credit: Courtesy)
cannabis plant 298.88
(photo credit: Courtesy)
On Thursday morning, David (not real name) left his home in Modi’in at 6:30 a.m. in a bid to beat the crowd of patients who must wait in a line for hours on the street for their supply of medical marijuana from the Tikun Olam dispensary in central Tel Aviv.
Tikun Olam is the largest of eight marijuana-growing companies, and while it used to do deliveries, these were stopped recently after the Health Ministry temporarily closed the company’s farm, citing improper conditions.
As of April 2019, licensed medical cannabis patients will no longer need to rely on dispensaries to fill their prescriptions; they will be able to purchase their medication from designated pharmacies around Israel as the ministry’s medical cannabis reform kicks in.
This will follow a yearlong pilot program in which 25 pharmacies around the country have sold medical cannabis in the form of green leaves, oil and tablets, and will expand to some 100 pharmacies.
The official date set for the reform to fully launch was April 1, but it is unclear whether this will happen all at once or occur gradually.
The reform seeks to standardize the manufacturing of medical marijuana, striving to improve the conditions it is made in and aiming to make the process of obtaining it simpler for those who have licenses. This means that eventually nobody will fill their prescriptions at one of the dispensary branches, as is done today, but everyone will fill them at a pharmacy. The marijuana-growing companies may, however, open their own pharmacies, as Tikun Olam has said it will do.
The reform will more than double the number of physicians who have permits to issue prescriptions and licenses to patients, training another 150 doctors, some of whom are currently participating in a ministry course. It is notable that cannabis is still not defined as a medication by the ministry.
Patients have a couple of major concerns about how the reform will impact their lives.
The first concerns a lack of variety of strains that will be available and a lack of information about the drugs. The drugs are required to detail information solely about the concentrations of cannabidiol (CBD) and tetrahydrocannabinol (THC) and not which strain they are.
“Those are just two of the cannabinoids; there are some 113 cannabinoids in the cannabis plant, and each has a different effect,” remarked David, 44. “They are completely ignoring the science of cannabis.”
Pointing to the “entourage effect,” David noted with irony that it was the Hebrew University of Jerusalem that found that the whole plant extract proved to be far more effective than CBD-only solutions in alleviating inflammation and pain sensation.
“So now they are completely ignoring this and only focusing on THC and CBD; they only have eight strains and no names,” he lamented. The ministry chart of the strains to be offered in pharmacies, he said, “is the polar opposite of what is going on in the rest of world with medical marijuana.... Different strains have different effects on different people, and they help people differently.”
David, who suffers from ankylosing spondylitis, a type of arthritis that affects the spine, has been using the same strain consistently for the past four years. “Now it’s just going to be taken away from me in April,” he said, adding that he has no way of knowing which of the strains that will be sold by then even resembles what he has been taking until now.
“It’s creating a new paradigm which is completely against the stream of what’s going on in the rest of the world,” he charged.
But Arnon Afek, associate director-general of Sheba Medical Center at Tel Hashomer who previously served as director-general of the ministry and was responsible for the reform, is confident that Israel is a pioneer in the field.
Organic chemist Prof. Raphael Mouchulam, who was the first to isolate, analyze and synthesize the major psychoactive and non-psychoactive compounds in cannabis, was part of the team that worked on the reform, Afek noted, in acknowledgment of the entourage effect.
“With time I’m sure we will find out more and add more substances that will be marked... but we started with the basic ones, the ones Mouchulam defined as the principle ones,” Afek told The Jerusalem Post last week. He also said that there are no restrictions on the manufacturers regarding labeling the strains. “They can still do it,” he said. “But the basis is the concentration of, at least some, of the active substances.”
He stressed that the standardization of the cannabis will result in drugs that have been more safely and accurately manufactured.
“You think a plant of one species always grows the same, but they might grow in different conditions; or even in the same farm during different times of the year, things change because it’s a plant – that is why it is so important to standardize it,” he said. “A mother who gives her child cannabis for epilepsy, for instance, will know the concentration of at least two major substances.”
Under the reform, he stressed, cannabis will be grown according to Good Agricultural Practice, Good Manufacturing Practice, Good Documentation Practice and Good Clinical Practice. “Everything is highly supervised and calculated,” Afek said.
“The way they are grown now is not as accurate as it will be or already is in the farms that have already adapted to the standards set out in the reform,” he added.
He also noted that in the 1970s when cannabis was classified as a dangerous drug in Israel, research into it was halted, which accounts for a gap in the research: “Cannabis couldn’t undergo the same research as other drugs, so we lack evidence, and so we have to do the best with what we have now – there is research being done right now.”
NOT EVERYONE is prepared to wait for the ministry to advance in the field, or to play by the rules of the game as set by the government.
Patients complain that the procedure to get medical cannabis in Israel is an arduous one. In Israel one can only get a prescription for medical marijuana if one’s condition does not improve after trying conventional drugs for one year.
“For someone like me who suffers from chronic pain on a daily basis, in order to qualify for medical cannabis I had to be treated in a pain clinic for a year,” David said. “I can’t count on one hand the amount of opioids I took, and only once you go through these things medical marijuana is considered a last resort. By then your quality of life is terrible.”
Unlike David, not everyone is prepared to take the required steps in order to get a license to use medical cannabis. Nir Youftaro, who is hailed as a hero among medical marijuana users for his homemade cannabis oil, is one of them.
“I’m sick but I’m not prepared to get a license, because they will make me take painkillers based on heroine [opioids] for a year, which will ruin my kidneys and liver and stomach... so I just use cannabis on my own – I’m not willing sacrifice all my organs,” he told the Post. “I would have had to be Zohar Argov in order to become Bob Marley,” he quipped, the former a reference to a famous Israeli singer who was addicted to heroin and cocaine.
Youftaro had begun a course of painkillers but said they made him feel terrible. Therefore, he decided to take his treatment into his own hands.
Youftaro, 36, suffers from chronic pain after two slipped discs and four metal plates were put in his back.
Two years ago, after having previously lost his mother to cancer – and blaming himself for not having been able to help her – Youftaro began voluntarily helping other sick people by illegally making cannabis oil in his kitchen out of cannabis they had purchased legally but were unable to get in oil form. He has been dubbed an “angel” by cancer patients who use his oil.
Some of those patients testified on how he had impacted their lives, some even claiming he had saved their lives, when he was arrested in April after police raided his home and seized the oil, which he illegally makes in his home for some 300 patients, which police described as a “drugs workshop.”
“I don’t want to do it, but people are dying, and this helps them,” Youftaro told Reshet while he was under house arrest in April. His patients are able to purchase cannabis in the form of buds only, and they find oil to be more effective in relieving their pain; some believe it also helps treat the cancer.
The ministry reform, Youftaro said, “will be wonderful in the long term, but in the short term it’s a mortal blow to the sick,” interfering in the consistency and continuity of the medication they have been taking and “an offense under the Human Dignity and Liberty [Basic] Law.” They are dramatically reducing dosage, limiting the strains and raising costs, he said.
While today, all patients pay NIS 370 a month, regardless of the amount of medical cannabis they purchase, in April, the prices will be about NIS 150 for 10 grams. For those who need high doses, the cost will increase dramatically. For David, for instance, the cost per month will almost double.
“In the end, if they´ll declare it as medication and it will enter the health basket, then everything will change... but the intermediary situation they are presenting is fatal,” Youftaro charged.
Health Minister Ya’acov Litzman has said that if prices drastically increase for certain patients, the ministry will intervene to prevent such a situation.
“The majority of patients will pay less,” Afek countered. “A solution should be found for the small percentage of people who need to pay much more,” he added. “But this is the medical world. You pay for what you get. You can’t pay the same if you get large and small amounts.”
With regard to its possible inclusion in the health basket, Afek said: “In the future there will be more evidence-based medicine, and then it will be easier for the Health Basket Committee to include it; I’m sure that in the future, once we have more evidence, it will be included, because it helps so many people.”
Youftaro is part of a group of patients and their families who protest against Litzman and his ministry, demanding improved rights for medical cannabis patients.
Einat Shomer is also active in the protests. Her 36-year-old sister, Merav-Haya (family name withheld) has been battling cancer for the past few years, and Shomer has been supporting her through it. She was first diagnosed with cervical cancer, and today she is fighting stomach cancer. Merav-Haya is one of the cancer patients who medicates with oil made by Youftaro.
“The first time she had cancer, we didn’t use the oil – we weren’t aware of the benefits,” Shomer said.
Today, she is undergoing aggressive chemotherapy treatments, and the cannabis oil, Shomer said, “is the only light for us.”
The doctors, Shomer, said, told her sister she was likely to die several months ago. “We think that thanks to the cannabis she is still alive.”
While Merav-Haya has a medical cannabis license, her sister said the oil she can get from Tikun Olam is only 3% cannabis, whereas the oil that Youftaro makes is almost 100% cannabis oil.
“My sister needs a ratio of 50/50 THC and CBD,” she explained. Shomer takes the Cannabis buds she gets for her sister from Tikun Olam to Youftaro, who makes oil from it.
But the dosage her license allows her, she says, is not enough. She is permitted 100 grams a month, whereas the maximum allowed is 250 grams. She can’t understand why her sister has not been granted 250 grams.
“I know other people who have, but there seems to be no rule; it’s like the Wild West,” she lamented.
According to ministry data released by Yediot Aharonot this week, the amount of patients applying for medical cannabis licenses has almost quadrupled in the past five years. The data also shows that almost a third of the applications are rejected.
Today, there are over 30,000 Israelis who have medical cannabis licenses. These include patients suffering from cancer, Crohn’s disease, colitis, chronic neuropathic pain, HIV/AIDS, multiple sclerosis, Parkinson’s, Tourette’s syndrome, terminal illness, posttraumatic stress disorder, epilepsy and others.
While those who are concerned about the reform comprise a vocal group, Afek believes they are a minority.
“People must understand that this [reform] is for their own good,” Afek said. “If they want something that is medical-grade, then this is the right way. Every change is hard, I understand that, but we will try to make it as easy as possible. That’s why we started with the pilot.”
Come April, when the pilot is over and the reform begins in earnest, it will begin to become clear whether patients are willing to accept it.