Taking the high road: how big is the case to stop medical cannabis patients from driving?

The Superintendence of Public Health has instructed doctors to consider each patient eligible for medical cannabis for their driving ability when under the influence – a situation that could result in these patients having to choose between their marijuana prescription or their driving licence.

Psychotropic drugs alter neurological function, impairing perception and reaction time, which would make motorists under the influence a liability.

But how big is the case for confiscating patients’ driving licences, especially if the marijuana strain and dosage are being prescribed by professional doctors?

Alcohol is legal and so is medical marijuana. Drunk driving isn’t.

Unlike cannabis, it is fairly easy to track the level of alcoholic intoxication and how this affects brain and bodily functions. So how would anyone define or estimate cannabis ‘intoxication’ that feels… “just a little high?” There is no equivalent to a breathalyser to determine the psychoactive content in cannabis.

Cannabis affects everyone differently, which is why the law should cater for the lowest common denominator. If the smallest possible dose of cannabis severely impairs a patient’s driving, then the law must accommodate and make it illegal to drive under the influence of that smallest possible dose.

There is no equivalent to a breathalyser to determine the psychoactive content in cannabis

This is the case in Canada where as recently as last July, legislation was altered so that anyone suspected of driving under the influence of cannabis would be subject to a saliva test and if taken to the police station, provide blood and urine samples. Any trace of the substance would lead to charges. It is an obviously undesirable situation that could significantly slow down processing.

Is Malta’s stricter alternative preferable? Is confiscating a driving licence the responsible thing to do?

The problem with cannabis is that street-level knowledge reigns supreme. It is subjected to what in psychology is called an “availability cascade”. It’s a self-reinforcing cycle that gains traction in popular discourse and shapes belief. What we know about cannabis in Malta is through the word-of-mouth recounting of experiences with the illegal drug.

Researchers have theorised that patients with access to medical marijuana may have substituted cannabis at home for alcohol in bars, and stayed off the roads

The truth is that very little is known about the overall affects of marijuana, and the general consensus is that medicinal drugs are considered unsafe until proven otherwise. So far, it hasn’t been proven otherwise in certain situations; we still do not know, for example, about the long-term effects of the chronic use of Cannabidiol, the concentrated solvent extract that is being given to patients. While the World Health Organisation has said that “to date, there is no evidence… or any public health-related problems associated with the use of pure CBD”, the risks have little to do with the compound itself and more with its contamination, an event that is sometimes deliberate to increase yield and potency and sometimes accidental when agents like moulds and metals enter the plant. Dutch coffee shops were found to sell cannabis products containing pesticides.

Dutch coffee shops were found to sell cannabis products containing pesticides

The oil may also contain traces of tetrahydrocannabinol (THC), the psychoactive constituent of cannabis, so that consumers would be ostensibly exposing themselves to the adverse effects of the psychotropic compound, such as intoxication, panic attacks and disorientation.

The Democratic Party MP, Godfrey Farrugia, a GP, had spoken about this issue before in Parliament. “The fascinating thing is that all these compounds work synergistically together, so when single compounds are isolated from the plant, they are not as effective. CBD alone can never be as effective as CBD with a bit of THC,” he told MaltaToday.

Farrugia still believes that cannabinoids are “remarkably safe” and that they are a safe and effective medicine.

He did contend, however, that psychosis could take place when patients exceed the prescribed dose. “Police Authorities have the right to revoke driving licences if persons misuse medicinal drugs, cannabis included.”

Staying at home with cannabis

There is no question that the THC constituent in cannabis impairs cognition, psychomotor function and actual driving performance. Several scientific reports and studies carried out by European and American universities came to such a conclusion. A 2004 epidemiological study at Maastricht University found that drivers who had THC in their blood, particularly at higher doses, are about three to seven times more likely to be responsible for crashing as compared to drivers who had not consumed the drug. The conclusion was that the recent use of cannabis may increase crash risk but past use of cannabis does not.    

Farrugia still believes that cannabinoids are “remarkably safe” and that they are a safe and effective medicine.

But pure CBD, unless contaminated, is not psychoactive and does not contribute to these effects. In other words, CBD does not get you high.

In 2011, the British Journal of Pharmacology published a study that found that the synergy between CBD and THC resulted in CBD modulating and diminishing the psychoactive effects of THC. CBD isn’t the only product given to patients, however, as the cannabis Indica strain – which is reported to cause what is known as “couchlock”, a sensation so relaxing that a condition of paralysis might be induced – is also usually handed out as treatment, which can contain a high proportion of THC.

How it reacts with CBD might counteract its mind-altering and “couch-locking” component but further research is required.

According to many licensed producers across the world, medical cannabis is presented to patients in a form that can either be inhaled through vapour or smoke, or oil that is ingested.

CBD isn’t the only product given to patients, however, as the cannabis Indica strain is also usually handed out as treatment

The difference between the two methods is that the latter will be processed through the liver and has a much slower onset time but the effects will last much longer, for up to four hours. If inhaled, the effect is almost immediate but does not last as long. Several surveys have shown that the average dose of medical marijuana is 1 to 3 grams per day when smoked or vaporised.

With cannabis, street-level knowledge reigns supreme… What we know about cannabis in Malta is through the word-of-mouth recounting of experiences with the illegal drug

A 2008 French study on the correlation between medications and traffic accidents concluded that since 1999 a high prevalence of cannabis was found in the blood of injured or killed drivers.

On the other hand, Columbia University’s Mailman School of Public Health in New York said that its research showed that since medical marijuana was legalised in 28 states, there was a reduction in road fatalities. The researchers still cautioned that marijuana impairs driving, and theorised that this result might reflect the fact that patients with access to medical marijuana may have substituted cannabis at home for alcohol in bars and have stayed off the roads.

Valium yes, cannabis no

What all these studies ultimately prove is that the situation concerning medical cannabis is still a tentative one and until further tests and experimentations are carried out – without risking human life – it is not safe to say with certainty whether driving under the influence of CBD and other medical strains is a hazard that merits the confiscation of driving licences.

Even Israel, the global leader in medical marijuana, is still carrying out tests. While the greatest evidence of CBD’s healing properties is in reducing chronic pain, nausea and vomiting during chemotherapy sessions, and spasticity related to multiple sclerosis, leading doctor and marijuana expert in Israel, Dr Adi Aran, is experimenting with medical cannabis as a treatment for children with autism.

Dr. Adi Aran, 47, director of the neuro-pediatric unit at Shaare Zedek Medical Center in Jerusalem (Credit: Tomer Appelbaum)

He does contend that there is still a lot of stigma surrounding the product and says that “CBD is not a drug. It’s medication.” However, he is not able to account for what might happen after long-term use or what happens to each patient when he or she operates vehicles and other machinery. This is a trial by human testing.

The legal inconsistency in Malta lies in the fact that other psychotropic medications are not treated in the same way or, at least, that’s what community-based pressure group, ReLeaf, insists: Why is a patient on Valium not submitted to the same tests that a person requiring marijuana is? Why is someone on sleeping pills not subject to tests on his driving abilities when the same cannot be said of medical marijuana patients?

The consumer medicine information leaflet that comes with Valium, which contains the active ingredient diazepam, warns readers not to drive or operate machinery until they know how the medication affects them. It may cause drowsiness and dizziness and may severely impair alertness but it’s not the same for everybody.

Speaking to MaltaToday, Superintendent of Public Health, Charmaine Gauci, said that the Superintendence of Public Health has a responsibility towards drivers and the conditions on the road.

“All we did was remind the doctors of this country to evaluate their patients vis-à-vis their driving abilities. This is done with regards to other medications and medical conditions.”

Thanks to the 2018 amendment to the 2015 Drug Dependence Act, patients can now obtain a prescription for medical cannabis from any licensed doctor and this does not have to be approved by the local medicines Authority or the EU’s watchdog.

Dr Charmaine Gauci: "All we did was remind the doctors of this country to evaluate their patients vis-à-vis their driving abilities"

“Foreign markets were prescribing medication that was approved by the Good Manufacturing Practice (GMP), so we followed suit,” Gauci said. She said that the Superintendence of Public Health encouraged Maltese wholesale dealers to bring this medicine from overseas and make it available on the market.

“The prescription process involves a specific application that might be approved by any prescribing doctor in the country. This named-patient application is sent to us, the Superintendence of Public Health, for our evaluation. We may grant permission to the relevant doctor to issue the prescription. This prescription is written like any other prescription of psychotropic medication and narcotic drugs – known as green prescription – according to the law. The doctor then fills the control card.”

Gauci says the authority referred doctors to Article 34, 45A of the Driving Licences Regulation to consider the patient’s driving ability accordingly. The law states that “driving licences shall not be issued to, or renewed for, applicants or drivers who regularly use psychotropic substances in whatever form, which can hamper the ability to drive safely where the quantities absorbed are such as to have an adverse affect on driving.”

This law ultimately calls upon police authority and not the Superintendence of Public Health.

“When you prescribe psychotropic drugs that might have an impact on driving, you need to do so with responsibility,” Gauci said. “Only a doctor can adequately evaluate a patient – he is the one who knows what dosage was prescribed, when this was prescribed, what the body weight of the patient in question is – all aspects which carry weight when it comes to a patient’s driving ability.”

The saying that everyone is wise after the event is becoming increasingly applicable to Malta, with trial and error situations resulting in senseless tragedies. On social media several have commented on their own driving experiences under the influence of heavier medications than CBD, and that they’ve never been in a road accident.

Just a question of time

But the point isn’t whether driving under the influence leads to an accident but whether it increases the risk of one. ReLeaf’s response to the controversy related more to the fact that other medications are not treated with the same scrutiny. “Valium and other medications can have stronger effects and can cause drowsiness but the driving licence is not revoked for these patients. It is therefore discriminatory,” Graziella Calleja, ReLeaf co-founder, told MaltaToday.

Calleja agrees that further research is required into the overall effects of cannabis. “Since we do not have any local statistics and record keeping, we should start compiling research on the substance. It should be done on all aspects of cannabis, for example on its creative psychoactive effect.” She also said, however, that since there is no regulated market at the moment, it would be hard to analyse the quality of the product and its health and psychological effects.

On social media several have commented on their own driving experiences under the influence of heavier medications than CBD, and that they’ve never been in a road accident... but the point isn’t whether driving under the influence leads to an accident but whether it increases the risk of one

Gauci’s response contradicted ReLeaf’s claim that other substances are treated differently. “All doctors who prescribe medication in whatever form, which can hamper the ability of a person to operate machinery or drive safely, are obliged to inform the Police about such prescription.” She claimed that since the 2018 amendment, there are 39 patients currently on medical marijuana.

“Patients who venture beyond the remit as indicated for therapeutic use for all green prescription medicines have their driving licenses revoked,” Godfrey Farrugia told MaltaToday. “We are not reinventing the wheel… persons who abuse the drug control system are earmarked by the Superintendent of Public Health for his own safety and for the safety of others.”

Farrugia argued that cannabis-as-medicine is a still an ongoing process – whether it impairs driving depends on many factors. “It depends on inherent tolerance, drug interactions, allergic reactions... it is not a case of one size fits all. Professional discretion is essential.”

ReLeaf Co-founder, Graziella Calleja: "Patients should not wait to get approval from the Superintendent of Public Health."

But ReLeaf disagrees with the process with which medical marijuana is prescribed. “A doctor’s analysis and prescription should be enough for a patient to qualify,” they said. “Patients should not have to wait to get approval from the Superintendent of Public Health.”

They also suggest that more illnesses should be recognised to qualify for the cannabis medication, such as depression, anxiety disorders, glaucoma and irritable bowel syndrome.

While ReLeaf are pushing for the authorities’ responsibility to patients who merit effective medication and for further research to be adequately carried out to reap the outmost benefits from the product, the Superintendence of Public Health is likewise evincing responsibility to users of this substance and the public at large since it is a tentative medication very recently added to the market. It seems that both well-intentioned opinions are at loggerheads over an issue of priority, which at first glance seems, for both sides, to be the public health.

Until further research is conducted, the Superintendence of Public Health is working within the confines of the law and asking doctors to consider the driving abilities of the patients before prescribing the medication.

Whether the law should be amended should not be a question of trial and error but a question of professional opinion. If doctors are a little lenient when it comes to diazepam and driving, it should be because Valium has been on the market for over 50 years and is a well-researched product.

So, it’s only a matter of time before patients using medical marijuana start enjoying the same clemency.