Is the tide of opinion turning? Is Southeast Asia becoming soft on the war on drugs? And what do the recent trends mean for Singapore? The programme Insight explores the issues.

BANGKOK: Medical cannabis has been called a wonder drug, one that can treat various conditions, including Parkinson’s, asthma, insomnia, autism and even cancer. But how valid are these claims about reducing pain and curing illnesses?

If they are, should the use of the substance – long considered harmful to heath – be legalised?



Thailand, a country known for growing cannabis, is about to find out the consequences of that following the decision in December to legalise its use for medical purposes – the first Southeast Asian country to do so.

Even as the regulations are being drafted, there are indications that more countries in the region are considering a move in the same direction. Among them are Malaysia and the Philippines.

The programme Insight looks at whether the tide of opinion on cannabis is turning, whether Southeast Asia is becoming soft on the war on drugs and what the recent trends mean for Singapore. (Watch the episode here.)



CRUX OF THE CONTROVERSY

The crux of the controversy is that cannabis contains two main – and polarising – ingredients: Tetrahydrocannabinol (THC), the main psychoactive constituent, which produces the “high” that drug addicts crave; and cannabidiol (CBD), which shows promise for medicinal purposes.

Medical cannabis research is focused on separating the two elements and harvesting the use of CBD, without the effects of THC.

The United States’ Food and Drug Administration and the European Union have approved a few CBD products – such as for epilepsy and chronic pain management – with “proven effects”, noted Singapore’s Dr Munidasa Winslow, an addictions psychiatrist at Promises Healthcare.

READ: Chronic pain most common reason US patients get medical marijuana

Other conditions for which cannabinoids have been used include multiple sclerosis, “where there are a lot of spastic changes, very tight muscles and a lot of pain”, cited anaesthetist Nicholas Chua, the president of the Pain Association of Singapore.

He also listed research being done in areas like migraines, glaucoma and cancer pain management.

But there is no conclusive evidence yet – beyond anecdotal examples – to support the safety and efficacy of cannabis as a form of medical treatment for major illnesses.

“The literature is divided. Well, there are a lot of good things that we can read about it, but experts aren’t convinced,” said Dr Chua.

“Because of the fact that we don’t have a huge body of evidence that says, ‘wow, the benefits far outweigh its risk’, potentially it can create issues, whether medically in the short term or socially in the long term.”

Thailand and its experts, however, are willing to give medical cannabis a try, convinced that their efforts will bear fruit one day.

“It could cure several illnesses and symptoms, such as bruises (and) pain … It could help a lot,” said Dr Sarita Pinmanee, who leads the research on hemp and cannabis at the Royal Agricultural Station Pang Da in Samoeng district.

“We should support one side (medical use) but control another side (recreational use) … Of course, there are people who want to use it for recreation. In fact, some countries allow it, within limits. I don’t support such (recreational) use.”

Insight producer Genevieve Woo with Dr Sarita Pinmanee.

Thailand’s Office of Narcotics Control Board is taking a similar position.

“It’s a plant that grows in nature. It, however, has negative effects, and humans can abuse it and be addicted. On the other hand, it can be utilised for medical purposes,” said the board’s secretary-general Niyom Termsrisuk.

“The main point is how to optimise the use of it for the benefit of society (and) nation.”

FACTORS IN THAILAND’S MOVE

To begin with, getting rid of the cannabis habit has been an uphill battle in Thailand, where several major hill tribes still rely on it as a form of folk medicine – a practice ingrained in their culture for generations.

“We’ve had the knowledge for quite a long time – more than 300 years,” said Dr Panthep Phuaphongphan, the Dean of Rangsit University’s Institute of Integrative Medicine and Anti-Ageing.

“We have the records in traditional Thai medicine recipes … (for) how to use cannabis in some diseases, which would be cured.”

As with the rest of 20th-century Asia, cannabis then became illegal in Thailand, and “this knowledge disappeared”, hence the need to “relearn” and “review those recipes”.

He added: “We have to find the facts because the most dangerous point is about the dose.”

Within the medical circle, one of the pioneers in Thailand who had been pushing for medical cannabis to be legalised is Dr Somnuk Siripanthong, a cancer and immunity therapy consultant at the Panacee Medical Centre in Bangkok.

He is aware that the research and evidence is not watertight, but he said he has witnessed too many success stories to dismiss cannabis outright.

Mr Chalor Nuchyangkul, for example, has been following up with the doctor since a brush with late-stage colon cancer gave the retired policeman “no choice” but to use cannabis oil.

“It was the ‘underground medicine’, we called it. It was illegal,” admitted Mr Chalor, who had stopped chemotherapy because of the “terrible” side effects. “Good or not good, I had to try it.”

He said that for 90 days, he relied only on cannabis oil, taken orally, to treat his cancer. The result of his blood test after that? “No cancer cells found,” he declared.

Dr Somnuk remarked: “The medical literature says, ‘Oh you have to go for an operation, radiation or chemotherapy.’ Some people spend millions of baht on these treatments, and they still die.

“Whether or not it's research-based, we want to put the patient at the centre of our interest … Cannabis is so-called illegal, but the patient is alive.”

Now, government hemp plantations have been approved in several districts, including Samoeng, which is some 50 kilometres from the northern city of Chiang Mai. The plants are cultivated under strict supervision and only for medical research and development.

There are seven greenhouses, each under lock and key, at the Royal Agricultural Station Pang Da.

“If we grow cannabis on a certain plot, the information on land size, the number of trees and the plant strain should be clarified. What disease is this strain cultivated for and at what quantity?” said Mr Niyom.

“And the plantation security system (must) prevent the legal cannabis from leaking out.”

With that legal status, medical cannabis has the potential to be a significant cash crop for the kingdom and to position it as the epicentre of an industry nicknamed the Green Gold Rush.

The global legal market is projected to grow to US$56 billion (S$76 billion) by 2025, according to business consultancy Grand View Research. And advocates claim that Thailand’s legal cannabis market could reach US$5 billion by 2024.

READ: Greece eyes pot of gold as medicinal cannabis licensed

Dr Jet Sirathraanon, chairman of the National Legislative Assembly's public health committee, can envision a tourism boost too.

“Maybe because Thailand has a lot of tourists – now we have more than 30 million tourists, in the last year – some tourists may come to Thailand for medical purposes,” he said.

“For the economic benefits, maybe we can lessen the import of medicine from Western countries.”

WHITHER THE WAR ON DRUGS?

Thai authorities emphasised, however, that their commitment to the war on drugs has not wavered.

“Cannabis won’t be legalised; it remains an illicit drug. We’ll make the public understand that it’s for medical purposes only, not for recreation,” said Mr Niyom.

“Cannabis is not to be used freely. The user still breaches the law unless he’s diagnosed as a patient and (cannabis is) prescribed by a medical doctor to use for medical treatment.”

Thailand’s narcotics agency also said search-and-destroy operations that include the Thai military are regularly mounted against illegal drug plantations.

The Office of Narcotics Control Board invited the Insight team to join in a multi-agency operation in the hills of Chiang Rai.

For decades, Southeast Asia has battled the drug problem. Drug laws in the region remain some of the toughest in the world, but the war has yet to be won.

To observers, what is especially surprising about Thailand’s move to legalise medical cannabis is that it comes amid a surge in criminal drug activities.

READ: Meth 'disaster' for region as seizures surge in Thailand

“What we see taking place here in Southeast Asia is an expansion of the drug business that’s quite profound. That surge has taken place extremely rapidly,” said United Nations Office on Drugs and Crime regional representative Jeremy Douglas.

“This region is now the largest methamphetamine producer in the world. And that took place with very large law enforcement activity in the region against that backdrop. So clearly, the cartels (and) organised crime are a few steps ahead.”

In Thailand, cannabis is also trafficked from countries such as Laos and Cambodia. “There’s still a very large cannabis market within the region. It's also unique in a sense that it's produced in most countries,” he added.

“It's grown wild in rural areas, but it's also produced commercially and trafficked. So it's not local production to meet local need; it's also got commercial production to meet trafficking need and to kind of serve large markets like Bangkok.”

Drug abuse and trafficking remain a scourge on the region, with its proximity to the Golden Triangle.

So is Thailand’s move to legalise medical cannabis a turning point in the region’s war on drugs?

“Authorities are concerned that if you go down the road of softening an approach to one drug, that sends a signal that drugs in general are acceptable and that there are no consequences of using those drugs,” said Mr Douglas.

“Our position is that if a drug is controlled … then states have to put in place measures in one form or another – health, law enforcement, regulatory, or whatever – to make sure that the supply can't be widely used and abused.”

Dr Winslow thinks that is possible “to a certain extent” when it comes to CBD oils.

“As long as you keep the THC component low, or not allow the part that gets you high to be more than a certain percentage, then it gives you an opportunity to observe what’s happening and … calibrate our responses,” he said.

Dr Chua believes that the war is against recreational drugs, so he “wouldn’t go as far as to say that it’s softening”. But apart from law enforcement challenges, he cited one medical conundrum.

“There’s no way to be able to separate the recreational use of cannabis from cannabinoids used for medical purposes because the drug test is the same. It’s a urine test. It can even be detected in the hair,” he said.

“I don't think there’s a way to differentiate at the moment.”

CHALLENGES FOR SINGAPORE

Doubts about medical cannabis are guided by two major considerations: A lack of scientific evidence and the high social cost associated with drug addiction.

“We know that for every one person who suffers from an addiction, at least five family members are affected,” said Dr Winslow.

And Singapore continues to have zero tolerance for drugs.

Cannabis seized in a Central Narcotics Bureau operation on Dec 14, 2018. (Photo: CNB)

Dr Gomathinayagam Kandasami, chief of the Addiction Medicine Department at the Institute of Mental Health, said: “The cost to the children is very huge because of someone as a parent having a substance addiction.

“If you have substance addiction, you can’t supervise your kids very well. Unsupervised means there’s a likelihood that as a child, you’d face a lot of adverse childhood experiences … Your trajectory of your growing up experience would completely change.”

In a joint statement yesterday, the Home Affairs and Health ministries affirmed the harmful effects of using raw or unprocessed cannabis, making a distinction between the illicit drug and pharmaceutical products containing cannabinoids with potential therapeutic uses.

Law and Home Affairs Minister K Shanmugam told Insight that the case for legalisation fails to convince for the same reason.

Cannabis is not just being legalised for medical use, however. In October, Canada became the second country to make recreational cannabis legal. Uruguay was the first to do so, in 2013.

Countries like Peru, Spain, the Netherlands and South Africa have relaxed legislation on personal use, while at least 10 states in the US have also legalised recreational cannabis.

READ: More precaution than promotion for Canadian cannabis tourism

READ: Michigan vote to legalize pot fires up investor momentum behind cannabis

Within the Association of Southeast Asian Nations (Asean), more member states are thinking along the lines of medical use. So there are “increasing challenges” ahead for Singapore.

“If there’s an official imprimatur for the use … then the stuff is more easily available, people can go out there and get it, and the impetus to bring more of it into Singapore is also there,” said Mr Shanmugam.

“Asean, so far, has taken a very strong stand against drugs. We speak with one voice internationally. We make a point of saying that each country has got to decide for itself how it prescribes drugs, what it does, what kind of penalties there are.

“We’ve had very good cooperation. Of course, if some countries take a different route, then there’s a potential for that cooperation to be slightly different from how it was in the past.”

The trend towards accepting cannabis for medical use is driven by the “power of money and propaganda”, with pharmaceutical companies having a "big interest in pushing this", Mr Shanmugam said.

What if a Singaporean resident were to be prescribed medical cannabis in Thailand and bring it back home?

“If people get prescribed medicine that has some cannabinoid compounds, and there’s a proper prescription for it, and if our doctors agree, then there’d be no issue. But you must get our doctors to look at it,” said Mr Shanmugam.

“But the truth is, under the rubric of medical cannabis, if you’re given basically cannabis to take with no clear medical purpose, we aren’t going to buy that. And my concern is, in some countries, that's what's going to happen.”

For patients in Thailand, it has been a risk taking cannabis, but to Mr Chalor at least, it was worth it. “I wanted to fight and survive for my wife and kids. I couldn’t leave them behind,” he said.

Whether or not medical cannabis had given him a cure, it is the what-if question in a topic that can be emotionally charged.

“If they have advanced carcinoma … what if they can find a way to cure themselves?” postulated Dr Jet. “Cannabis may be the last door, maybe the last hope, for them.”

Others point to evidence that it is harmful, yet the trend towards legalisation has renewed debate. Medical cannabis is also a multibillion-dollar industry. And the region’s policymakers will continue to grapple with the cost-benefit analysis – medical, economic and social.

Watch the episode here. The programme Insight is telecast on Thursdays at 8pm.