Alan Flashman

Israel destroys its medical cannabis program

About thirty thousand Israelis, all suffering from severe and debilitating chronic illness, depend upon the Medical Cannabis program of the Ministry of Health for their survival and well-being. The Ministry through its IMCA (Israel Medical Cannbis Authority) has assumed sole medical authority and therefore responsibility for this treatment.

Up to the present, the program is adminsitrated in a bizarre manner unlike any other program known to me. The IMCA makes decisions (with absolutely no transparency) about what medical conditions qualify as “indications.” Any Israeli specialist who treats the given condition is entitled to request a license for medical cannabis for a patient from the IMCA. The request is filled out online but then printed and faxed (fax to mail) to the IMCA. The online request is of no consequence. Receipt of fax has to be validated by calling a number where the waiting time often exceeds an hour – sometimes up to three. Th IMCA personnel search for the fax by the hour it was sent and number of pages, and as is often the case this arcane method fails and the fax has to be resubmitted. Once identified, the fax goes to a “panel” whose composition is a state secret for consideration. For children a license is granted- or denied – within a week or two, for adults a month or two at best. When a license is granted, the patient and one designated Supplier are notified – but not the requesting physician. The patient and the supplier (there are eight) then figure out just what strains of cannabis the patient receives. The dose is fixed by the IMCA and is nearly impervious to physician requests based upon the real needs of patients. This leads to a situation of arbitrary underdosing for many patients.

When I treated adults with PTSD and asked why I was excluded from knowing what cannabis my patients were receiving, I was informed that there are 80 strains, a number beyond the capacity of the physician to master. After all, s/he had to learn about 2000 medications, no room for a simple excel chart with 80 cells.  In the past 18 months that I have been treating autistic children, I simply imposed myself into the decisions, making me the only physician in Israel, to my knowledge, who has any clue what “medical cannabis” means concretely for each patient.

I have published previous blogs speculating of the meaning of this strange operation. Now I am writing to report – and protest – a directive fo the IMCA from Friday, May 11, which essentially dismantled all that was good in the program,creating wanton danger for thousands of patients with no evidenced based rationale. I remind my readers that altering successful treatment for reasons external to a patient’s welfare is not mere malpractice, it is a criminal offense.

This issue at hand is the well-known fact that cannabis is a plant. Plants contain a plethora of chemicals which are never fully characterized. Cannabis has two active ingredients that have been characterized, CBD and THC at least a hundred more that have never been characterized. These additional molecules are presumably responsible for the well known and undisputed “entourage effect,” the difference of the effects of different strians despite similar CBD and THC composition. The obvious result is that the medical use of cannabis respects the need for different strains on a trial-and -error basis. This is “science” in the true sense that a given field is approached with the approprotae precision that can be expected. Expecting mathematical precision from a plant is not scientific, as the father of Western science, Aristotle, noted on every possible occasion (for one quote, scroll to the end).

Just yesterday the IMCA delivered its new edict, a pseudo-scientific reform that will impair the treatment of thousands. Billed a a “Reform”, it one-sidely forces patients to relinquish the strain thay have come to rely on empirically in favor of some CBD THC compositions now provided in pharmacies. This is treating cannabis like a medicine, not the medicinal use of a plant. The plan, as best I understand it, is to move all cannabis licesnes into the hands of 80 physicians trained two years ago by the IMCA, who will have exclusive privelege to write a license that specifies a CBD and THC composition and a dose according to the very restrictive and not evidence based IMCA underdosing regulations. The patient then has a pharmacist who knows nothing about cannabis dispense according to CBD and THC composition. Patients will have no discretion regarding strains.

Let me give one example of this impact. A friend at my local synagogue wanted to thank me this evening for directing him regarding cannabis for a family member. The patient had tried Tikun Olam’s (a leading Supplier) high THC “Alaska” with poor results. He the tried the parallel “Erez” strain with equal THC and CBD profile and received a substantially superior result. I told him that his thanks were premature and outlined yesterday’s bad news. He was hosrrified and offered his services as a lawyer. “How can the IMCA do something so irresponsible to its patients!?” he exclaimed.

In the nearly 250 autistic children whom I have treated, I have myself encountered any number of chidren who respond well to “Better”‘s “EPIONE” and poorly to “Tikun Olam”‘s “Avidekel,” and vice versa, despite equivalent CBD and THC. This is true of the 1000 or so epileptic children receiving medical cannabis as well. It sometimes takes months to arrive at the optimally effective strain, an empirical fact now disavowed by the IMCA.

Mounting a response that will be effective in protecting patients promises to be problematic due to a variety of factors. The first factor is the medical vaccum around the IMCA. There are parhaps several dozen physicians country wide actively engaged in medical cannabis. An attempt to create a founding meeting of a Medical Cannabis Society two months ago drew about a dozen physicians. A subsequent attempt now has attractedprecisely  four who are willing to be founding members (yours truly is one). In autism there are perhaps half a dozen child psychiatrists, one (yours truly) in the South and no one in the North. Other specialties suffer from similar numbers. So there is no medical presence that can effectively thwart this irresponsible and destructive “Reform”.

Why are there so few physicians? The IMCA has a record an attitude towards physcians that ranges from disrepectful to downright hostile. The Executive Director, who calls himself Magister Yuval Landschaft (the title means he has an MA, in case you have never heard of anyone calling himself so), early after his appointment, denied a patient of mine the continuation of his license to grow. When the patient had started, there were hardly any Suppliers and the IMCA was glad to have someone who could successfully treat himself. The growing was win-win, the patient using his greenhouse as a sort fo occupational therapy. I said as much to the Magister, who insisted on  arguing with me about psychiatric rehabilitation programs. I suggested he was practicing medicine without a  license. The next license was issued with the sarcastic provision that I explain what rehabiltation program had replaced the greenhouse. My patient and I decided that a complaint about abuse of people with disabilities could be justified but would endanger a more than sarcastic cancellation of the license. People simply fear the Magister. At the same time IMCA engaged in unannounced visits to pain clinics and made all kinds of threats to some prominent and experienced pain physicians that they could lose their license. Many clinics abruptly stopped treating with cannabis. So what physician needs this hassle, together with the excessive paperwork? And perhaps some Big Pharma influence in the negative direction…

There will probably be a legal response. Here one opinion is that an Appeal (BaGaTs in Israeli speak) could succeed only after there is proven damage. Wait till somone dies… I can understand this view, because I would see the High Court constrained by the medical vaccum which the IMCA has consistently encouraged. Why should a court make a legal finding based on the opinion of so few physicians? An alternative approach, which I favor, would see the appeal as an instrument to gain the High Court’s likely strong censure of an obviously harmful decision, even if there are not grounds sufficient for injunction.

Now the current system is flawed in many ways. No public sector physicians participate, so most patients have to turn to private sector physicians for the license request. This puts a financial burden upon patients. The communication between IMCA and the requesting physicians requires attention. A recent report of the State Comptroller raised some of these critcisms. However, these are minor logistical flaws that can be addressed without forcning patients away from the strains of cannabis they need.

What has the IMCA up its sleeve? I have written previously that I fear that we are in the stage of treating cannabis like a drug in order to the have a drug (a derivative of cannabis that can be standardized and patented)  replace the medical use of cannabis. I have suggested that under the influence of Sheldon Edelson, Prime Minister Netanyahu is committed to preventing legalization. Legalization would of course give the pharmaceutical derivative little chance of success.

Wait a moment – Are you saying that the State of Israel is willfully using the patients needing cannabis as hostages to developn a new drug? But then the State would be exploiting rather than relieving suffering!? See my Losing It, p. 78.

About the Author
Alan Flashman was born in Foxborough, MA, and gained his BA from Columbia, MD from NYU, Pediatrics, Adult and Child Psychiatry specialties at Albert Einstein College of Medicine, The Bronx, NY. He has practiced in Beer Sheba since 1983, and taught mental health at Hebrew University, Tel Aviv University and Ben Gurion University. Alan has edited readers on Therapeutic Communication with Children (2002) and Adolescents (2005) in Hebrew, translated Buber's I and Thou anew into Hebrew, and authored Losing It, an autobiography, and From Protection to Passover. He recently published two summary works of his clinical experience (both 2022) Family Therapies for the 21st Century and Mental Health in Pediatrics.
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