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Perspectives on formation of medical cannabis market in Ukraine based on holistic approach

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Background Nowadays, medical cannabis still remains inaccesible for patients in the former Union of Soviet Socialist Republics (USSR). Even registered medicinal products based on herbal or synthetic cannabinoids, like Sativex, are practically unavailable due to their high cost and narrow scope of application (for example, in Lithuania). However, before the absolute prohibition of medical cannabis in the USSR, in line with Single Convention of 1961, the State Pharmacopoeia of the USSR (eighth edition) published monographs on such medicinal products as “Herba Cannabis indicae”, “Extractum Cannabis indicae spissum” and “Fructus Cannabis”, which could be prescribed by physicians with precaution. Objectives Formation of a holistic approach aimed at the creation of appropriate conditions for the development of medical cannabis market and the improvement of life quality and health of Ukrainian patients. Methods We analyzed legislation and regulation mechanisms for medical cannabis in the USSR, and the present availability of these products for patients in the former USSR, such as Lithuania, Georgia, Estonia, Russian Federation, and Ukraine. Four hundred thirty-five Ukrainian pharmacy students participated in the quantitative analysis (a survey) that took place on April–May, 2019 at Bogomolets National Medical University (Kyiv, Ukraine). They were surveyed about legalization of medical cannabis in Ukraine, advisability of including cannabis and cannabinoids related data into educational programs, and other issues. Qualitative analysis we applied consisted of the stakeholder analysis and Strength, Weakness, Opportunity, and Threat (SWOT) analysis. We classified the key stakeholders into the patients, healthcare professionals, legislative and regulatory bodies, pharmaceutical companies, pharmacies, etc., and ranked them based on their power and interest in the development of potential medical cannabis market in Ukraine. We also identified their expectations and goals. SWOT analysis allows us to evaluate predictable risks and opportunities, as well as strong and weak aspects of the effective development of medical cannabis industry in Ukraine. Results According to the survey among pharmacy students, about 80% support the legalization of cannabis for medical purposes. However, two-thirds of them think that there is a risk of illicit turnover. Nearly half of the respondents are not informed or poorly informed about cannabis therapeutic properties. At the same time, nearly 90% consider that materials on medicinal properties of cannabis and cannabinoids should be included in the training program. Nowadays, such stakeholders as legislative and regulatory bodies have the highest power over the development of potential medical cannabis market in Ukraine: more than two million Ukrainian patients still cannot access an effective cannabinoids based treatment. There are over 20 thousand children among them suffering from drug-resistant epilepsy due to the lack of adequate legislation. Moreover, a lot of stakeholders with high level of interest, such as growers, manufacturers of cannabidiol (CBD) products, pharmaceutical companies, pharmacies, higher education institutions, even scientists and healthcare professionals are still waiting for the legalization of cannabis for medical and scientific purposes in Ukraine. SWOT analysis shows that present business structures, educational and scientific institutions, regulatory bodies, and the competency of domestic specialists are strong enough to develop a new market of cannabis-based medicinal products in Ukraine. However, a long-term ban on medical cannabis requires more time for creating the entire ecosystem. This market can be quite attractive in Ukraine. It is characterized by high growth rates, low entry barriers and a substantial demand. Yet, its advancement depends significantly on the appropriate regulatory framework, high level of awareness among health professionals and society as a whole, and involvement in scientific study to become a part of the global medical cannabis market. Discussion The holistic approach is aimed to improve health and life quality of Ukrainian patients through cannabis-based medicinal products. It consists of three components: changes in legislation and regulation procedures; changes to value orientations in society; observance of stakeholders’ interests and purposes. Specific recommendations are worked out to realize this approach in Ukraine.
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O R I G I N A L R E S E A R C H Open Access
Perspectives on formation of medical
cannabis market in Ukraine based on
holistic approach
Nataliia Aliekperova
1*
,Кostyantyn Kosyachenko
1
and Oleksandr Kaniura
2
Abstract
Background: Nowadays, medical cannabis still remains inaccesible for patients in the former Union of Soviet
Socialist Republics (USSR). Even registered medicinal products based on herbal or synthetic cannabinoids, like
Sativex, are practically unavailable due to their high cost and narrow scope of application (for example, in
Lithuania). However, before the absolute prohibition of medical cannabis in the USSR, in line with Single
Convention of 1961, the State Pharmacopoeia of the USSR (eighth edition) published monographs on such
medicinal products as Herba Cannabis indicae,Extractum Cannabis indicae spissumand Fructus Cannabis,
which could be prescribed by physicians with precaution.
Objectives: Formation of a holistic approach aimed at the creation of appropriate conditions for the development
of medical cannabis market and the improvement of life quality and health of Ukrainian patients.
Methods: We analyzed legislation and regulation mechanisms for medical cannabis in the USSR, and the present
availability of these products for patients in the former USSR, such as Lithuania, Georgia, Estonia, Russian Federation,
and Ukraine. Four hundred thirty-five Ukrainian pharmacy students participated in the quantitative analysis (a
survey) that took place on AprilMay, 2019 at Bogomolets National Medical University (Kyiv, Ukraine). They were
surveyed about legalization of medical cannabis in Ukraine, advisability of including cannabis and cannabinoids
related data into educational programs, and other issues. Qualitative analysis we applied consisted of the
stakeholder analysis and Strength, Weakness, Opportunity, and Threat (SWOT) analysis. We classified the key
stakeholders into the patients, healthcare professionals, legislative and regulatory bodies, pharmaceutical
companies, pharmacies, etc., and ranked them based on their power and interest in the development of potential
medical cannabis market in Ukraine. We also identified their expectations and goals. SWOT analysis allows us to
evaluate predictable risks and opportunities, as well as strong and weak aspects of the effective development of
medical cannabis industry in Ukraine.
(Continued on next page)
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* Correspondence: aliekperova18@gmail.com
1
Department of Organization and Economics in Pharmacy, Bogomolets
National Medical University, 13, T. Shevchenko blvd., Kyiv 01601, Ukraine
Full list of author information is available at the end of the article
Journal of Cannabi
s
R
esea
r
c
h
Aliekperova et al. Journal of Cannabis Research (2020) 2:33
https://doi.org/10.1186/s42238-020-00044-y
(Continued from previous page)
Results: According to the survey among pharmacy students, about 80% support the legalization of cannabis for
medical purposes. However, two-thirds of them think that there is a risk of illicit turnover. Nearly half of the
respondents are not informed or poorly informed about cannabis therapeutic properties. At the same time, nearly 90%
consider that materials on medicinal properties of cannabis and cannabinoids should be included in the training
program. Nowadays, such stakeholders as legislative and regulatory bodies have the highest power over the
development of potential medical cannabis market in Ukraine: more than two million Ukrainian patients still cannot
access an effective cannabinoids based treatment. There are over 20 thousand children among them suffering from
drug-resistant epilepsy due to the lack of adequate legislation. Moreover, a lot of stakeholders with high level of
interest, such as growers, manufacturers of cannabidiol (CBD) products, pharmaceutical companies, pharmacies, higher
education institutions, even scientists and healthcare professionals are still waiting for the legalization of cannabis for
medical and scientific purposes in Ukraine. SWOT analysis shows that present business structures, educational and
scientific institutions, regulatory bodies, and the competency of domestic specialists are strong enough to develop a
new market of cannabis-based medicinal products in Ukraine. However, a long-term ban on medical cannabis requires
more time for creating the entire ecosystem. This market can be quite attractive in Ukraine. It is characterized by high
growth rates, low entry barriers and a substantial demand. Yet, its advancement depends significantly on the
appropriate regulatory framework, high level of awareness among health professionals and society as a whole, and
involvement in scientific study to become a part of the global medical cannabis market.
Discussion: The holistic approach is aimed to improve health and life quality of Ukrainian patients through cannabis-
based medicinal products. It consists of three components: changes in legislation and regulation procedures; changes
to value orientations in society; observance of stakeholdersinterests and purposes. Specific recommendations are
worked out to realize this approach in Ukraine.
Keywords: Medical cannabis, Market regulations, Pharmacy students, USSR, Former USSR countries, Ukraine
Introduction
At present, the medical cannabis market is one of the fastest-
growing and most perspective markets worldwide. As of
2019, it was estimated at $3.5 billion, and according to the
2025 forecast, a stable growth up to $20.2 billion is expected,
with the compound annual growth rate (GAGR) index of
24.4% (Industry Research 2019). By 2020, more than 50
countries have legalized cannabis and cannabinoids for med-
ical purposes, including Canada, most of the US, Germany,
Luxemburg, Switzerland, Uruguay, Australia, etc. In Ukraine,
the process of national legislation liberalization concerning
cannabis application for medical purposes is at a nascent
stage. It is, therefore, appropriate to conduct a complex ana-
lysis of stakeholderstargets, expectations and possible ac-
tions, evaluate opportunitiesandrisksforthismarketand
develop recommendations for suitable conditions for its
sound development.
The purpose of the study is to form a holistic ap-
proach aimed at establishing a comprehensive environ-
ment to develop the market of cannabis for medical
purposes and, consequently, improve life and health
quality of Ukrainian patients.
Tasks of the research
to carry out a general study of legal and regulatory
norms regarding medical cannabis in the USSR and
former Soviet Republics, including Ukraine;
to study pharmacy studentsopinion on the
feasibility of medical cannabis legalization in Ukraine
and their awareness of its therapeutic properties;
to analyze the aims and interests of the key
stakeholders of the perspective medical cannabis
market in Ukraine, as well as its strengths and
weaknesses, opportunities and threats, by applying
strategic analysis tools;
under a holistic approach, offer recommendations to
encourage a full-scale groundwork for medical can-
nabis in Ukraine, backed by legislative initiatives and
changes in social value orientations.
Background
The study of medical cannabis status in the USSR and ex-
USSR countries
Even though, according to the Convention of 1961 and
the Convention of 1971, cannabis and cannabinoids can
be used for medical and scientific purposes, their enu-
meration into the Schedules of the highest prohibition
degree makes the regulation of these substances consid-
erably harder (United Nations 1961,1971). The coun-
tries of North and South America, most countries of the
European Union (EU), and others found various ways of
making cannabis-based medicinal products (CBMP)
available for patients. However, medical cannabis in the
former Soviet Union countries mostly remains inaccess-
ible for patients due to the lack of legalization of
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 2 of 19
cannabinoids for medical purposes and the high-
prejudiced population.
To perform complex analysis of the situation regarding
cannabis legalization for medical and scientific purposes,
it is worth analyzing the use of this plant, both in the
Ukrainian Republic as a part of the the USSR and in ex-
USSR countries these days. Before 1961, cannabis use
for medical and scientific purposes was legal in the
USSR. However, the free circulation of cannabis, co-
caine, opium, morphine, heroin, and other substances
was limited, according to the Decree of the USSR Cen-
tral Executive Committee (CEC) of 1928 On measures
to regulate the trade in narcotic drugs. There was also a
stated list of enterprises allowed to produce and trade in
narcotic substances (Fedorov 2008).
In the USSR State Pharmacopoeia of 1948 (eighth edi-
tion), composed between 1938 and 1944, there were
monographs devoted to descriptions of Herba Cannabis
indicae,Extractum Cannabis indicae spissumand
Fructus Cannabis(Pharmacopoeia Committee 1948).
These monographs referred to Herba Cannabis indicae
and Fructus Cannabisdescribing their general appear-
ance, microscopic characteristics, numerical indicators,
possible impurities, storage requirements, the maximum
single and daily dose. As concerns Extractum Cannabis
indicae spissum, preparation, properties, identity tests,
purity tests, the maximum single and daily dose were rep-
resented. It is worth noting that Herba Cannabis indicae
and Extractum Cannabis indicae spissumwere included
into Schedule B the list of potential medicines, the pre-
scription, dosage and storage of which had to be done
with precaution (Pharmacopoeia Committee 1948).
Despite the possibility of Cannabis indica cultivation
for medical purposes, since 1934, in accordance with the
Decree of the USSR CEC, illegal seeding of this plant
was covered by an article of the Criminal Code of
Ukrainian SSR (Fedorov 2008). After the USSR ratified
international conventions the Single Convention on
Narcotic Drugs (1961), the Convention on Psychotropic
Substances (1971) and the United Nations (UN) Con-
vention Against Illicit Traffic in Narcotic Drugs and Psy-
chotropic Substances (1988) (United Nations 1961,
1971,1988)- the turnover of cannabis plant, including
for medical and scientific purposes, was completely pro-
hibited. Illegal activity related to seeding of prohibited
plants that contained narcotic substances was regulated
by the criminal codes of the USSR republics, including
the Criminal Code of Ukraine. As a rule, a person was li-
able to a prosecution in case of repeated actions related
to the cultivation of narcotic drug-containing plants
within a current year after the imposition of administra-
tive penalty (Korneev 2010).
After the collapse of the USSR, newly independent
states completely borrowed the Soviet system of
regulation of narcotic and psychotropic drugs flow,
where cannabis and cannabinoids were completely pro-
hibited to be used for recreational, medical and scientific
purposes. Relatively recently, some ex-USSR countries
began to liberalize legislation to regulate the flow of
these substances.
Today, the only country in the post-Soviet territory,
where cannabis and cannabinoids for medical purposes
are legalized, is Lithuania. On October 11, 2018, the
Saeima of Lithuania voted for amendments introduction
into the Laws on Pharmacy and Narcotic Drugs and Psy-
chotropic Substances which came into effect on May 1,
2019. Thus, according to legislative changes, physicians
are allowed to prescribe registered cannabis and
cannabinoids-based medical products only for certain in-
dications: multiple sclerosis, HIV/AIDS, severe forms of
epilepsy and oncology diseases (Marijuana Business
Daily 2019). It is possible to manufacture, import, ex-
port, sell (wholesale or retail) medical products contain-
ing cannabis substances after receiving the relevant
license. At the same time, the cultivation of cannabis
plants in Lithuania remains banned (Aviza 2019). In fact,
legalization is allowed only for medicinal products based
on herbal or synthetic cannabinoids like Sativex, pro-
duced by GW Pharmaceuticals, in a similar way to the
majority of EU states. The main disadvantage of this ap-
proach is the low economic accessability of cannabinoid-
based products, because of their high cost and narrow
scope of application. At present, despite the official
legalization of cannabis and cannabinoids, preparations
based on them are practically unavailable for Lithuanian
patients.
Georgia decriminalized the use of cannabis. However,
it was not legalized for medical purposes. Thus, on No-
vember 30, 2017, the Constitutional Court of Georgia
completely abolished criminal liability for the use of can-
nabis, considering this norm to be unconstitutional ref-
erence the right for freedom in personal development.
Before that, the consumption of cannabis was imposed a
penalty for the first time and a criminal liability further
on. Later, on November 30, 2017, the Constitutional
Court of Georgia ruled out an administrative punish-
ment for the use of cannabis to be unconstitutional. Ac-
tually, it allowed the individuals aged over 21 to use
cannabis, except smoking in public places, which is fined
at $300 $450. Besides, storing of cannabis in Georgia
leads to administrative punishment (up to 5 g of dried
cannabis) and criminal punishment (if exceeding) (Akh-
meteli 2018; Schiller 2018).
In Estonia, in spite that cannabis for medical purposes
is not legalized, the unregistered medicinal products
containing cannabinoids can, nevertheless, be available
for patients. Thus, the Estonian State Agency of Medi-
cines (ESAM), on a physicians advice, can consider a
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 3 of 19
claim on the unregistered import for a definite patient.
That is to say, claims on Sativex (Nabiximols), contain-
ing herbal cannabinoids, were twice approved by ESAM.
Besides, in Estonia, there is no criminal responsibility for
cannabis storage up to 7.5 g of dried bud (Marijuana
Doctors 2018; European Monitoring Centre for Drugs
and Drug Addiction 2018).
In the Russian Federation, the Federal Law N 168-FЗ
was adopted by the Gosudarstvennaya Duma On Intro-
ducing Changes into the Federal Law On Narcotic Drugs
and Psychotropic Substances, as Regards the Improve-
ment of Order of Cultivation of Drug-Containing Crops,
which came into effect on July 5, 2019 (The Russian Fed-
eration Federal Law 2019). According to this law, it is
allowed growing narcotic drug-containing plants for re-
search and scientific purposes, in expert activity for the
production of narcotic and psychotropic substances in
medicine and veterinary science. This activity can be per-
formed only by the licensed state enterprises obliged to
submit annual reports on placement and area of land plots
used for cultivation of narcotic drug-containing crops.
However, according to the Decree of the Russian Feder-
ation 101 of 06.02.2020, On determining strains of
narcotic plants permitted for growing to be used in pro-
duction of narcotics and psychotropic substances for med-
ical and (or) veterinary use, and for industrial growing, not
related to production or manufacture of narcotics and
psychotropic substances, including requirements to strains
and conditions for growing, only the strains of opium
poppy are permitted for medical and veterinary purposes.
Cannabis containing maximum 0.1% of tetrahydrocanna-
binol (THC) is only allowed for industrial growing (The
Russian Federation Decree 2020).
It is worth summarizing that patients access to medical
cannabispreparationsisstilllimitedinex-USSRcountries,
despite the legislation liberalization all over the world. Baltic
countries (Lithuania, Estonia), being the EU members, take
a more active position. The decriminalization of cannabis
use in Georgia also testifies to democratic initiatives and ac-
tions to observe human rights. At the same time, in other
countries of the former Soviet Union, including the Russian
Federation, cannabis is under absolute prohibition, both for
medical, recreational purposes and for scientific research.
Legislation liberalization in these countries is likely to hap-
pen only after changes are introducedintotheSingleCon-
vention on Narcotic Drugs (1961), the Convention on
Psychotropic Substances (1971), in line with recommenda-
tions suggested at the 41st Expert Committee on Drug De-
pendence (ECDD) meeting.
Specific features of the regulation of cannabis and
cannabinoids for medical purposes in Ukraine
In Ukraine, cannabis and cannabinoids for medical and
scientific purposes are prohibited at the legislative level.
The regulation of these substances is performed under
the Law of Ukraine On Narcotic Drugs, Psychotropic
Substances and Precursorssetting legal and
organizational frameworks of the state policy concerning
the traffic of above mentioned substances in Ukraine,
with cannabis and cannabinoids being part of this group
(Law of Ukraine 1995). According to the Decree of the
Cabinet of Ministers of Ukraine (CMU) 770, as of
May 6, 2000, On the Approval of the Schedule of Nar-
cotic Drugs, Psychotropic Substances and Precursors,
cannabis, cannabis resin, cannabis extracts, and tincture
are included into Schedule I as especially dangerous
narcotic drugs, with the circulation to be prohibited,
and THC and its isomers into Schedule II especially
dangerous psychotropic substances, with the circulation
to be prohibited(Decree of CMU 2000).
The application of Cannabis species plant is allowed
only for industrial purposes, under Schedule III: plants
containing narcotic and psychotropic substances, the cir-
culation of which is allowed for industrial purposes
(Decree of CMU 2000). Herewith, growing the plant of
Cannabis species for industrial purposes is allowed pro-
vided that the dried straw of seeds used has the max-
imum THC content of 0.08%. At this date, certain
companies operate in Ukraine dealing with the produc-
tion of cosmetic products based on technical hemp, food
products made of hemp seeds, clothes, equipment for
growing technical hemp, plant culturing units, software,
etc. (CannaFair 2019). Research activity, new strains cul-
tivation and hemp growing technologies are exercised by
the Institute of Bast Crops (2019).
Despite the ban on cannabis and cannabinoids use for
medical and scientific purposes in Ukraine, there is a
considerable need for preparations based on them. Thus,
according to the online Petition To regulate cannabis
for science and medicine means to defend citizenscon-
stitutional rights, over 2 million people in Ukraine do
not receive any effective pharmaceutical care (Verkhovna
Rada of Ukraine 2019). Among them, over 20 thousand
children are suffering from drug-resistant epilepsy, hun-
dreds of thousands of cancer patients, over 100 thousand
of palliative patients, dozens of thousands of war vet-
erans with post-traumatic stress disorder.
The usage of CBMP will enable satisfying partially the
need for pain-relieving preparations, considering a low
availability rate of opioid analgesics in Ukraine. Accord-
ing to the analysis of International Narcotics Control
Board data, the intake of narcotic opioid analgesics
(fentanyl, oxycodone, morphine, hydromorphone, and
pethidine) in Ukraine had dropped nearly 30% during
20142016, compared to that of 20042006: from 93 to
66 daily doses for statistical purposes (s-DDD) per
1.000.000 inhabitants. Ukraine takes the lowest positions
among European countries in this matter, taking into
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 4 of 19
consideration that opioid use in many western countries
(Austria, Belgium, Denmark, Germany, Netherlands,
Spain, Switzerland, USA) exceeds 10.000 s-DDD per
1.000.000 inhabitants (Bosetti et al. 2019; International
Narcotics Control Board 2019). According to the data of
the Institute of Analysis and Advocacy report, morphine
availability rate for patients in various regions of Ukraine
constituted 11.2 to 14.3% in 20122016 (Institute of
Analysis and Advocacy 2018). These indices demon-
strate the importance of studying medical cannabis and
cannabinoidsproperties, and the need to establish a
congenial atmosphere to form the CBMP market in
Ukraine.
The issues of medical cannabis legalization are of
interest to the Ukrainian public. With this respect, in
May 2019, the sociological group Ratingconducted re-
search in which over 2000 people from all regions of
Ukraine took part (Social Group Rating 2019). Accord-
ing to the results, 30% of respondents heartily supported
to legalization of medical cannabis, 28% partially sup-
ported it. However, a quarter of respondents expressed
their strong opposition to this initiative. Most often, re-
spondents approving legalization of medical cannabis
and cannabinoids are males aged between 18 and 35,
having a high-income level and living in the capital of
Ukraine, Kyiv. Opponents of legalization are normally fe-
males over 50, with a low-income level, living in the
western regions of Ukraine. It stands to reason, that gen-
erally a higher education level, broader knowledge, ab-
sence of established prejudices influence the positive
attitude to medical cannabis legalization.
In recent years, the movement to change the official
status of cannabis plant has gained momentum consid-
erably, including the need to liberalize the national legis-
lation. Specifically, Cannabis marches have been held in
Ukraine for more than 5 years, bringing up the issues of
medical cannabis legalization and its usage
decriminalization. The latest march took place in Octo-
ber 2019. It was participated by individual activists, and
representatives of over 10 various public organizations
representing the interests of oncologic patients, HIV/
AIDS patients, people suffering from post-traumatic
stress disorder and other diseases. The main demand
was to register a new legislative draft providing access to
cannabis- and cannabinoid-based preparations for
Ukrainian patients (UNIAN Information Agency 2019a).
On May 312,019, the II International Medical Cannabis
Conference (IMCC 2019) took place covering speakers
from the EU countries, the USA, Israel. About 400 spe-
cialists, including more than 200 physicians from all over
Ukraine, took part in it (Ukrainian Association of Med-
ical Cannabis 2019). However, the online Petition To
regulate cannabis for science and medicine means to de-
fend citizensconstitutional rightspromoted legislative
changes for cannabis and cannabinoids legalization for
medical and scientific purposes and garnered the neces-
sary amount of votes.
The main claims of this Petition are as follows: obser-
vance of human rights related to use of effective
cannabis-based preparations; establishment of adequate
conditions for comprehensive application of herbs in
medical and scientific activity; the settlement of legal
turnover of cannabis-based products (Verhovna Rada of
Ukraine 2019). On March 202,019, its public discussion
took place in the Committee of the Verkhovna Rada of
Ukraine on Issues of Human Rights of National Minor-
ities and Interethnic Relations; however, due to the lack
of a quorum they did not take a decision. On May 152,
019, this Committee unanimously supported the draft
law submitted by nongovernmental organizations On
the introduction of changes to certain legislative acts of
Ukraine concerning support of the fundamental human
right to lifeaimed at cannabis legalization for medical
and scientific use (UNIAN Information Agency 2019b).
However, the 8th Verkhovna Rada of Ukraine never put
this draft law to a vote. As of the date of writing this art-
icle, the new bill on legalization of cannabis and canna-
binoids for medical and scientific purposes, which is
being prepared by the governing coalition in the new
9th Verkhovna Rada, has not been registered yet, and its
text is inaccessible for acknowledgement.
Methods
Qualitative analysis
Stakeholder and SWOT analysis are most reasonable to
reveal the complex effect that legalization of medical
cannabis in Ukraine may have for various parties
concerned.
Stakeholder analysis is based on the process of system-
atically gathering and analyzing qualitative information.
It will allow identifying and evaluating the expectations,
purposes, interests of stakeholders and predicting their
possible actions. Kammi Schmeer noted that stakeholder
analysis allows policymakers and managers to interact
more effectively with key stakeholders and to increase
support for a given policy or program(Schmeer 2000).
Besides, according to Schmeer (2000), if this analysis is
conducted before a policy or a program is implemented,
policymakers and responsible executives (managers)
can detect and act to prevent potential misunderstand-
ings and/or opposition to the policy or program.To
identify key stakeholders, a stakeholder power-interest
grid was used (Eden and Ackerman 1998). According to
this grid, stakeholders can be divided into four groups
(players, context setter, subjects and crowd) depending
on the level of their interests and power. In this paper,
the expectations and interests of key stakeholders were
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 5 of 19
analyzed, and their actions after legalization of medical
cannabis were predicted.
The next qualitative analysis in this research is the
SWOT analysis which can be used as a strategic plan-
ning framework while studying both an organization and
a particular market or industry. The SWOT analysis is a
descriptive tool rather than a prescriptive one, however,
it allows shaping a specific vision of the market with due
regard for various factors. Thus, the potential market of
medical cannabis requires an understanding of the in-
ternal strengths and weaknesses, in particular the follow-
ing ones: existing resources and capabilities and core
competencies of the main players. External opportunities
and threats enable us to evaluate trends and drivers, the
possible competitive situation in the market, as well as
the influence of political, economic, technological, legis-
lative, international and other factors affecting the devel-
opment of the cannabis market in Ukraine (Sammut-
Bonnici and Galea 2015).
Quantitative analysis
Sampling justification
To determine the awareness level about the significance
of cannabis and cannabinoids use for medical purposes
among future specialists in pharmaceutical sphere (gen-
eral population), the quantitative analysis was conducted,
i.e. a survey. As a sampling frame, the School of Phar-
macy students at the Bogomolets National Medical Uni-
versity (Kyiv, Ukraine) were selected. To sum up, about
2500 students study at the School of Pharmacy, includ-
ing full-time and part-time programs. Probability sam-
pling techniques were used, random sampling in
particular, which, according to Walliman (2006), allows
obtaining reliable data on general population. Besides,
random sampling is vital in case when general popula-
tion has similar characteristics. The sample size in this
research comprised 435 persons with the following indi-
ces: confidence interval 97% and confidence level
5%. In the basic survey, the participants were part-time
students 77.5% and full-time students 22.5%. Most
respondents have incomplete higher education (53.3%)
and are fourth-year students. More detailed information
on the respondents is given in Table 1.
It should be observed that the majority of pharmacy
students at the Bogomolets National Medical University
study part-time to obtain a degree of Specialist (Master)
of Pharmacy which directly influences the sample struc-
ture. These degrees are practically identical in Ukraine,
as a Masters degree in Pharmacy had been introduced
comparatively recently with the purpose of
harmonization of national educational standards to
international ones. Some students already have higher
education (in economics, medicine, biology, philology,
etc.), 15.4% of students have already received the
specialized secondary education in medicine, and 20%
have got the same in pharmacy (a Junior Specialists de-
gree). In fact, a Junior Specialists degree can be consid-
ered as a Bachelors degree. In this connection, the
majority of students, who already have the specialized
secondary education in pharmacy, actually work in phar-
macies and receive their higher education part-time
(mostly, these are second-year students). Some of the
students entered part-time study after graduating from
secondary school, and the rest are the full-time students.
Although pharmacy students are not full-rate health
care specialists, it is reasonable to study their awareness
level and attitude towards the use of cannabis for med-
ical purposes. Since cannabis and cannabinoids are pro-
hibited for medical and scientific purposes in Ukraine,
the issues on their therapeutical properties, the endocan-
nabinoid system and others are not considered in curric-
ula and programs to prepare degree-seeking pharmacy
students. Therefore, pharmacy practitionersawareness
respecting this problem is likely to be at the same level
as that of students. Besides, the survey included students
who mostly study in their final year at the university,
they have already had their internship in pharmacies, in
accordance with the standards of Specialist (Master) of
Pharmacy program. Some part-time students have ex-
perience of working in pharmacies. Senior students, who
already got the knowledge in physiology, pharmacog-
nosy, pharmacology, etc., consider it important to in-
clude materials on cannabis and endocannabinoid
Table 1 Educational characteristics of 435 pharmacy students at
the Ukrainian Bogomolets National Medical University who
answered a questionnaire about medical cannabis during April
to May 2019
Evaluation criteria Number of
respondents
Percentage
(%)
Form of study:
Full-time 98 22.5
Part-time 337 75.5
Year of study
100
2 45 10.4
300
4 337 77.5
55212
Education level
Higher education 47 10.8
Incomplete higher education 233 53.5
Specialized secondary education
in pharmacy
87 20
Specialized secondary education
in medicine
67 15.4
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 6 of 19
systems properties, and their specific medical use into
the educational program. It is doubtless that general
population and sampling frame selected for the research
cannot provide the appropriate evaluation of awareness
and attitude level to legalization of cannabis and canna-
binoids for medicine. However, this allow obtaining use-
ful data for holistic approach concerning development of
the perspective CBMP market in Ukraine, with the pur-
pose of providing patients with effective pharmaceutical
care.
Data collection technique
We have developed a questionnaire to study the aware-
ness level of pharmacy students at the Bogomolets Na-
tional Medical University. The survey took place during
April to May 2019. The questions cover such issues as
the necessity to provide Ukrainian patients with CBMP,
legalization of these products, expediency of conducting
this research, incorporation of information on properties
of cannabis and cannabinoids in courses for pharmacists,
and regulation of these products market. Structure of
the questionnaire consists of three parts, namely respon-
dentsdetails, main part, and feedback (see the online
Appendix). There are two types of questions in the main
part. Some questions include a brief analysis of the prob-
lems with medical cannabis and cannabinoids to deter-
mine the awareness level of respondents or their opinion
on different initiatives on CBMP. The answers to these
questions are illustrated in the pie and bar charts. An-
other type of questions rate the importance of certain is-
sues regarding cannabis for medical and scientific
purposes on a scale of 1 to 5, where 1 is not important
and 5 is very important. The survey results were proc-
essed with Microsoft Excel. It is worth saying that the
developed questionnaire also bears an educational char-
acter. Since the information on CBMP is very contra-
dictory and imperfect in Ukraine, there exist many
prejudices as to its use-related risks. Besides, many
people, including healthcare professionals, are ill-
informed on cannabis and cannabinoids use for medical
purposes. Thus, 64.5% of respondents noted that they
received useful information on medical cannabis and
cannabinoids throughout the survey, and 21.8% noted
that they would rather receive this information. Also,
50% of students considered the information obtained to
be very important for them, and 35.5% marked it as
important.
Results
Survey results of students, getting higher pharmaceutical
education in Ukraine
It is vital to study this issue among health specialists
since Ukraine is now in a process of liberizing its
cannabis-related legislation to regulate the use for
medicine and science. The Petition To regulate canna-
bis for science and medicine means to defend citizens
constitutional rightsstates that there are over 2 million
citizens deprived of their access to effective treatment in
Ukraine (Verkhovna Rada of Ukraine 2019).
We have examined the respondentsawareness of the
above mentioned matter based on questionnaire taken
by 435 Ukrainian pharmacy students at Bogomolets Na-
tional Medical University during April to May 2019. It is
worth noting that other results presented in figures
below are also based on the analysis of this survey.
Thus, around a third of Ukrainian pharmacy students
are well aware that over 2 million Ukrainians have a lim-
ited access to effective treatment, 43% confirm they are
quite aware, and over 20% of the future pharmacy pro-
fessionals practically do not know about this problem
(Fig. 1). At that, over 75% of respondents agree that it is
very importantto solve this problem.
Only 16% of the polled students are well aware of can-
nabis and cannabinoids properties for the treatment of
certain diseases, while 34% are hardly aware, and 12%
are not aware at all (Fig. 2).
More than 65% support legalization of cannabis and can-
nabinoids for medical and scientific purposes, but, at the
same time, they are apprehensive of possible risks, 14% fully
support legalization and 13% do not support it (Fig. 3).
Generally, it is possible to conclude that the great ma-
jority of future Ukrainian pharmacy specialists have a
positive attitude to cannabis plant legalization for med-
ical and scientific purposes. Besides, nearly 44% of re-
spondents have noted that it is very importantto create
a national research basis for studying therapeutic prop-
erties of cannabis and cannabinoids.
In many countries where cannabis and cannabinoids
are legalized in this or that way, for instance, in Canada,
the USA, Israel, academic programs have been elabo-
rated for healthcare professionals regarding properties
and medical use of these substances (Pennsylvania Phar-
macists Association 2018; Ontario College of
Fig. 1 Awareness by Ukrainian pharmacy students of limited access
to effective treatment for more than 2 million Ukrainians
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 7 of 19
Pharmacists 2018). We examined the feasibility of in-
cluding materials on cannabis, cannabinoids, endocanna-
binoid system and other aspects in the program for
Master of Pharmacy, and obtained positive feedback.
54% agree that such materials should be included,
while 32% consider that they should rather be included
(Fig. 4).
Besides, nearly half of the students surveyed (48.5%)
think that it is very importantto compensate for Master
of Pharmacy academic programs with studying cannabis
and cannabinoids for medical and scientific use.
Taking into consideration that the use of cannabis and
cannabinoids, including for medicine and science, is
completely prohibited, and legislation liberalization is
under preparation design, it is vital to evaluate the im-
portance of certain changes in the status of these sub-
stances. 58% of the future pharmacy specialists consider
a present shaping of public opinion on medical cannabis
use to be very important. 56% consider it is very im-
portantto advise the key stakeholders on non-
psychotropic properties of certain substances in cannabis
plant, in particular, those of CBD. This cannabinoid, ac-
cording to the reports of ECDD, is a harmless and useful
substance for human health and public welfare. It has
numerous applications in industry, nutrition, cosmetics.
It is also used to relieve certain states, for instance, those
related to epilepsy (World Health Organisation 2018).
55% of pharmacy students consider it is very important
to set conditions for a sound scientific research on can-
nabis and cannabinoids (Fig. 5). On average, about 5% of
respondents consider these initiatives to be rather not
important, and a bit over 1% to be unimportant.
It should be noted that the above-mentioned points, in
the respondentsopinion, are preliminary stages before
cannabis and cannabinoids are legalized for medical pur-
poses, and prospectively for recreational purposes. They
facilitate minimization of possible risks on the part of soci-
ety and reduce a number of popular prejudices that during
a long time cannabis was believed to be a dangerous nar-
cotic drug having no therapeutic effect. In consequence,
this will help create the environment for effective and con-
secutive liberalization of legislation in Ukraine.
Despite that legalization of cannabis for recreational use
is not regarded in Ukraine yet, the existing global trends
are aimed at this very issue. In this respect, it is vital to
learn the future pharmacistsattitude to cannabis
legalization not only for medical but also for recreational
purposes. So, according to the research result, the majority
of students (46%) support only legalization of cannabis
and cannabinoids for medical purposes, and 14% do not
support it at all. At the same time, 32% of respondents
quite support marijuana legalization, similar to alcohol
and tobacco. 8% of them support total legalization and
24% think it would be feasible to legalize marijuana on a
phased basis: first for medical and scientific purposes, and
only later for recreational ones (Fig. 6).
It is worth noting that 65% of respondents said they
received useful information about medical use of
Fig. 2 Awareness by Ukrainian pharmacy students of therapeutic
properties of cannabis and cannabinoids in treating certain diseases
Fig. 3 Ukrainian pharmacy studentsattitude to legalization of
medical cannabis in Ukraine
Fig. 4 Ukrainian pharmacy studentsattitude to including data on
medical cannabis and cannabinoids in academic programs
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 8 of 19
cannabis while filling in the survey form, and 22% con-
firmed that it was quite useful. At that, 50.5% of future
pharmacy specialists agreed that information presented
in the survey form was very important. The results test-
ify that providing information on medical cannabis both
for public health professionals and the rest of society is a
key and necessary instrument to implement effective
liberalization policy in regards to these substances.
Stakeholder analysis results of the potential CBMP market
in Ukraine
Legalization of cannabis and cannabinoids for medical
and scientific purposes, and consequently, the status
change for these substances in Ukraine will involve vari-
ous stakeholders having different interests on this issue
and various level of power and influence. Thus, depend-
ing on the power and interest level, we can distinguish
several stakeholders in the Ukrainian market of medical
cannabis (Fig. 7).
At the stage of providing conditions for legalization of
medical cannabis, the key stakeholders are those who
possess high power and high interest. Public groups,
separate activists and other parties concerned literally
push throughthe necessity of legislative regulation of
medical cannabis for the benefits of patients. Stakeholders
having a high power and low interest level are state
policymakers. They do not only possess exclusionary
power for legalization but also create conditions to regu-
late this market.
However, an adequate functioning of the medical can-
nabis market requires both to identify potential stake-
holders and to analyze their expectations and
predictable actions after legalization is approved. For
more detailed information see Table 2.
SWOT analysis results of the potential CBMP market in
Ukraine
Legalization of medical cannabis in Ukraine opens up
space for the development of new markets, as it has
already taken place in many European countries, the
USA, Canada, South American countries and other
states. Both CBMP containing a high concentration of
TCH and its isomers, and CBD-dominant products, the
full-spectrum extracts or broad-spectrum extracts, can
be applied for medical use and improve peoples health
life quality.
However, it is necessary to evaluate predictable risks
and opportunities, as well as strong and weak aspects,
what should be the focus of attention of the participants
in these markets for effective development of medical
cannabis industry in Ukraine. As an effective strategic
instrument, the SWOT analysis would suit this best.
Fig. 5 Estimating factors affecting liberalization of Ukrainian legislation concerning cannabis and cannabinoids for medical purposes based on
Ukrainian pharmacy studentsopinion
Fig. 6 Ukrainian pharmacy studentsattitude to legalization of cannabis and cannabinoids for recreational purposes in Ukraine
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 9 of 19
So, Strengths of the potential market of medical can-
nabis in Ukraine are as follows:
1. The considerable growth of research articles
devoted to use of cannabis and cannabinoids in
medical practice: by the end of January 2020, 21.459
papers were published on PubMed, 15.391 of them
concerned the influence of cannabis on a human
body. During the last 5 years, articles growth on the
topic constituted 105%. Besides, the report of the
American National Academy of Sciences, the
Health Canada review, etc. are accessible, so a
considerable experience of medical use of cannabis
is obtained (PubMed 2020; Usenko and
Kosyachenko 2019).
2. The presence of the potential participants for this
market in Ukraine: domestic and foreign
pharmaceutical manufacturers, agriculture
companies, analytical laboratories, higher
educational establishments, scientific research
institutions, pharmacies, in particular those having
licenses for extemporaneous compounding,
wholesale pharmaceutical companies, etc.
3. The current legal and regulatory framework does
not require considerable changes. Basically,
corrections and amendments are needed to be in
line with the international conventions
requirements. The positive factor is also
liberalization of the national legislation on the
circulation of narcotic and psychotropic drugs,
aimed at the improvement of their physical and
economic availability for patients, in the palliative
medicine sphere in particular.
4. The presence of state regulatory bodies which can
function as the Cannabis Agency in accordance
with the requirements of Art. 23 and Art. 28 of the
1961 Convention (United Nations 1961), and also
of the Monitoring center to gain information on
narcotic and psychotropic drugs consumption to
assess the needs and quota limits.
5. The presence of qualified personnel (specialists of
pharmaceutical and agriculture businesses,
scientists, teachers, physicians, pharmacists, Health
Technology Assessment (HTA) professionals,
representatives of state regulatory bodies, etc.) who
can practically apply the obtained knowledge and
skills in the public health sphere, business, science,
education, regulation sphere and so on.
Weaknesses
1. The attitude of Ukrainian society towards cannabis
is rather constrained. There are prejudices against,
for instance, the idea that legalization of medical
cannabis can facilitate access to it in the illicit
market. According to the survey, 65% of future
pharmacy specialists, who support cannabis
legalization for medical and scientific purposes, at
the same time, believe there is a risk of its illegal
circulation.
2. Evidence-based medicine provides insufficient
information regarding the efficiency and safety of
Fig. 7 Stakeholder power\interest grid on the potential market of medical cannabis in Ukraine. Note: Healthcare professionals (physicians,
pharmacists and others), after medical cannabis legalization, are transferred into the status of stakeholders having high power and low interest, as
they have a direct impact on the products accessibility for patients
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 10 of 19
Table 2 Expectations and predictable actions of the key stakeholders in the medical cannabis market in Ukraine
Expected results Predictable actions after legalization Notes
Stakeholders: high interest / high power
Public organizations (activists): patients, healthcare professionals, lawyers, politicians, scientists, business representatives and other concerned parties
Ensuring the interests of patients in
obtaining economically and physically
available, high-quality, effective, safe med-
ical and pharmaceutical care when using
medical cannabis.
Monitoring patientsrights to receive
appropriate medical and pharmaceutical care,
cooperation with state regulatory bodies, health
professionals, patients and other stakeholders.
Creation and support of the stakeholders
network to inform and exchange ideas and
experience. Carrying out activities for better
social awareness of medical cannabis,
advantages and risks of its use including
activities participated by opinion-leaders (PR-ac-
tions, operation of various societies and volun-
tary organizations).
These stakeholders are a driving forceat the
stage of preparation to the process of medical
cannabis legalization, especially concerning
stakeholders having a high power but low
interest.
They possess high power due to their
leadership qualities, charisma, the ability of
inspiring and uniting people with similar values.
Stakeholders: low interest / high power
Legislative and regulatory authorities
Development and adequate performance
of the system that provides affordable and
effective medical and pharmaceutical care
by using medical cannabis through various
tools, such as the Health Technology
Assessment (HTA), under the international
Conventionsrequirements, the WHOs
recommendations, reports and alerts of the
INCB and other international documents.
Creation of legal framework regulating the
medical cannabis turnover, also as a component
of the general strategy of state narcotic drugs
policy, which may include legalization of other
drug containing plants and decriminalization of
their use. Introduction of amendments and
changes to various normative legal documents,
for instance, to the Law of Ukraine On Narcotic
Drugs, Psychotropic Substances and Precursors
(Law of Ukraine 1995), as well as to subordinate
laws, such as the Decree of CMU 770 (Decree
of CMU 2000) and others. Establishing
conditions to create new herbal medicinal
products or herbal preparations by developing
monographs in the State Pharmacopoeia of
Ukraine (SPhU). Introducing the mechanisms of
cannabis traffic regulation for medical and
scientific purposes according to Art. 23 and Art.
28 of the 1961 Convention (United Nations
1961).
The medical cannabis market is new for Ukraine,
yet the existing legal and regulatory system can
provide regulating instruments, according to
the requirements of International Conventions
(licensing, quoting, needs assessment, harvest
control, etc.). For this reason, it requires some
amendments to be introduced on behalf of
government, in particular the Ministry of Health
of Ukraine (MHU) and the State Service of
Ukraine on Medicines and Drugs Control.
Law enforcement authorities
The presence of a legal framework to
regulate and prevent the illicit trafficking of
cannabis-based preparations, containing
narcotic drugs and psychotropic
substances.
Providing preventive mechanisms for illicit
turnover of medical cannabis containing
narcotic drugs and psychotropic substances
(herbal substances, herbal preparations or
medicinal preparations of herbal origin, both
registered and prepared in pharmacy
conditions) in accordance with the current
legislation of Ukraine.
The lack of decriminalization of cannabis and
corruption element in Ukraine may reduce the
effectiveness of regulating its illicit trafficking.
Stakeholders: high interest/ low power
Patients
Obtaining physically and economically
available, effective and safe medical and
pharmaceutical care with the application of
CBMP to improve the health and life
quality.
Monitoring additional information on cannabis-
based preparations for treatment and their offi-
cial status: cooperation with health specialists
(physicians, licensed pharmacists), association
into public organizations (groups) for self-
assertion as to obtaining accessible medical and
pharmaceutical care.
Negative tendencies in Ukraine should be taken
into consideration: the average availability level
of the golden pain management standard’–
morphine was between 11.2 and 14.3%
during 20122016, even despite the
liberalization of legislation (Institute of Analysis
and Advocacy 2018).
Growers of cannabis
Possibility of official cultivation and
growing of cannabis plant, both of outdoor
(hemp) and indoor (medical marijuana),
with various THC and CBD content, within
the legislative environment framework.
Legislation liberalization as concerns the
growing of hemp. The purpose is to create
Cultivation and growing of cannabis strains with
various THC and CBD content for industrial and
medical purposes, depending on the
requirements of the current legal and regulatory
framework. Investment promotion for creating
relevant conditions for growing cannabis,
especially indoor, personnel preparation and
Additional advantages: new job opportunities,
development of business activity, including
small businesses, investments promotion,
encouraging illicitgrowers to come out of the
shadow, etc.
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 11 of 19
Table 2 Expectations and predictable actions of the key stakeholders in the medical cannabis market in Ukraine (Continued)
Expected results Predictable actions after legalization Notes
a sustainable business (investment
promotion, gaining a market share,
profitability).
training, safety provision, automation of the
process, as well as formation and support of
sales markets considering competition, etc.
Manufacturers of CBD-products
Liberalization of growing, processing and
manufacturing of CBD-products based on
the varieties with a low THC-content (their
turnover shall not fall into the scope of the
law on narcotic drugs and psychotropic
substances). Creating conditions for the de-
velopment of a sustainable profitable busi-
ness within the legislative environment.
Manufacturing CBD-products in accordance with
the legal framework considering the minimum
permissible THC level (0.2% in the EU countries,
0.3% in the USA, 1% in Switzerland). Investments
promotion: establishing economic and technical
conditions for processing cannabis herbal sub-
stance, manufacturing and qualified staff train-
ing. Creation of identifiable brand, the product
portfolio reaching the preferences of target
audience, product promotion, formation and
realization of a competitive strategy for business
development.
The CBD-products market is highly competitive:
there are fewer legal limitations, high growth
and profit rates and, currently, low entry barriers
in the Ukrainian market (an attractive factor for
foreign companies). Additional advantages: cre-
ating new jobs, business promotion,
revenues for local and state budgets, etc.
Pharmaceutical manufacturing companies
The product portfolio diversification due to
development and manufacturing of
cannabis-based products, including narcotic
and psychotropic products, gaining a new
market share, profitability improvement,
image creation, brand formation. For for-
eign companies: entering a new market
with goods from their product portfolio.
For domestic companies: creation of new
medications including narcotic and
psychotropic ones (preclinical and clinical trials,
formulation of dosage forms and methods of
quality control), registration, manufacturing,
sales, promotion, pharmacovigilance.
For foreign companies: entering a new
medicinal products market, their registration
(Epidiolex, Sativex) or entering the standardized
products market, for instance, of cannabis
flowers, including manufacturing of CBMP under
pharmacy conditions.
Foreign companies have an advantage
compared to domestic ones, which is the time
factor and intangible resources including
effective promotion of cannabis-based prepara-
tions. Their major disadvantage is the product
price and low economic accessibility for the
Ukrainians.
Distributors (wholesale pharmaceutical companies)
An opportunity of purchasing, storing and
selling of CBMP to wholesalers
(distributors), retailers (drugstores) and for
storing (health care institutions) backed up
with licensing. Consequently, there is the
entrance into a new market, product range
enlargement and profitability.
Purchasing of cannabis-based preparations from
manufacturers (foreign and domestic ones), lo-
gistics organization, storing, trading (wholesale
pharmaceutical companies, pharmacies, health-
care facilities) in accordance with legal require-
ments, including those for narcotic and
psychotropic substances circulation.
These intermediaries are currently interested in
the market of registered medicines or of CBMP
containing narcotic or psychotropic substances
that can be sold only via drugstores.
Pharmacies (with extemporaneous compounding)
Legal opportunity of CBMP manufacturing
under the pharmacy conditions in line with
current legislation - for instance, cannabis
oil from standardized raw materials or
dronabinol. Writing monographs on
cannabis plant, cannabinoids (THC, CBD),
etc. Entering new markets (patients, health
care facilities), brand formation, profitability.
Purchasing of cannabis herbal substances for
CBMP manufacturing under magistral formulas,
establishing economic and technical basis for
extemporaneous compounding, drugs form
formulations, qualified personnel training, and
quality control under the current legislation.
Cooperation with physicians, studying of the
current legal framework, providing high-quality
pharmaceutical care.
Cannabis-based preparations made under
magistral formulas have a competitive
advantage. They are not subject to state
registration in Ukraine. Besides, pharmacies can
sell finished pharmaceutical products or dietary
supplements containing cannabinoids.
Higher education institutions (scientific research institutions)
Formation of new competencies for
students and scientists, adjustment or
creation of training programs in
accordance with current scientific results
(for example, meta-analysis).
Obtaining new knowledge through the science
and consequently creating scientific products
(dissertations, articles, monographs, patents, etc.)
to improve lives and society.
Adjustment of training programs and curricula
for medical and pharmaceutical higher
education institutions (departments) given the
scientific-based results on cannabis and cannabi-
noids therapeutic properties, their application in
medical and pharmaceutical practice, etc. Con-
ducting scientific research, creation of new re-
search products, organization of scientific
conferences, regular experience exchange. De-
velopment of HTA issues and standards (proto-
cols) of treatment.
Higher education institutions are, normally,
scientific centers, which allow research results to
be integrated into training programs for
students. Besides, scientific research institutes
can be separately considered as the basis for
conducting scientific research.
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 12 of 19
medical cannabis for treating various diseases. Its
data base is quite moderate and weak so far. Clear
evidence relates to cannabis and cannabinoids use
in the treatment of muscle spasm in patients with
multiple sclerosis, neuropathic pain and intractable
childhood epilepsy (Barnes and Barnes 2016;
European Monitoring Centre for Drugs and Drug
Addiction 2018).
3. The absence of clear and unified classification and
terminology concerning medical cannabis: there are
different definitions to describe the products
containing cannabis and cannabinoids and allowed
for medical purposes in various countries. Besides,
the additional findings are required regarding the
scientific research on cannabis plant, interoperation
of phyto- and endocannabinoids and other
biologically active substances in a human organism
(Health Canada 2018).
4. Low availability of complete and actual data on
therapeutic efficiency, possible advantages and risks
of cannabis and cannabinoids use for medical and
scientific purposes. Thuswise, according to the
International Narcotics Control Board (INCB)
report of 2018, the main factors limiting controlled
substances availability for patients are the lack of
knowledge, addiction development concern,
including that of health professionals (International
Narcotics Control Board 2018).
5. Due to a complete statutory ban on cannabis use
for medical and scientific purposes in Ukraine,
there is almost no practical experience of its
cultivation, manufacturing, production, conducting
scientific research, etc. As a consequence, the
effective functioning of national participants on new
potential markets depends also on the time scale.
The absence of articles (monographs) in SPhU
about cannabis plant and cannabinoids is a
restrictive barrier to the production and quality
control of CBMP, including an extemporaneous
production under pharmacy conditions.
6. There is a big risk of fungus diseases and
microbiological contamination for cannabis plant.
These factors are of critical importance for
providing the needed quality of herbal substance
and, consequently, finished herbal product
(Greenwell 2012). Besides, growing of cannabis
strains aimed at obtaining a herbal product with a
high rate of CBD and/or THC suggests using only
female plants: cultivation of a crop containing male
plants reduces the rate of cannabinoid contents
considerably (Spitzer-Rimon et al. 2019).
Opportunities
1. About 2 million people in Ukraine, according to the
Petition To regulate cannabis for science and
medicine means to defend citizensconstitutional
rights, suffer from diseases that can be relieved by
CBMP. Among them are patients with chronic
pain, epilepsy, post-traumatic stress disorder, mul-
tiple sclerosis and other illnesses (Verkhovna Rada
of Ukraine 2019).
2. The use of cannabis for medical purposes can affect
the consumption rate of other preparations, opioid
analgesics, in particular, taking into consideration
the research results and experience of other
Table 2 Expectations and predictable actions of the key stakeholders in the medical cannabis market in Ukraine (Continued)
Expected results Predictable actions after legalization Notes
Stakeholders: low interest / low power
Healthcare professionals (physicians, pharmacists)
For physicians: availability of CBMP with
effectiveness evidence base and safety for
treating various diseases, existence of
treatment protocols and clinical guidelines,
legal framework allowing them to prescribe
cannabis-based preparations for medical
use.
For pharmacists (licensed drugstores):
existence of legislative framework allowing
them to legally purchase, store, produce
and sell CBMP, including those with
narcotic and psychotropic properties.
Acquiring new knowledge on medical cannabis,
modes of action, evidence base, functioning of
endocannabinoids system and other
information through self-education and training
programs. Establishing professional associations,
sharing experience and knowledge, studying
the legal and regulatory framework on
cannabis-based preparations turnover and their
availability in various countries.
It is important for state bodies, public
organizations and professional associations to
take necessary adjustment steps in terms of
little interest and low motivation shown by
many health specialists. This is determined,
among other factors, by insufficient awareness
of medical cannabis, prejudices and reluctance
to change the legal and regulatory framework.
Citizens
Safety and good order legal protection
through the enforcement authorities and
prevention of the illicit turnover of CBMP
containing narcotic and psychotropic
substances.
Compliance with national laws regulating the
flow of medical cannabis containing narcotic
and psychotropic substances.
These stakeholders are heterogeneous. For
instance, a greater focus should be placed on
church representatives, separate local
communities, as they can have their special
purposes, expectations and values.
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 13 of 19
countries (Wiese and Wilson-Poe 2018; Khan et al.
2019). However, considering a low availability rate
of opioids (morphine, fentanyl) in Ukraine, using
medical cannabis will allow patients not to substi-
tute, but rather to compensate for their deficit (In-
stitute of Analysis and Advocacy 2018).
3. CBMP markets are attractive: fast growth rate, high
demand index, possibility of differentiating the
product portfolio for different market segments,
relatively low barriers for entering a new market,
which, as a consequence, influences the formation
of sustainably profitable business (Grand View
Research 2019). Besides, the emerging new markets
facilitate formation of new workplaces, development
of small and medium businesses and budget
revenues.
4. Market legalization, concerning cannabis-based
products for medical purposes, will facilitate a re-
duction of illicit volume. As for patients, quality
standardized products on a doctors recommenda-
tions will be available. Potential market participants,
for instance, plant growers, will be able to come
out of the shadowsand run their business activity
on a legal basis (Global Commission on Drug Policy
2016).
5. Decriminalization of use and storing cannabis in a
limited quantity not for sales can be good for
patients because legalization of CBMP, especially in
the initial stage, does not always presuppose
physical and economic availability of these
products. Besides, decriminalization will ease the
burden on the state penal setting of Ukraine: 80% of
criminal law violations relating to narcotic and
psychotropic substances trafficking comprise their
use and storage, and not sales. Among narcotic and
psychotropic substances seized by law enforcement
authorities during 2018, over 70% was cannabis
(Center for Mental Health and Drugs and Alcohol
Monitoring of Ministry of Health of Ukraine 2019).
Threats
1. Legislative and regulatory restrictions related to
CBMP in Ukraine can considerably reduce their
availability for patients, as well as the investment
appeal of potential markets. However, a non-
regulated or poorly regulated market, the CBD-
products market in particular, can initiate distribu-
tion of low quality products, aggressive promotion
and consumers cheating on actual cannabinoids
content and other negative after-effects (U.S. Food
and Drug Administration 2019).
2. Despite the World Health Organisations (WHOs)
recommendations to transfer cannabis, cannabis
resin, extracts and tincture of cannabis, as well as of
THC and its isomers to less regulated Schedule of
the 1961 Convention, the UN Commission on
Narcotic Drugs has not yet taken a positive decision
on this issue (Walsh et al. 2019). This factor plays a
negative role in liberalization of medical cannabis in
Ukraine on the part of state policymakers.
3. The lack of one-for-all approach to regulate the
world cannabis products market, including the
medical cannabis market (for instance, the defin-
ition of maximum allowable THC rate in various
countries is based rather on political decisions than
on scientific ones) (Clark et al. 2012). Each country
independently chooses approaches to regulate med-
ical cannabis flow: the majority considers Conven-
tionsrequirements, and some states which legalized
cannabis for recreational purposes (Canada,
Uruguay, some states of the USA) even contradict
them.
4. Foreign registered medicinal products containing
both herbal and synthetic cannabinoids (dronabinol,
nabiximols, nabilon, CBD) are usually characterized
by a high cost which can influence their economic
availability for Ukrainian patients (Aliekperova
2019). Besides, the CBMP market belongs to
emerging markets which is characterized by
enhanced activity with intellectual property (Hahn
2019). This allows Big Pharma to strengthen their
competitive positions, which will have a negative
effect on the development of a domestic market
(Prohibition Partners 2019). Thus, starting with the
early 1990s, pharmaceutical giants like AbbVie,
Sanofi, Merck, GW Pharmaceuticals started the
process of patent covering of the results relating to
cannabinoidseffect on a human organism (Reuters
Graphics 2019).
5. Considering a low availability of opioid analgesics in
Ukraine because healthcare specialists (physicians,
pharmacists) are not ready to prescribe and
dispense them in a necessary quantity for patients,
there are risks relating to medical cannabis too
(Institute of Analysis and Advocacy 2018). These
risks include health professionals having lack of
motivation, necessary knowledge, skills and
qualification concerning these preparations. An
insufficient evidence base is another risk factor in
prescribing preparations of medical cannabis.
6. The existence of illicit cannabis market in Ukraine
threatens development of the medical cannabis
market, especially at initial stages: established
channels and distribution system, more affordable
prices, obtaining the product without prescription,
absence of bureaucratic procedures, etc. However,
without a systematic approach to drug policy it is
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 14 of 19
impossible to give up a total ban, according to
recommendations of the International Commission
of Drug Policy (Global Commission on Drug Policy
2018,2019).
Discussion
To provide physical and economic availability of CBMP
for patients suffering from certain diseases, it is neces-
sary to apply a holistic approach making a system con-
sideration, with regards to possible changes and
transformations. This approach is based on three key el-
ements: legislative base and regulatory mechanisms, in-
terests and values of the key stakeholders, and changes
to value orientations in society. Together they will allow
improving health and life quality indicators of patients
(Fig. 8).
Given that we have already analyzed the interests, ex-
pectations and anticipated actions of stakeholders in the
potential market of medical cannabis in Ukraine, we
focus on approaches to form the legal framework and
regulation mechanisms for this market and to change
value orientations in society. These approaches have a
strategic character and are developed based on instru-
mental analysis results (for instance, the stakeholder
analysis and SWOT analysis), as they determine the dir-
ection and specifics of this market development.
Approaches and recommendations reference to legal
framework formation
1. To establish a state strategy respecting narcotic and
psychotropic substances to develop the one-for-all
approaches to regulating the turnover of these sub-
stances, including cannabis and cannabinoids in
Ukraine. In its formation, it is advisable to target on
both the international human rights conventions
providing the right to life, the highest attainable
standard of physical and mental health, be free from
discrimination and mental health and social and
economic rights (International Drug Policy Consor-
tium 2016), and the information reported by Global
Commission on Drug Policy (GCDP). For instance,
the reports mentioned focus on the regulations-
change paradigm for narcotic and psychotropic sub-
stances: both the total banand the absence of ad-
equate regulation facilitate development of the illicit
drug market (Global Commission on Drug Policy
2019).
2. In accordance with Art.16 of the Law of Ukraine
On Narcotic Drugs, Psychotropic Substances and
Precursors, to set the course of development of
new narcotic and psychotropic preparations,
including those containing cannabis and
cannabinoids by means of regulatory by-laws (Law
of Ukraine 1995). Attention should be paid to con-
flicts of laws: for instance, illicit drugs seized by law
enforcement authorities cannot be used later for the
production of legal medicinal products. According
to Ukrainian legislation they must be utilized. It
does not just help improve access to narcotic and
psychotropic substances for Ukrainian patients and
refine income deficiency for pharmaceutical com-
panies, it also leads to additional state expenses on
imported raw materials and utilization of the illicit
substances.
3. In accordance with the approved state strategy
concerning narcotic drugs, to develop a new law on
cannabis or introduce relevant amendments to the
Law of Ukraine On Narcotic Drugs, Psychotropic
Substances and Precursors. This is believed to
contribute to legal activity related to cannabis and
cannabinoids use for medical and scientific
purposes (Law of Ukraine 1995). This law must
consider the requirements of Art. 23 and Art. 28 of
the Single Convention on Narcotic Drugs (1961), in
particular, the foundation of a state cannabis agency
with specified functions. This includes stating the
soil lots for cannabis cultivation for the production
of narcotic drugs, granting licenses, crop purchasing
and its further distribution, liability for export and
import, needs estimation, submission of statistic
information to INCB and other functions (United
Nations 1961).
4. Ukraine already has efficient mechanisms to
implement the requirements of international
conventions on drugs control. Thus, the State
Service of Ukraine on Medicines and Drugs
Control can perform as a cannabis control
agency. More particularly, it refers to its
structural branch. The Directorate of state
regulation and control deals with circulation of
narcotic drugs, psychotropic substances and
precursors and counters their illicit turnover.
Fig. 8 Holistic approach to full supply of medical cannabis to
Ukrainian patients
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 15 of 19
This branch is responsible for lisensing and
quoting the cultivation of narcotic drug-
containing plants, identifying needs in narcotic
substances, collection of statistics and its submis-
sion to international structures/bodies and others.
Besides, the Center for mental health and drugs
and alcohol monitoring at the MHU has been
functioning in Ukraine since 2009. Its functions
cover both the monitoring of drugs and collect-
ing information on use of narcotic products (In-
stitute of Analysis and Advocacy 2018).
5. To introduce changes into the Decree of CMU
770 in May 6, 2000 On the Approval of the
Schedule of Narcotic Drugs, Psychotropic
Substances and Precursors(Decree of CMU 2000)
in accordance with recommendations approved at
the ECDD WHO 41st session (WHO 2018). And
specifically, to exclude cannabis, cannabis resin,
extracts and tincture of cannabis from Table I,
Schedule 1 Especially dangerous narcotic drugs,
with the circulation to be prohibitedand to
include cannabis and cannabis resin into Table II,
Schedule 1 Narcotic drugs, with the circulation to
be limited, and to include extracts and tinctures of
cannabis into Table III, Schedule 1 Narcotic drugs,
with the circulation to be limited; in relation to
these substances the exceptions to some control
measures shall be allowed. Besides, to exclude
THC (isomers and their stereochemical variants)
from Table I, Schedule 2 Especially dangerous
psychotropic substances, with the circulation to
be prohibited,aswellasdronabinolandits
stereoisomers (Δ9-THC) from Table II, Schedule
2Psychotropic substances, with the circulation
to be limitedand to include them into Table II,
Schedule 1.
6. To exclude from the Schedules of narcotic drugs,
psychotropic substances and precursors of the
Decree of CMU 770, May 6, 2000, cannabis with
the total THC content not exceeding 1.0% and CBD
with admixed THC not exceeding 1.0%, because
there is no psychotropic effect and the risk of drug
addiction development (the case of Switzerland and
Uruguay). CBD preparations with THC content of
1.0% have a far stronger therapeutic effect for
medical use than a pureCBD (entourage effect)
(Russo 2018). To obtain official interpretation or
advisement from the state bodies of Ukraine
(MHU) regarding that preparations containing pure
CBD are not subject to control under Conventions
regulating the traffic of narcotic drugs.
7. To approve necessary subordinate acts allowing
policy implementation for medical cannabis
turnover: Decrees of CMU, Orders of MHU, etc.
To develop relevant monographs on cannabis plant
and cannabinoids in SPhU, treatment protocols,
clinical guidelines and other regulating documents.
With the help of HTA tools to substantiate the
importance of medical cannabis application for
treating certain symptoms or diseases, in particular
through budget funds or health insurance.
8. To provide a comprehensive framework for
conducting research on cannabis and cannabinoids
by scientific research and higher education
institutions of all types of ownership without
licenses and quotas (for a definite number of
plants). Considering requirements of the national
legislation on medicinal products to allow research
and higher educational institutions to cultivate
cannabis, to develop medicinal substances and
products based on cannabis and cannabinoids, to
carry out preclinical and clinical trials.
9. To introduce changes to the Criminal Code and the
Code of Administrative Offences of Ukraine to
decriminalize the possession and storing of cannabis
in a limited quantity without intention to sell it,
taking into consideration information provided in
Art. 3, p. 2 of the UN Convention on countering
illicit turnover of narcotic drugs and psychotropic
substances (1988) (United Nations 1988), materials
laid in the GCDP reports (Global Commission on
Drug Policy 2018,2019).
Approaches to the formation of value orientations in
society
1. To shape public opinion on the significance of
cannabis and cannabinoids use for medical and
scientific purposes both among specialists (doctors,
pharmacists, scientists), and Ukrainian citizens: 58%
of pharmacy students from the Bogomolets
National Medical University has noted that it is
very important, and 38% that it is rather
important. Moreover, it is worth focusing on the
principal difference between recreational and
medical cannabis. Because of prejudices, lack of
knowledge and negative convictions in the society
there may occur marginalization of potential
patients (Bottorff et al. 2013).
2. A significant role in shaping public opinion on
medical cannabis is played by active participation of
various stakeholders, in particular by public
organizations, opinion leaders among
representatives of science, health care, business,
politics, other spheres of public activity. For this,
various instruments of communication with the
public should be used, considering the reach of
audience, impact effectiveness and the possibilities
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 16 of 19
of integration to increase a desirable result. For
instance, for the second year in a row, the
International Cannabis Conference is held in
Ukraine. There are physicians, scientists and
patients from the USA, Czechia, Switzerland,
Germany, Portugal, France, Spain, Israel among the
speakers experienced in practical application of
cannabis-based products and with information on
the achievements of contemporary science (Ukrain-
ian Association of Medical Cannabis 2019).
3. To develop and put into practice informational
training programs in educational institutions
(schools, colleges, universities) concerning
importance of using narcotics-containing plants as
medicinal products for the treatment of certain
symptoms and diseases, with a focus on the risks of
their application for recreational purposes, espe-
cially by children and teenagers.
4. Among the professional community, in particular
among the representatives of the health care
system, who to a large extent determine
availability of medicinal products and CBMP for
patients, it is necessary to run awareness
campaigns concerning cannabis plant,
cannabinoids, their properties and advantages,
usage risks, interaction with endocannabinoid
system, etc. Such campaigns can be organized in
the form of practical seminars, lectures, courses,
congresses, conferences, working sessions
including those with the participation of state
bodies. It will result in the development and
publishing of recommendations and guidelines,
conference, articles, monographs and other
scientific and practical materials.
5. Cannabis plant should be considered in complex
speaking of high attractiveness of potential cannabis
markets. It can be applied in various economic
industries, different from health care, beauty and
well-being, like building materials (hempcrete),
seed-pressed oils for paints and sealants, biocompo-
sites, green energy and others.(Riboulet-Zemouli
et al. 2019). To implement the win-win strategy,
value orientations should be formed in a society
that can create long-term benefits for all
stakeholders.
6. Creation of new cannabis-related spheres and mar-
kets will directly influence various social and eco-
nomic indices in the country, especially if high
value-added products are manufactured. It will im-
prove humans and petshealth and life quality, cre-
ate additional workplaces, promote the
entrepreneurship, science, innovative technologies,
and consequently provide a steady revenue for local
and state budgets.
Limitations
The survey of cannabis and cannabinoids legalization for
medical purposes in Ukraine has covered only the phar-
macy students from the Bogomolets National Medical
University, which certainly does not present a full pic-
ture of the health specialistsopinion on the issue stud-
ied. However, considering its small size, the research is
representative and reflects the attitude towards the med-
ical cannabis problem among the students seeking a
Specialists or Masters degree in Pharmacy. In reviewing
the literature, we have analyzed only those countriesle-
gislation with medical cannabis and cannabinoids legal-
ized that are the main players in the market of these
products. Besides, this analysis is quite workaround and
superficial, as it lies beyond the aims of this research. It
is necessary for preparing recommendations to develop
the relevant legal framework in Ukraine which would
enable a decent development of the medical cannabis
market. This article also presents the stakeholder and
SWOT analyses results. However, since the market of
these products is still prohibited in Ukraine, it is rather
difficult to identify and evaluate all concerned parties,
their goals, interests, expectations, as well as weak and
strong points of a potentially new branch and opportun-
ities and threats of its development.
Conclusions
Toimprovethequalityoflifeandhealthofpatients
suffering from various diseases, it is vital to consider
the issue of legalization of cannabis and cannabinoids
for medical and scientific purposes, as it has already
been done in many countries worldwide. However, to
provide adequate conditions for developing these
products market and consequently its physical and
economic availability for patients, it is advisable to
apply a complex approach to study this situation. In
this view, we have studied the present accessibility of
medical cannabis for patients in the USSR and former
USSR countries such as Lithuania, Georgia, Estonia,
Russian Federation, and Ukraine. We conducted a
survey among pharmacy students to evaluate the an-
ticipation of the future healthcare professionals in
Ukraine about cannabis legalization for medical pur-
poses and its adequate use to improve the quality of
life and health of patients. So, according to the survey
results, the vast majority of respondents demonstrate
a positive attitude towards legalization of medical
cannabis. At the same time, slightly less than half of
the students are practically not informed about the
therapeutic properties of these products. Nearly 90%
of students think that educational materials on canna-
bis and cannabinoids use for medical purposes should
be included in training programs. They should also
include risks and advantages of such application,
Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 17 of 19
functioning of endocannabinoid system etc. Using a
holistic approach, we performed the stakeholder and
SWOT analysis to provide recommendations for an
adequate supply of medical cannabis for the patients
in Ukraine. It reveals the existing legal framework
and regulation mechanisms, compliance with stake-
holdersinterests and expectations, as well as forma-
tion of value orientations in society speaking.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s42238-020-00044-y.
Additional file 1. Survey Questionnaire.
Abbreviations
CBD: Cannabidiol; CBMP: Cannabis-based medicinal products; CEC: Central
Executive Committee; CMU: Cabinet of Ministers of Ukraine; ECDD: Expert
Committee on Drug Dependence; ESAM: Estonian State Agency of
Medicines; EU: European Union; GAGR: Compound annual growth rate;
GCDP: Global Commission on Drug Policy; INCB: International Narcotics
Control Board; HTA: Health Technology Assessment; MHU: Ministry of Health
of Ukraine; SPhU: State Pharmacopoeia of Ukraine; SWOT analysis: Strength,
weakness, opportunity, and threat analysis; THC: Tetrahydrocannabinol;
UN: United Nations; USSR: Union of Soviet Socialist Republics; WHO: World
Health Organization
Acknowledgements
We gratefully acknowledge Vitalii Usenko (MD, MBA) for his intellectual
contribution and provision of useful materials and data as well all
participants and those who shared our survey link.
Authorscontributions
NA developed the study design, conducted quantitative and qualititative
research, analyzed the data, prepared the manuscript. NA and KK were
responsible for the conception of the study. KK and OK reviewed and edited
the manuscript. All authors read and approved the final version of manuscript.
Authorsinformation
Nataliia Aliekperova Ph.D. in Pharmaceutical Sciences, Associate Professor of
Organization and Economics in Pharmacy Department of Bogomolets
National Medical University, Kyiv, Ukraine.
Кostyantyn Kosyachenko Doctor of Pharmaceutical Sciences, Professor, Head
of Organization and Economics in Pharmacy Department of Bogomolets
National Medical University, Head of Public Association Ukrainian Agency of
Health Technology Assessment, Kyiv, Ukraine.
Oleksandr Kaniura Doctor of Medical Sciences, Professor, Vice-rector of
scientific-pedagogical and educational work of Bogomolets National Medical
University, Kyiv, Ukraine.
Funding
The study was self-funded by the authors.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Ethics approval and consent to participate
Not Applicable.
Consent for publication
Not Applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Organization and Economics in Pharmacy, Bogomolets
National Medical University, 13, T. Shevchenko blvd., Kyiv 01601, Ukraine.
2
Bogomolets National Medical University, 13, T. Shevchenko blvd., Kyiv 01601,
Ukraine.
Received: 21 November 2019 Accepted: 25 September 2020
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Aliekperova et al. Journal of Cannabis Research (2020) 2:33 Page 19 of 19
... The global increase in the legalization of cannabis (Cannabis sativa L.) for medical or recreational use [1,2] has increased the demand for cannabis products worldwide [2,3]. The increasing interest in medical cannabis is accompanied by newly attained researchbased knowledge regarding the many therapeutic properties of this unique plant, and a better understanding of its potential impacts on the human body [4][5][6]. ...
... The global increase in the legalization of cannabis (Cannabis sativa L.) for medical or recreational use [1,2] has increased the demand for cannabis products worldwide [2,3]. The increasing interest in medical cannabis is accompanied by newly attained researchbased knowledge regarding the many therapeutic properties of this unique plant, and a better understanding of its potential impacts on the human body [4][5][6]. ...
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We have demonstrated in previous studies that the essential macro-nutrients nitrogen (N) and phosporous (P) have profound effects on the production of cannabinoids and terpenoids in the cannabis plant. The present study was undertaken to evaluate the hypothesis that potassium (K) supply, which is known to substantially affect plant development and function, affects the secondary metabolism of the cannabis plant. Two cultivars of medical cannabis were grown in controlled environment conditions, under five levels of K supply: 15, 60, 100, 175, and 240 mg L−1 K. The results revealed that the development and function of plants that received the low K supply of 15 mg L−1 K were impaired, as the plants suffered from visual chlorosis, and the inflorescence yield was reduced in both cultivars. Plants that received higher K inputs in the range of −175 mg L−1 K demonstrated optimal plant function and high yield, and one cultivar demonstrated over-supply symptoms under the high K level of 240 mg L−1. The concentrations of most cannabinoids and terpenoids declined with the elevation of K supply, thus supporting the hypothesis. As secondary metabolite concentrations decreased with the increase in K supply, and higher K levels had no positive effects, 60 mg L−1 K is the suggested application level to maintain high function and yield combined with high secondary metabolism.
... In Ukraine, recreational cannabis use is illegal. Industrial hemp can be grown in Ukraine using seeds from cannabis plants with a THC level of less than 0.08% in dried straw, as long as they are listed in the State Register of Plant Variety of Ukraine ("Industrial Hemp") (Aliekperova et al. 2020). ...
Chapter
Cannabis is the most versatile species. Hemp and marijuana have been used for fibre, oil, medicinal and recreational purposes from millennia. Throughout the last century, the plant has been generally outlawed because of its psychotropic effects in many nations. In recent past, the studies on cannabis revealed the evidence of its high medicinal properties and its uses in treating life threatening diseases, which leads to the relaxation of legislation in many counties. Now, the genetic and genomics as well as the cannabis derived products enjoys renewed attention. In this chapter, the discussion was made on the advent of genomics and breeding strategies to improve various traits of cannabis. This will bring insights on future direction of cannabis breeding.
... In Ukraine, recreational cannabis use is illegal. Industrial hemp can be grown in Ukraine using seeds from cannabis plants with a THC level of less than 0.08% in dried straw, as long as they are listed in the State Register of Plant Variety of Ukraine ("Industrial Hemp") (Aliekperova et al. 2020). ...
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Hemp is a member of the Cannabaceae plant family, which includes cannabis. It is grown particularly for industrial and therapeutic reasons and has less chemical ingredients than Cannabis. Hemp, is one of the world's fastest growing plants and is used to make a number of goods such as fibres, clothing, paper, rope, paint, insulating material, food, and biofuel. Because hemp and cannabis are profoundly established in diverse countries’ civilizations and traditions, they have long been a moral and social issue of laws across the world. With the passage of time, more and more nations are permitting the therapeutic and recreational use of cannabis and hemp. We’ve covered the laws and economic benefits of hemp all across the world in this chapter. The information is intended to provide readers with a quick overview of the legal status and economic values of those nations.KeywordsHempCannabisTHCCannabinoidsEconomyExportMedical useCultivation
... Cannabis, as the most efficient natural source of secondary metabolite cannabinoids, has been widely used in therapeutic and industrial applications. Owing to increased demand for hemp-derived products, Cannabis has been one of the most economically valuable medicinal plants, and its growing market is expected to increase to 20.2 billion in 2020-2025 [136]. Thus, novel biotechnological tools are of great importance to the introduction of genetically modified hemp strains containing phytochemicals with improved quality and quantity. ...
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The clustered regularly interspaced short palindromic repeats (CRISPR)-Cas gene editing technology has opened a new era of genome interrogation and genome engineering because of its ease operation and high efficiency. An increasing number of plant species have been subjected to site-directed gene editing through this technology. However, the application of CRISPR-Cas technology to medicinal plants is still in the early stages. Here, we review the research history, structural characteristics, working mechanism and the latest derivatives of CRISPR-Cas technology, and discussed their application in medicinal plants for the first time. Furthermore, we creatively put forward the development direction of CRISPR technology applied to medicinal plant gene editing. The aim is to provide a reference for the application of this technology to genome functional studies, synthetic biology, genetic improvement, and germplasm innovation of medicinal plants. CRISPR-Cas is expected to revolutionize medicinal plant biotechnology in the near future.
... CBD is one of the most prominent non-intoxicating cannabinoids that has potential in treatment of various medical conditions including epilepsy, chronic pain, autism and post-traumatic stress disorder. Currently, medical Cannabis is legal in more than 50 countries including China, Australia, Germany, Israel, Canada and most of the U.S. The medical Cannabis market is rapidly growing from $3.5 billion at retail prices in 2019 to an estimated $20.2 billion during 2020-2025 (Aliekperova et al., 2020). Hemp is one of the earliest documented fibre crops used by humans with claims of domestication as early as 12,000 years ago (Ren et al., 2021). ...
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Hemp (Cannabis sativa L.) is a multipurpose crop with many important uses including medicine, fibre, food and biocomposites. This plant is currently gaining prominence and acceptance for its valuable applications. Hemp is grown as a cash crop for its novel cannabinoids which are estimated to be a multibillion-dollar downstream market. Hemp cultivation can play a major role in carbon sequestration with good CO2 to biomass conversion in low input systems and can also improve soil health and promote phytoremediation. The recent advent of genome editing tools to produce non-transgenic genome-edited crops with no trace of foreign genetic material has the potential to overcome regulatory hurdles faced by genetically modified crops. The use of Artificial Intelligence - mediated trait discovery platforms are revolutionizing the agricultural industry to produce desirable crops with unprecedented accuracy and speed. However, genome editing tools to improve the beneficial properties of hemp have not yet been deployed. Recent availability of high-quality Cannabis genome sequences from several strains (cannabidiol and tetrahydrocannabinol balanced and CBD/THC rich strains) have paved the way for improving the production of valuable bioactive molecules for the welfare of humankind and the environment. In this context, the article focuses on exploiting advanced genome editing tools to produce non-transgenic hemp to improve the most industrially desirable traits. The challenges, opportunities and interdisciplinary approaches that can be adopted from existing technologies in other plant species are highlighted.
... At present, the medical cannabis market is one of the fastest-growing markets worldwide, which was worth $3.5 billion at retail prices in 2019. A growing market worth $20.2 billion is expected in the forecast period of 2020 to 2025 (Aliekperova et al., 2020). By 2020, medical cannabis and cannabinoids have been legalized in more than 50 countries, including China (YUNNAN and HEILONG-JIANG), Australia, Germany, Israel, Canada and most of the US, etc. ...
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Hemp (Cannabis sativa L.) is an annual and typically dioecious crop. Due to the therapeutic potential for human diseases, phytocannabinoids as a medical therapy is getting more attention recently. Several candidate genes involved in cannabinoid biosynthesis have been elucidated using omics analysis. However, the gene function was not fully validated due to few reports of stable transformation for Cannabis tissues. In this study, we firstly report the successful generation of gene-edited plants using an Agrobacterium-mediated transformation method in C. sativa. DMG278 achieved the highest shoot induction rate, which was selected as the model strain for transformation. By overexpressing the cannabis developmental regulator chimera in the embryo hypocotyls of immature grains, the shoot regeneration efficiency was substantially increased. We used CRISPR/Cas9 technology to edit the phytoene desaturase gene and finally generated four edited cannabis seedlings with albino phenotype. Moreover, we propagated the transgenic plants and validated the stable integration of T-DNA in cannabis genome.
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Background Recently, legislative shifts in cannabis regulation away from exclusively prohibitionist controls have been seen in sub-Saharan African countries. However, the extent to which public perceptions are aligned with policy trends is unclear. Given that views concerning cannabis may be influenced by associated legislation we aimed to compare public opinion towards cannabis amongst countries with legislatively different cannabis policies. Methods We conducted an online survey of the general adult population in six purposively selected countries representative of maximum policy variation across sub-Saharan Africa i.e., Ghana, Nigeria, Sierra Leone, South Africa and Zimbabwe. Survey questions covered perceptions towards users, risks and benefits, regulations and public health impacts as well as sociodemographic characteristics. Chi square tests were used to analyse the association between categorical variables and explore country level differences. Results Totally 1216 responses were received. Large variations were noted in responses towards user stereotypes, risks and preferred legislation. In relation to users being honest (X²=43.316, P<0.0001), most in Sierra Leone(52.9%), Nigeria (45.6%) and Uganda(48.6%) disagreed whereas in Ghana(39.4%), South Africa(43.3%) and Zimbabwe(40.1%) most agreed. Differences in smoking cannabis and smoking tobacco products(X²= 27.712, P=0.002) saw respondents from Ghana(51.4%), Nigeria(58.8%), Uganda(50.9%) and Zimbabwe(46.8%) agreeing that smoking cannabis is more harmful to health, whereas majorities in Sierra Leone(45.7%) and South Africa(49.8%) disagreed. Apart from South Africa were the greater proportion opted to allow cannabis for all purposes(28.8%), majorities in other countries supported only medicinal legalisation(X²= 96.631, P<0.0001). Conclusion Dependent upon the question of focus, at the liberal end of the policy spectrum are Ghana, South Africa and Zimbabwe whilst Nigeria, Sierra Leone and Uganda were more conservative. Responses tended to reflect the policy position of respective countries, however our findings suggest overall increasing medicinal cannabis support. Greater understanding of policy dynamics may help create frameworks for countries contemplating reforms.
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The inflorescence is the main product of medical cannabis. Hundreds of specialized metabolites with potential bioactivity are produced and accumulated in the glandular trichomes that are highly abundant mainly on female inflorescences. Understanding the morphophysiological and genetic mechanisms governing flower and inflorescence development is therefore of high scientific and practical importance. However, in-depth investigations of cannabis florogenesis are limited. Cannabis producers and researchers consider long photoperiod to be “non-inductive” or “vegetative,” but under these growth conditions, the development of solitary flowers and bracts in shoot internodes clearly indicates that the plant cannot be defined as vegetative or non-inductive in the classical sense. Most probably, induction of solitary flowers is age-dependent and controlled by internal signals, but not by photoperiod. Short photoperiod induces intense branching, which results in the development of a compound raceme. Each inflorescence consists of condensed branchlets with the same phytomer structure as that of the larger phytomers developed under long day. Each phytomer consists of reduced leaves, bracts, one or two solitary flowers, and an axillary shoot (or inflorescence). Therefore, the effect of short photoperiod on cannabis florogenesis is not flower induction, but rather a dramatic change in shoot apex architecture to form a compound racemose inflorescence structure. An understanding of the morphophysiological characteristics of cannabis inflorescence will lay the foundation for biotechnological and physiological applications to modify architecture and to maximize plant productivity and uniformity in medical Cannabis.
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Updated toolkit available at www.cannabis2030.org – También en español: www.cannabis2030.org/es –––––– Subtitled "Recommendations for the implementation of Cannabis policies aligned with international Human Rights standards, the 2030 Agenda for Sustainable Development and the 2016 UNGASS outcome document", this report explains how the reform of hemp and cannabis policies can sustain or make harder – depending on the policy options chosen – the attainment of the 2030 United Nations agenda for Sustainable Development. | The reformist trend in Cannabis policy globally is an ongoing movement unlikely to be stopped. A deficit of democratic monitoring of the generalization of legal Cannabis markets could represent a threat for affected populations and public health. Ethics are needed. A renewed interest and takeover of the topic Cannabis by all categories of the population are urgent. A one-size-fits-all policy seems neither desirable nor possible, both for geographical imperatives and for the diversity of uses and products of the plant. This makes consensual policy models (exportable and generalizable) difficult to emerge. Rather than trying to solve the equation of the perfect Cannabis policy and its infinite variables, a more feasible approach would be to step aside, list all the different public policies that affect, or are involved with Cannabis, and address them individually. The 2030 Agenda for Sustainable Development and its 17 Goals is but a perfect tool for this purpose. This discussion paper highlights important research and experiential outcomes from scholars, civil society organizations, affected populations, and market stakeholders. It seeks to show the potential of the Cannabis plant in appropriately regulated settings as transformative for our societies – so long as ethical practices and sustainable approaches are kept central. This document is not intended to be an exhaustive guide. It is designed as a valuable resource to contribute to post-prohibition studies, and help understand, from diverse public policy perspectives, the links between the policies of Cannabis and the Sustainable Development Goals, and the impact of the former on the latter. The latest updated 2021 version is available at www.cannabis2030.org
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The topic of Cannabis curries controversy in every sphere of influence, whether politics, pharmacology, applied therapeutics or even botanical taxonomy. Debate as to the speciation of Cannabis, or a lack thereof, has swirled for more than 250 years. Because all Cannabis types are eminently capable of cross-breeding to produce fertile progeny, it is unlikely that any clear winner will emerge between the “lumpers” vs. “splitters” in this taxonomical debate. This is compounded by the profusion of Cannabis varieties available through the black market and even the developing legal market. While labeled “strains” in common parlance, this term is acceptable with respect to bacteria and viruses, but not among Plantae. Given that such factors as plant height and leaflet width do not distinguish one Cannabis plant from another and similar difficulties in defining terms in Cannabis, the only reasonable solution is to characterize them by their biochemical/pharmacological characteristics. Thus, it is best to refer to Cannabis types as chemical varieties, or “chemovars.” The current wave of excitement in Cannabis commerce has translated into a flurry of research on alternative sources, particularly yeasts, and complex systems for laboratory production have emerged, but these presuppose that single compounds are a desirable goal. Rather, the case for Cannabis synergy via the “entourage effect” is currently sufficiently strong as to suggest that one molecule is unlikely to match the therapeutic and even industrial potential of Cannabis itself as a phytochemical factory. The astounding plasticity of the Cannabis genome additionally obviates the need for genetic modification techniques.
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Introduction: The opioid epidemic has become an immense problem in North America, and despite decades of research on the most effective means to treat opioid use disorder (OUD), overdose deaths are at an all-time high, and relapse remains pervasive. Discussion: Although there are a number of FDA-approved opioid replacement therapies and maintenance medications to help ease the severity of opioid withdrawal symptoms and aid in relapse prevention, these medications are not risk free nor are they successful for all patients. Furthermore, there are legal and logistical bottlenecks to obtaining traditional opioid replacement therapies such as methadone or buprenorphine, and the demand for these services far outweighs the supply and access. To fill the gap between efficacious OUD treatments and the widespread prevalence of misuse, relapse, and overdose, the development of novel, alternative, or adjunct OUD treatment therapies is highly warranted. In this article, we review emerging evidence that suggests that cannabis may play a role in ameliorating the impact of OUD. Herein, we highlight knowledge gaps and discuss cannabis' potential to prevent opioid misuse (as an analgesic alternative), alleviate opioid withdrawal symptoms, and decrease the likelihood of relapse. Conclusion: The compelling nature of these data and the relative safety profile of cannabis warrant further exploration of cannabis as an adjunct or alternative treatment for OUD.
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Despite its increasing prevalence and acceptance among the general public, cannabis use continues to be viewed as an aberrant activity in many contexts. However, little is known about how stigma associated with cannabis use affects individuals who use cannabis for therapeutic purposes (CTP) and what strategies these individuals employ to manage associated stigma. The aim of this Canadian study was to describe users' perceptions of and responses to the stigma attached to using CTP. Twenty-three individuals who were using CTP for a range of health problems took part in semi-structured interviews. Transcribed data were analyzed using an inductive approach and comparative strategies to explore participants' perceptions of CTP and identify themes. Participant experiences of stigma were related to negative views of cannabis as a recreational drug, the current criminal sanctions associated with cannabis use, and using cannabis in the context of stigmatizing vulnerability (related to existing illness and disability). Strategies for managing the resulting stigma of using CTP included: keeping CTP 'undercover'; educating those who did not approve of or understand CTP use; and using cannabis responsibly. Understanding how individuals perceive and respond to stigma can inform the development of strategies aimed at reducing stigma associated with the use of CTP and thereby address barriers faced by those using this medicine.
Article
With the opioid epidemic reaching new heights in the USA, it has become critical to find suitable alternatives to opioids. Cannabis, an antinociceptive, is a strong contender to help patients reduce their opioid usage. A growing literature has been examining the complex effects cannabis has on pain relief and on opioid usage; whether it is a substitute for opioids or increases their use. This review explores the studies that compare cannabis-opioid interactions and presents some challenges of cannabis research and usage. The practical clinical pharmacology of cannabis as an analgesic, including the route of administration, safety and pharmacokinetics, are discussed to address the concerns, as well as possible solutions, of cannabis as a pain reliever.
Article
Background Over the last decades, consumption of opioids for the treatment of pain increased steadily in the USA, Australia, and a few European countries. To date, no study has analysed time trends in opioid consumption across Europe. Methods We analysed data provided by International Narcotics Control Boards on the consumption of fentanyl, oxycodone, morphine, hydromorphone, and pethidine in 40 European countries over the last decade. Trends in total opioid consumption from 1990 to 2016 in 22 selected European countries, the European Union (EU) as a whole, and, for comparison purpose, the USA, were analysed using the joinpoint regression analysis. Results In 2014‐16, opioid use was >10,000 defined daily doses for statistical purposes (s‐DDD) per 1,000,000 inhabitants die in Western/Northern countries, whereas it was <1000 s‐DDD in Southern/Eastern ones. In most European countries, opioid consumption increased to a great extent between 2004‐06 and 2014‐16; it rose from 6477 to 8967 s‐DDD (+38.4%) in the EU, and from 14,598 to 16,491 s‐DDD (+13%) in the USA. The increase in opioid use was steady since the early‐mid 1990's in most European countries and it slowed down after the mid‐late 2000's. In Denmark, Finland, France, Ireland, Switzerland, Poland, and the EU, opioid use levelled‐off or declined over most recent years. Conclusions Consumption of opioid analgesics sharply increased in most of European countries since the early‐mid 1990's. This notwithstanding, in the mid 2010's there was still a more than 10‐fold difference between the highest consumption in Western/Northern countries and the lowest one in Southern/Eastern countries. Significance This study provides the most updated and comprehensive analysis of time trends and geographic variations in opioid consumption use across European countries over the last three decades. This article is protected by copyright. All rights reserved.