Türkiye Legalizes Medical Cannabis: A Step Toward Health Innovation or Public Risk?

Hemp derivatives are an expanding market. According to Market Research Future Analysis, it is expected to reach USD 56.8 billion by 2030, increasing at a compound annual growth rate of 32.3% from 2024 to 2030. This growth is mainly tied to the ecological advantages of hemp products and rising demand for their derivatives. The expected growth is starting to project into reality as Türkiye has just decided to join the hemp market.

"The Bill on Amending Some Laws Related to Health and Decree Law No. 663" opens the way for the sale of medical cannabis in pharmacies. According to the bill, the Ministry of Agriculture and Forestry will be responsible for the cultivation and harvesting of cannabis. However, the processing, export, licensing, registration, permits, and sale of medical cannabis will be under the Ministry of Health. Sales of the product will only be permitted in pharmacies, and its control and safety will be ensured through an electronic tracking system. In a statement regarding the bill at the Grand National Assembly of Türkiye (TBMM), AKP Deputy Chair Leyla Şahin Usta noted that cannabis is widely used in the health sector around the world and stated that they aim to increase Türkiye’s competitive power through the bill.

What distinguishes medical cannabis from marijuana is the amount of its psychoactive component, THC. Cannabis with a THC concentration of less than 0.3% is qualified as hemp; anything above that threshold is considered marijuana. THC is the main component in all cannabis types that results in the feeling of being “high” by affecting mood, thoughts, and perception of reality. Thus, the lower THC level of hemp prevents it from being used as a recreational drug like marijuana, allowing it to be used medically instead.

Another important component found in cannabis plants is CBD, which is effective in treating epilepsy, autism, and chronic pain, and increasing sleep quality. Anecdotal evidence also suggests that it may help with anxiety, although the scientific community is still debating this claim. Unlike THC, CBD doesn’t cause a “high,” and its side effects are minimal. While THC’s benefits are mostly related to anxiety, its potential harms include cognitive impairment and mental health disorders. On the other hand, CBD has greater potential in treating diseases and only causes harm at high doses. A report from the World Health Organization states, "In humans, CBD exhibits no effects indicative of any abuse or dependence potential…. To date, there is no evidence of public health-related problems associated with the use of pure CBD." Thus, the discussion regarding the use and legalization of cannabis largely hinges on the concentration and effects of THC. Hemp is currently preferred over marijuana, despite the latter having higher levels of both THC and CBD, which have demonstrated therapeutic benefits for epilepsy, nausea, glaucoma, and potentially multiple sclerosis and opioid dependency. So, the choice between marijuana and hemp is ultimately down to how much risk the government can take regarding THC and its side effects.

For example, in the U.S., 15 states have legalized recreational marijuana, but it remains federally illegal. Meanwhile, the 2018 Farm Bill legalized the growth and sale of hemp. This would suggest that hemp-derived CBD is federally legal too, but it remains in a gray area, as several states, such as Nebraska and Idaho, still regulate CBD oil as a Schedule 1 substance, similar to marijuana. For Türkiye, this means that the use of medical cannabis, which is starting with the integration of hemp-based medicine, could expand in the coming years to include marijuana-based medicine due to its greater therapeutic benefits. It is important to note that in 2016, the Turkish Ministry of Health approved the limited sale of cannabis-based pharmaceuticals for medical purposes, specifically sublingual sprays like Sativex, which require a physician’s prescription. Therefore, the passage of the aforementioned bill can be considered an expansion in itself. Furthermore, the case of Canada serves as an example of how cannabis legislation can evolve. Canada first legalized medicinal cannabis in 2001. It was fully legalized on 17 October 2018, after Parliament passed Bill C-45, the Cannabis Act. Whether Türkiye follows a similar path is dependent on how hemp-based medicine is received and the progress of marijuana-related research processes, especially since studies on it are more limited due to federal restrictions in many countries. Nevertheless, the U.S. still leads in clinical research, with 4,034 active cannabis-related clinical trials.

The main reason that has pushed countries like Türkiye to explore options such as medical cannabis is the growing bacterial resistance to antibiotics and the urgent need for alternatives. Antibiotics fight bacterial infections by killing the bacteria or by inhibiting their ability to grow and multiply. Multiple cannabinoids have shown potent antimicrobial properties against Gram-positive pathogens, such as MRSA. Therefore, medical cannabis could serve as a new source of treatment for bacterial infections that are increasingly becoming untreatable due to antibiotic resistance.

Projected average proportion of infections caused by bacteria resistant to antimicrobial treatment for 12 antibiotic-bacterium combinations in 2009, 2019, and 2035

According to the Health Policy Studies report by the Organization for Economic Co-operation and Development (OECD), Türkiye is among the countries that will experience the most serious consequences of antimicrobial resistance (AMR). The report’s microsimulation model estimates that antibiotic-resistant bacteria will cause 4.3 million infections annually in Türkiye. Furthermore, by 2050, antibiotic-resistant infections will cause an average of 23,281 annual deaths in Türkiye, which makes up ⅓ of the total annual deaths projected across the listed countries. Because of AMR, Türkiye is projected to experience one of the largest declines in both life expectancy and healthy life expectancy among the listed countries. Thus, Türkiye’s introduction of cannabis medicine is not merely innovative or bold but rather necessary to a certain extent.

Projected average proportion of infections caused by bacteria resistant to antimicrobial treatment for 12 antibiotic-bacterium combinations in 2009, 2019, and 2035

Speaking to BBC Turkish, Taner Ercanlı, a member of the Central Council of the Turkish Pharmacists Association, states that low-THC medical cannabis is recommended for patients suffering from severe pain due to illnesses such as cancer and MS:

"We are referring to the medicinal product, not the cannabis used for recreational purposes. These products will be licensed by the Ministry of Health… The word 'hemp' has drawn public attention, but ultimately it is a health product, and it needs to be delivered to patients in a controlled manner through pharmacies."

Medical cannabis is already being used in Canada, Italy, Germany, Israel, Uruguay, Australia, the Netherlands, and many other nations. In fact, it is already possible for some cancer patients undergoing chemotherapy in Türkiye to obtain these medications from abroad through the Turkish Pharmacists Association. However, it would be more practical for the entire process, from sales to disposal of expired or problematic products, to be managed domestically by the Ministry of Health through the drug tracking system after the drugs are legalized.

One of the main obstacles to the introduction of cannabis medicine into the Turkish pharmaceutical market is the uncertainty surrounding public reception. The prevalence of antibiotic resistance can be attributed to both the lack of governance and the ignorance of users. The widespread misuse of antibiotics despite years of public service announcements demonstrates the difficulty of changing public behavior. Cannabis medicine is even less understood than antibiotics, and experts themselves have limited knowledge about it. Therefore, it’s unrealistic to expect the Turkish public to use cannabis medicine responsibly without oversight.

There are thousands of cases where people fake symptoms, pressure doctors to write prescriptions, write fake prescriptions, or use their friends’ prescriptions to get antibiotics, even when they don’t need them. Although it is not reflected in official statistics, self-medication with antibiotics without a prescription is common. A study conducted by Ümmügülsüm Gaygısız, Timo Lajunen, and Esma Gaygısız, which has been published in MDPI journals and featured in the U.S. National Institutes of Health's National Library of Medicine, displayed that among 945 Turkish-speaking respondents (61.3% female), 34.2% of them had self-medicated themselves with antibiotics without a valid prescription. The most common way to self-medicate was to use leftover antibiotics. While 80.4% knew that antibiotics are used to treat bacterial infections, 51.4% thought that antibiotics are effective for viral diseases.

Keeping these facts in mind, it is reasonable to question whether cannabis medicine will also be misused like antibiotics and even end up sold illegally if obtained by prescription but left unused. According to a research article published in The American Journal of Drug and Alcohol Abuse,  medical cannabis laws increase adult but not adolescent cannabis use, and provisions of the laws associated with less regulated supply may increase adult cannabis use disorders. However, the ultimate answer solely depends on the rigor of the government’s regulations.

Edited by: Leyla Hacıoğlu