Amid high demand, medical cannabis experts hail ‘game-changing’ relaxation of rules

Cannabis activist Nir Youftaro became a countercultural folk hero in 2018, when he was arrested for making and distributing homemade cannabis oil to hundreds of chronic pain sufferers who didn’t want to have to try opioid pain relievers first, as required for official cannabis patients at the time.

That episode earned him the moniker “Nir the King” — and also an ongoing, unresolved court case.

But now, the regulation that Youftaro fought against — that patients must take up to three years of conventional medicine before becoming eligible for medical cannabis treatment — is set to be removed for many conditions that it is used for, as Israel is poised to implement a new, comprehensive reform in medical cannabis policies.

These policy changes, currently set for the end of March, combined with a projected increase in patients seeking treatment due to the Israel-Hamas war, are expected to dramatically increase the already high number of registered cannabis patients in the country.

“Israel has one of the largest and most organized medical cannabis markets in the world, and the market is growing, with 3,000 new patients added every month,” Youftaro said, speaking with The Times of Israel on a video call.

Youftaro, along with Dr. Idan Harpaz, an immunologist, now runs a boutique consulting firm advising cannabis professionals, doctors and patients.

The new regulations, taken as a whole, represent a top-to-bottom update that will be “a general change in every aspect of cannabis in Israel. Everything will be easier, with a lot less supervision,” he said.

Demand, more demand and PTSD

In early March, Israel had more than 137,000 licensed medical cannabis patients according to Health Ministry data, making Israel, according to the experts consulted for this article, the largest per-capital medical cannabis market in the world.

Most of this growth has come over the last few years; only some 30,000 patients were registered at the beginning of 2019. Since October 1, 2023, just before the terror assault in southern Israel that led to the outbreak of the Israel-Hamas war, more than 10,000 new licenses have been granted.

If the changes are implemented reasonably smoothly, the number of patients could grow by as much as 70 percent in 2024, according to an estimate published in January in the Israeli Cannabis Report, an annual industry analysis.

The ongoing war is likely to play a part in increased patient numbers, as “the conflict in Israel is anticipated to result in an increased number of soldiers suffering from PTSD, potentially expanding the pool of medical cannabis users,” the report notes.

Israel can expect at least 30,000 new PTSD patients as a result of the Israel-Hamas war, which is a “conservative estimate,” trauma expert Prof. Yair Bar-Haim of Tel Aviv University recently told the Times of Israel.

The Health Ministry has stressed that cannabis is not a recommended treatment for recent trauma, and two weeks after the outbreak of the war it released a statement warning against using cannabis to treat the immediate aftereffects of traumatic experiences, or ASD (acute stress disorder).

This is different from PTSD (post-traumatic stress disorder), a long-term condition usually manifesting some time after the initial trigger events that can be treated in debilitating cases with cannabis, the ministry said.

The IDF has long been interested in various treatments for PTSD and began investigating the use of cannabis to treat it in 2003. Currently, about 17% of Israel’s cannabis patients are being treated for this disorder, according to Health Ministry data.

The issue of PTSD and cannabis is further complicated by a scandal that broke in December 2022 involving ministry-approved doctors handing out fraudulent licenses for exorbitant fees. According to a February update in the Hebrew news site Mako on the case, the doctors had handed out thousands of false licenses, mostly for PTSD.

More and easier patient access

Under the new regulations, PTSD sufferers will have to show at least a 30% impairment in their functionality and still undergo a year of conventional treatment before being prescribed cannabis, which in the case of PTSD will be implemented in tandem with psychological treatment.

But for most conditions, the requirement to first undergo treatment with conventional medicines has been eliminated.

Youftaro said he and other activists have waited a long time for cannabis to become a “first-stage treatment.”

“If now we can get cannabis first, for example to reduce the side effects for chemotherapy patients, it’s wonderful. It’s a huge change in quality of life,” he said.

The new regulations will enable many more doctors doctors to prescribe it, after approval from a specialized department that will be established by each of the major healthcare providers, he explained.

This change — a key part of the reforms — is a pivot to medical cannabis becoming available through simple prescriptions, like any medicine, as opposed to the previous model of medical cannabis licenses granted to patients by a small number of Health Ministry-approved private doctors.

The new policy will expand who is eligible for medical cannabis treatments, partially by eliminating some age limits, enabling children to receive treatment for certain chronic conditions and older adults to more easily receive prescriptions, he said.

The majority of medical cannabis licenses in Israel are granted for various chronic pain conditions, according to Health Ministry data. Licenses are also granted to treat cancer and chemotherapy side effects, PTSD and other psychiatric conditions, various neurological disorders, gastroenterological diseases and other ailments.

More smoke isn’t good

Cannabis use does have negative effects and its use can become addictive, as noted by the Israel Medical Association in comments about the reforms sent to lawmakers. One of the IMA’s main recommendations, that medical cannabis be administered primarily in oil form so that the harmful effects of smoking are mitigated, was not integrated into the updated policy.

There is “no medical justification” for the personal health damage and secondhand smoke damage caused by smoking medical cannabis and therefore oil should be the default, the IMA wrote in a 2023 document sent to The Times of Israel.

The medical group also noted that smoking cannabis “is more typical for recreational consumption than for consumption as part of medical treatment” and noted the “widespread practice of mixing cannabis with tobacco” as a factor in “an increase in tobacco addiction and an increase in smoking rates.”

According to Health Ministry figures, the vast majority of medical cannabis products bought by licensed patients are dried marijuana flowers. Israel allows the sale of cannabis oil to patients, but not cannabis products such as edibles or topical creams. That is not slated to change with the new regulations.

A revived cannabis economy

The Health Ministry announced the reform in its current incarnation in early August, although some of the policies had been touted previously by officials. Already approved by the government, the changes were to have been implemented by the end of 2023 but were delayed due to the outbreak of the Israel-Hamas war.

Currently, most elements of the reform are to come into effect at the end of March, some of them for a trial period to be expanded by the end of 2024. The new regulations can be downloaded (in Hebrew) from the ministry website.

Israel is already “the largest market for medical cannabis per capita in the world,” and could eventually see as many as 250,000 medical cannabis users, according to industry lawyer Adi Rozenfeld, a partner who heads the cannabis desk at Herzog, Fox and Neeman, a major law firm in Tel Aviv.

The new update is likely to be “a game changer,” she said, because aside from the sections that will greatly ease access and increase the pool of patients, the update also includes a streamlining of a difficult business regulatory environment, which she called “the nine layers of hell.”

Israeli medical cannabis companies, many of which have been “at death’s door,” have had to navigate a complex system of permissions and oversight, interfacing not only with the often slow-to-respond Health Ministry but also the police, the Agriculture Ministry and other official bodies, each with their separate schedules for frequent inspections and paperwork, Rozenfeld said.

The new regulations, she said, will make doing business in the field much easier. “There is optimism and a sense that something positive is happening,” she added.

The new regulations are similar “to a process that every industry in the world has gone through,” said Ophir Nevo, head of the Israel Cannabis Association, a leading industry trade group that co-produces the Israeli Cannabis Report.

“I think that the government is trying to do it correctly and not do anything that will make more issues down the road,” he said.

“The minute the regulation goes through there will be tons of companies opening up,” Nevo added, noting that the new regulations will enable cannabis businesses to engage in clinical research and to export their products much more easily.

Bumps in the road

It remains to be seen how smoothly the complex reform will be implemented, but there is already a sign of bumps in the road: the data published by the Health Ministry in March, which showed some 137,000 licensed patients, reveals a drop of some 3,000 from the previous February report, after months of rapid growth.

The Israel Cannabis Maganize, an industry website, called the drop “extreme” and the “sharpest decrease ever recorded.”

A Health Ministry spokesperson told The Times of Israel that “it’s impossible to point out one reason” for the decline but noted that in previous years at around the same time there were similar, albeit smaller, drops in patient numbers.

At the beginning of the Israel-Hamas war the ministry implemented a system of auto-renewing licenses, but that policy has since been rescinded, so it could be that patients simply didn’t complete the process for renewal on time, the spokesperson said.

One possibility raised by industry expert Nevo for the “very unusual” drop in patients is that licenses falsely granted by “problematic doctors” were being removed from the official registry. However, the Health Ministry said that this issue was “in the hands of the police” and wasn’t a factor in the decreased patient numbers.

Legalize it?

Israel has long been at the forefront of the cannabis field. The main psychoactive component of marijuana, tetrahydrocannabinol or THC, was famously isolated by Hebrew University researchers back in 1964. The government gave its first approval for the medical use of cannabis back in the 1990s, and subsequent decades saw the country’s medical cannabis industry develop by leaps and bounds.

Israel decriminalized cannabis for personal adult use in 2019, making possession of small amounts legally akin to a parking ticket and not a criminal offense, although it technically has remained an illegal, controlled substance.

Despite gaining support both in the court of public opinion and among a majority of lawmakers, various efforts toward full legalization have stalled in the Knesset. The march goes on internationally, however; in February, Germany, Europe’s largest economy, fully legalized marijuana for adult recreational use.

Non-medical use in Israel is widespread; industry maven Nevo cites an unverified figure of more than 1 million regular recreational marijuana users, in a country of some 9 million. After imports were approved in 2020, Israel became the world’s largest single importer of medical cannabis in terms of volume, but some of that finds its way into the illegal market, he noted.

The country “has a large, growing gray market where you can see a lot of medical cannabis,” Nevo said, but added that he isn’t for full legalization, which would create “a lot of bureaucracy, taxes and higher prices.”

The current conditions — decriminalized for private use, and new regulations to strengthen both patient access and the business side — could be reminiscent of the market in California before marijuana was fully legalized for recreational use in 2016, which was “the best situation” for patients, businesses and casual users, Nevo said.

The other experts interviewed for this article did not agree, however. Rozenfeld, the Tel Aviv lawyer, said that full legalization in Israel is inevitable and desirable. An Israel with fully legalized cannabis, “open for R&D, innovative products, medical devices, delivery systems and agro-tech,” would be able to make a unique mark on the worldwide industry, she said.

And activist Youftaro, said that given the high numbers of cannabis users in Israel he is also firmly “in favor of full legalization, with the medical track subsidized by the health authorities separately.”

“As long as I haven’t hurt someone else, or myself, then it’s okay,” he said.