Side event: Strengthening the Prevention and Treatment of Cannabis Problematic Use

Organized by Dianova International with the support of the European Coalition for Just and Effective Drug Policies (ENCOD), the European Federation of Therapeutic Communities and Rotary International

Lucía Goberna – Dianova International: Dianova is a network of 25 organisations working in 19 countries. We mainly work in the fields of prevention and treatment of drug dependency. Given that cannabis legal status has been so hotly debated at the international level and that we work with people presenting cannabis problematic use we thought it is was necessary to come with an institutional positioning towards it. Since we defend evidence based drug policies we thought that we really needed to come up with a robust basis for having this debate. We contacted Antonio Molina from the University of Madrid to conduct a study on the regulation and legalisation of the therapeutic and recreational uses of cannabis. With that in hand, we were able to conduct internal discussions and to come up with a positioning. This study confirmed that there are serious weaknesses concerning the prevention and treatment programmes for treating cannabis problematic uses. That is why we conducted a series of online meetings gathering the expertise of professionals working in the field, on how we could improve those programmes. We think it is high time to broaden the debate around cannabis and include aspects that need an immediate response. 

Antonio Jesús Molina Fernández – Universidad Complutense de Madrid: Today we are going to talk especially about health and social consequences of possible cannabis regulation and the implications for prevention and treatment of problematic cannabis use. Most of the people that are using cannabis today or going to use cannabis maybe they are not going to develop any kind of disorder but sometimes we forget that there is a group, a very significant group of people that have got problems with cannabis use. We first establish the aims of the study: 1) to develop a policy position helping to promote global consensus, 2) to provide an in depth analysis of the problematic use of cannabis using several perspectives; not all the perspectives can be considered as problematic but a few can create social and health problems for all, 3) to prepare a clear position about the legalisation of cannabis for medical and recreational purposes. Through our literature review of reports/papers that were written the last 10 years we were able to identify a few biases; confirmation bias, favouring one or the other position. We also did not only want to make a study to site but one that can be applied in several contexts. [ ] The main socio- and health problems we identified were: the increase in consumption, the decrease in the age of consumption, the number of possible work related accidents, traffic accidents, and the consequences on mental health. What was also important is the identification of the processes and outcomes of the regulation of cannabis [to inform] prevention policies; also in the prevention of polydrug use and other risky behaviours. That is particularly important for young people in the context of an early consumption opening a debate about health promotion, prevention by early intervention for problematic cannabis use and health education. We need to talk about which population groups may develop risk patterns; not only young people but also other groups like women with children etc. It is important to identify those biases and misconceptions and develop and implement quality programmes with trained professionals.

Heidi Heilman – Rotary Action Group for Addiction Prevention (RAG AP): I was asked to present on the prevention of problematic use of cannabis and I will do so from a primary prevention perspective. I come from the US where marijuana laws are continuing to change from state to state. We know that commercialization of addictive commodities drives up use rates which drive up problematic use and risk of dependency as well as the associated adverse outcomes. We can learn a lot from the history of other addictive commodities like tobacco in how to reduce and prevent problematic marijuana use. Those other markets of addictive commodities like tobacco along with opioids or alcohol or even sugar offer lessons learned that we must not ignore. Based on those industry experiences and what has worked to decrease problematic use and addiction to other drugs we can put measures in place now to deter the predictable rise of problematic use and cannabis use disorder as the commercial markets take hold. The marijuana industry is using similar marketing strategies that the tobacco industry used to downplay harms of marijuana to advance market growth and we need to be aware of that. Addictive commodity industries rely on product dependency for market growth and profit. In the United States 75% of our alcohol is consumed by 10% of adult consumers. This essentially means that the alcohol industry relies on individuals with alcohol use disorders to meet their large profit margins. We allow industries to manufacture lifetime daily users of their addictive products and sadly we allow them to do it through our young people who are the most vulnerable population. I am assuming people are aware of the brain science that reveals that the developing youth brain is primed for addiction. This is extremely important and when we look at preventing cannabis use disorder and problematic use. In my mind, saturating our community environments with addictive drugs like marijuana and expecting our children to not use becoming addicted or have problematic use by simply choosing not to use is as unrealistic as contaminating our natural water supply and expecting our children to not experience those health harms by simply drinking bottled water. 

In order to respond and reduce and prevent marijuana addiction and problematic use we need to put in place a prevention enforcement response. Preventing problematic cannabis use requires counteracting industrial driven addiction. This means going way upstream to stop the problem at the source through laws and policy otherwise we risk the downstream outcomes getting bigger and bigger and that stream wider and wider where people are experiencing problematic use and the associated harmful outcomes. Prevent problematic cannabis use requires attending to large population health by encouraging a public health policy framework. For recommendations, we must protect public health through legislative and policy related actions and a primary focus must be on protecting youth. The overall goal is to restrict availability and access, and denormalize marijuana use. Age restrictions regulations must include density caps to avoid not only rapid and widespread proliferation but to also avoid having marijuana businesses concentrated in low income neighbourhoods that would lead to further social and health inequities that have disproportionately impacted populations. We must build enforcement protocols for compliance with laws and regulations that serve to protect youth and offer strong local control that require communities to opt in to participate in the market and forbids marijuana businesses in areas where children and families spend time. These regulatory standards are critical because every marijuana facility, whether it’s a cultivation site or a storage site or dispensary is a new access point for marijuana diversion to youth. We need to raise the price of marijuana through taxation and reinvest tax revenues in public health education programmes, especially those that seek to protect youth. We must also regulate packaging products that don’t appeal to children; thinking about flavours, shapes and forms of marijuana and the branding. We can also safeguard pregnant and breastfeeding women through education about the potential harms related to marijuana use which also protects the developing foetus and infants from potentially harmful brain structural changes that can happen in utero as the science is revealing. We can also mandate that all product and promotional materials have warning labels and restrict packaging. We can mandate health warnings posted clearly in stores and on products. We should not allow home delivery; that’s another dangerous access point for young people. We must prohibit advertising and promotion of marijuana products in the broader community, including billboards and on roadsides and media materials like playbills and magazines and newspapers. Likewise prohibiting marijuana advertising on social media sites like Instagram, Facebook and Snapchat where young people frequent use, as well as on TV and radio.

It’s very important to also fund data monitoring efforts across a range of data collection sources, both before and after policy changes occur to ensure that policies do not negatively impact public health and safety, and then to ensure that public health approaches are targeted and measurable and effective in impacting behaviour change and health outcomes. Now, like policy and regulations, education is key. The public needs to be clear on all the harms the links to psychosis and mental health disorders, the risk of marijuana use dependency and the brain neuro-pathway connection to other addiction. The science is clear that perception of harm of marijuana is directly linked to use rates. The more people know and understand the drugs harm the less likely they are to use it and the less likely they are to go into a problematic use position. People need to fully understand the brain science and the susceptibility of the developing brain to marijuana addiction. Parents and young people need to know the target market; there is an economic and market force at play working to make lifetime daily users of marijuana  out of young people because it is lucrative. It is a billion dollar market. 

One of the best measurable behavioural change results we have ever seen in youth drug prevention came from the American legacy Foundation’s Truth campaign. In this campaign that aimed at curbing youth cigarette smoking in the United States smoking rates dropped at 43% over an eight year period. Now according to a study in the American Journal of Public Health the campaign is not only associated with decline of use smoking but it also accelerated reduction of youth. Out of all the youth substance prevention programmes ever implemented this is the only programme that has shown such significant attitude and behavioural changes sustained over time. It is astounding outcome make it the most successful prevention programme, ever. The message that is conveyed to the public through tobacco control media campaigns evolved over time to focus less on the health of dangers of smoking and more on revealing the deceptive practices of the tobacco industry. So lessons from that campaign reveal two strategic elements that are critical for successful prevention campaign and that is the method must include information about how marketing tactics and strategies work to increase sales and profit, and that the method must create opportunities for peer participation and be interactive, where there is strong student engagement. 

When an industry takes over its regulation and control it is called regulatory capture. It is a very serious problem and can compromise every effort to put in place sound public health measures. It is very important that control board representatives not be affiliated with a marijuana industry and that non governmental representatives have no association with government office, as well as no connection to the marijuana industry. Lastly, we need to place limitations on lobbying where industry actors are not allowed to oppose any proposed legislation or regulation that worked to protect youth or oppose any excise or income tax provision or user fee or other payments related to marijuana products or misrepresent the facts regarding the harms of using marijuana. Advocacy and lobbying for strong public health measures built into our laws and regulations standards is essential. Primary prevention doesn’t stand a chance of making an impact on rates of problematic marijuana use without the voice and pressure from the private sector that include all stakeholders and NGOs. We need to build this advocacy work into our strategies and programming. It will require a real movement of the people to push back on the advancing commercial marijuana industry and put in safety measures now in order to avoid the widespread problem use that the data science and history warrants. It is predictable. 

Phaedon Kaloterakis – European Federation of Therapeutic Communities (EFTC): I am very glad that the focus is shifting from the legal discourse/dimension to prevention and treatment. I would like to say that we cannot demonise substances. I think it is the use of substances that can be proven problematic or not healthy. Also with a global society functioning with the laws of free market we are observing now the boom of cannabis industry. Cannabis can certainly create psychological dependence, also damage brain cells especially when the brain is still developing. [Cannabis use is] connected to mental and psychological disorders; it can trigger psychosis. [ ] Regarding its pedagogical dimension, in some cases the use of cannabis can be viewed as as a learned behaviour. Unlike alcohol use, the use of cannabis aims to make one high when in the case of alcohol one can just stick to a glass; just for the taste of it. Like alcohol, cannabis use is now socially acceptable and that adds to its problematic use. When we refer to problematic use the main group is adolescents and young adults according to treatment admissions. «Therapeutic community for addictions emerged theoretically outside of mainstream mental health and social science. Over time a theoretical framework has evolved from clinical practice and research which classifies the therapeutic community as unique social learning approach captured in the phrase community as method, defined as the purpose of the use of the community to teach individuals to use the community to change themselves». We need the community and the community can provide this healing. One main part of treatment when we deal with people who are using cannabis in a problematic way involves activities; the promotion of a healthy lifestyle of living outdoors. To be passive is actually a characteristic of the problematic use of cannabis. In order to help people we not only use psychotherapy groups but also we help them understand that what they need is to take their lives in their own hands and become more active. We need to design programmes and interventions that are true to the needs of the people with the problematic use.

Ana Afuera – European Coalition for Just and Effective Drug Policies (ENCOD): Coming from users’ organisations we defend people’s right to consume substances for recreational and therapeutical purposes; with all information and knowledge available in order to reduce the harms in the contexts of consumption, cultivation and supply. After 60 years of international prohibition there is no evidence of demand increase. Cannabis is and will be a plant of regular use for humans. Consumption of cannabis for recreational purposes is a reality that will not disappear. Additionally, the human body has a specific system to detect cannabinoids. The endocannabinoid system is not [harming] any vital organ and no one has ever died; it is the synthetic cannabinoids [that have caused deaths]. Authorities and agencies should separate one from the other concept in data collection tasks to make a more reliable landscape. In informed societies people adapt their perception of risk to the tangible harm of a substance [like with] sugar. We must approach each substance for what it is considering the harms and the benefits; in a balanced approach analysing the effects [of the substance use] but also without demonising or creating alarmism. The last indicators signal the increasing consumption in developed and accommodated societies. Cannabis is an issue for drug policies due to its low toxicity and its high prevalence. Using data from EMCDDA in 2018 more than 20 million people use cannabis in the European community, more than 90 million reported [having used at least once] during their lifetime. Less than 1% of people who are using cannabis are [in need of treatment]. It is a fact that there is an increasing in demand for those services. States use this tool as an alternative to punishment, even for possession of a small quantities applied to non problematic uses. Therefore, it is not a sincere relationship with users and should be reinforced by empathy with attractive and effective services in a holistic approach. The strategies followed the increasing in demand were not working at all. Harm reduction also has to re-scope to [meet] the existing demand with [the aim] to teach users to consume in a less harmful way. Humane services and care through peer relationships and non stigmatising perspective is a crucial point to take into account. It is essential to fight against inequalities and stigma. In the case of other vulnerable populations such as people with cardiovascular [pathologies] or mental health problems doctors should inform of the side effects of consuming cannabis like with other prescribed medications. Self management on pleasures, and substances and the effects is a challenge. It is unavoidable to point out that the worst side effects of cannabis use is associated with the most common way of consumption; smoking. Harms associated to smoking are usually [attributed] to cannabis use. Working on recommendations on the least harmful ways of cannabis use such as vaping is a good starting point for a preventive [scope]. Also trying to find ways for more responsible consumption (filters, quantity of cannabis in a joint etc.).

The collaboration of activism and harm reduction entities is a fundamental factor for improving services. Putting people rights at the centre of cannabis services and programmes is an innovative concept to enhance harm reduction. Within the Social Club model we have the possibility to implement evidence based practices in safe places for consumption by accessing the targeted population. There they can share experiences [in their discretion]. Also drug testing allows us to eliminate practices such as adulteration. The knowledge of fertilisers, contaminants and pesticides promotes healthier cultivation methods. The model allows us to [address] environmental and sustainability issues regarding cannabis cultivation. Lastly, cannabis regulation [should be] a mandatory agenda item for member states in the next decade. Harm reduction services and street expertise combined with activists’ lessons is an essential element to develop human drug policy.

Q: There are many studies on the effects in young people. Can you indicate studies for adults that defend reasons not to use cannabis, and why?

Antonio Jesús Molina Fernández: First there is an issue when describing adults. We can find several studies that find cannabis to be problematic in development of people from 18 to 24-25 years. 18 is just the legal age. In a proposition in the Portuguese law and in assessments and monitoring that has been done in Canada has shown increase in problems in people between 18 and 21 years; not only for the use of cannabis. The problem is not only the use of cannabis. We don’t have enough predictors for addictive behaviour. We don’t have enough predictors on the use of cannabis. We have predictors for other kinds of mental health problems. What we know is that between 18 and 21 years the use of cannabis can increase the risk of mental problems; not only psychotic cases but anxiety disorders. It’s true that for people that decide to use cannabis older than 21 there is still a risk for developing disorders.

Ana Afuera: I agree with the development of the brain and all the stuff about young people but you can decide whether to use or not. We can advice young people [of the risks] but we cannot forbid because they will find [substances eventually]. 

Q: From your perspective which improvements should treatment prevention organisations should undertake regarding cannabis misuse.

Phaedon Kaloterakis:  Addiction is the problem and addiction is mainly a behaviour. It is not a sickness in the classical meaning of the word. Treatment should try to address the deeper [issues] that lead people into addiction; that lead people [into seeking an] escape from their  painful reality. In that case treatment should [focus on] a combination of things. The basic ingredient should be activities that they are designed for young people.

Heidi Heilman: My sense is that we really need a widespread education campaign so that folks can understand the teen brain science. It is really critical for people to understand that the developing brain is primed for addiction. Also to understand the link between marijuana use with young people and its connection to the use of other drugs. There is so much research out there showing that there are neuro-pathway links with the cannabinoid that can lead to that. So do opioids, on the same receptors. What is being revealed through the science is that when you modify one part of your brain with cannabinoid you are also modifying the opioid part of your brain as well. You are sort of desensitising the brain towards other drugs. It is a brain phenomenon. Regarding prevention, I think an education campaign is crucial. Also addiction marketing strategies; people need to know. There is real competing factors between prevention and making profit and we have to somehow put in measures where there is a balanced approach. If not we are at the risk of seeing what happened with tobacco, opioids and alcohol.

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