Side event: Impact of cannabis legalization from a scientific perspective

Organized by the UNODC, Research and Trend Analysis Branch with the support of the International Society for the Study of Drug Policy

Chair: Jean-Luc Lemahieu, Director, Division for Policy Analysis and Public Affairs, UNODC. We hope you will hear about the complexity of cannabis markets and also where we stand. I thank our co-hosts: France, Germany, and Global Partnership on Drug Policies and Development. I will now give the floor to Rosalie Liccardo Pacula. She has been evaluating the impacts of cannabis legalisation in the USA and public health for over 20 years.

Rosalie Liccardo Pacula, Professor, University of Southern California. It is a pleasure to be sharing research with you today. We have done this research in preparation for a bill that is coming this spring on cannabis legalisation in the entire USA. We are concerned because of weak regulation (less restrictive than other countries that have legalised so far). Commercial distribution, advertising and max THC contents are key aspects of regulation. The element that is most important on distribution is the amount of cannabis allowed to be sold in a single transaction or over a period of time. Everybody in Uruguay and Canada have such restrictions. But in the USA it is done through private establishments. In the case of Uruguay, there is a cap of 40g per month for cannabis flowers and you have to register with pharmacies. In Canada, no more than 30g can be sold in one sale. In the USA, there is a max amount of concentrate but much larger than in the UK and Canada. On advertising, Uruguay and Canada have adopted a very strong restriction for this. It’s prohibited in Uruguay, in Canada there are many restrictions. In the USA, there are some limits but it’s more lax, even though advertising to children is not allowed. Finally on THC content, for Uruguay THC in flowers is capped to 9%. There is no capping in social clubs. In Canada there are caps in amounts of THC. In the USA, there is only one state that has caps in THC, in Vermont. All other US states have yet to do that. Implications of this are that typical products on US markets have very high levels of THC compared to other countries. What you can see is that the average THC potency sold in US illegal drug markets has tripled since 1995. And the THC level is much higher in legal stores in Washington State. The typical potency of cannabis observed there is  above 20% for the cannabis flower. Even products with balanced amounts of THC and CBD have THC levels above 40%. This is much higher than in Canada and Uruguay. In a different study, we can see that the flower share of the market is growing but it is still much smaller than the other products sold in Washington State, such as concentrates and edibles which represent about 25% of the market. What is happening in Washington State is not unique, the same trends are being observed in Oregon. After regulation, there was a big jump in the availability of edibles, concentrates and extracts as they are cheaper. There are also more retailed outlets and there is more promotion. There is no regulation on the types of products sold in the USA so there are many new product types. With this promotion, weaker regulation allowed in the USA explains why it’s not surprising that the prices are low per dose of THC. Prices have almost halved between September 2014 and December 2020. We’re seeing that states are not doing a great job at regulating the amounts of cannabis being sold. We engaged in a study focusing on 10 states having legalised cannabis up to 2020. No state had a maximum limit although most states fell within the range of 500 to 1500 doses of 10mg THC in a single sale. The bottom line is that cannabis is being regulated as a commercial enterprise, we’re not following practices from other countries. We should have licences, we should focus on public health, we should focus on testing for mild, pesticides and contaminants, and focus on taxation based on sales and volumes of amounts sold. Public health regulations pertain mostly on edibles and other products receive very little attention. So we see harmful effects associated with these drugs.

Wayne Hall, Emeritus Professor, University of Queensland. Rosalie presented a very comprehensive overview of cannabis regulation in the USA, focusing on commercialisation, with reduced retailed prices, diversification of cannabis products and increased availability. In the short term, we expect reductions in price and increased potency to lead to an increased level of use, and more acute adverse effects. This is something we’re seeing already in the USA and Canada. We are expected to see more regular users, and adults using daily. This could have more public health impacts. We have 8 years of data now from US states that have already legalised. Measures from Uruguay and Canada could minimise those effects. We might expect to see more car crashes with more users driving while impaired, using cannabis with alcohol. We may expect to see more emergency attendances for acute psychological distress and hyperemesis syndrome. We might expect to see more foetal effects if more cannabis is used during pregnancy, with reduced birth weight and premature delivery. The other big determinant of the scale of this will depend on the effect of cannabis use mixed with tobacco and alcohol. Looking at Ontario, Canada, the state has adopted an approach that is in between Uruguay’s model and the US commercialisation model. It has seen a large increase in ED visits for adults and youth following the loosening of strict regulation on a number of retail stores. In Ontario there’s also been an increase in accidental exposures among children with increased commercialisation and sales of edibles, with poisoning and indigestion. Because there is very similar data from the USA, we expect to see something similar there. Now turning to the potential adverse effects of regular cannabis use: we may see an increase in the numbers suffering from cannabis dependence. We need to check how this will affect treatment seeking, as there will be no legal compulsion for people to get treated. The other big impact is seeing more adults using medically for chronic pain and disrupted sleep. Will this increase cannabis dependance? Or cognitive impairment? Two other potential adverse effects of legalisation are 1- an increase in psychotic symptoms and schizophreniform psychoses, especially if they use higher levels of THC. This is why we should keep examining the impacts. There are also risks of hyperemesis syndrome, leading to expensive investigations and treatment. Other long-term health effects of legalisation include respiratory risks of cannabis smoking, and cardiovascular disease. I also mentioned the potential effects of legalisation in young adults with decreased age of cannabis initiation, more use in their 30s and beyond. There is also a question as to whether legalisation will affect socially disadvantaged groups: will it reduce unequal imposition of sanctions? But will it also adversely impact them in terms of more adverse consequences for their use?

Angela Me, Chief, Research and Trend Analysis Branch, UNODC Q&A session. My objective here is to pick up on some questions made here. What are we learning from the USA, Canada and Uruguay? Can these lessons be applied elsewhere? If I had to answer quickly: not really. What is happening in the Americas is not necessarily transferable. Rosalie has picked up on this: legalisation is different everywhere, including within one country. It may be too early to analyse the impacts of legalisation, for example the level of taxation and the way states are trying to balance it: to too low to encourage more use, or too high to allow illicit markets. In many countries including Uruguay, illegal markets have not disappeared. In some jurisdictions there is a cap on THC contents. By 2007, when many states in the USA had access to medical cannabis, shortly after this happen, the market started to happen. This is not when legalisation started to happen, this was 2012. And when legalisation happened, in both states that did and didn’t legalise, the cannabis market was expanding. When we analyse trends in cannabis markets, there is no exact ideas on the impact of legalisation. We can’t distinguish the dynamics of whether markets have expanded because of legalisation, or not. The link is not strong here. If a country legalises when the market is shrinking, there might be a different trend. The same goes for Uruguay: when legalisation happened, the use indicators were going up before legalisation. But of course context matters. There are a few indicators in the USA and Europe on past month use of cannabis. The USA has had a much higher level of use compared to Europe. Legalisation happened at a much higher level of use than we currently see in Europe. Regarding risk perception, before legalisation the risk perception was going down, so it’s hard to say what the impact of legalisation has been. Lower risk perception has actually probably caused legalisation, rather than the other way around. We need to show here that if legalisation in another market starting in lower levels of use might have a different impact than in the USA. I cannot say that nothing can be learned from the Americas, and it will take a long time to see the impacts of legalisation. But we need to use caution. Is legalisation changing risk perception or the other way around? Will there be a replacement effect on use of cannabis vs. other drugs? The research is not mature enough to give this answer.

Rosalie. We have seen some industry capture some forms of regulation by the industry. It is important in these first moves that people keep in mind the goals of the policy and the business interests that will need to be kept in perspective.

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