Cannabis
Options for Social Control in the Context of other Licit and Illicit Psychoactive Substances
A
Public Health Approach
The opinions expressed in this paper are my own and do not represent the positions of any organization or department of government.
My
qualifications to write on this topic are as follows;
I have a 25
year career in public health, have served as medical health officer for
the cities of Victoria and Toronto as well as the Province of British
Columbia. In addition it was my privilege to act as President and CEO of the
Addiction Research Foundation of Ontario from 1995 to 1998. During that time I
was able to meet and have discussions with some of the most eminent
researchers in psychoactive substances, addictions and social policy in North
America and indeed Europe and Australia.
This submission
is concerned mainly with the issue of a regulatory framework for cannabis, but
by implications will offer a public health approach to the control of other
psychoactive substances.
The present
regime governing cannabis has been described as exemplifying bad pharmacology,
bad sociology and bad economics. My analysis also leads me to believe that it
exemplifies bad law as well.
In terms of
pharmacology, the classification of cannabis as a narcotic under the CDSA is
simply incorrect. A feature it shares with a number of other illicit
substances.
Its
classification with central nervous system depressants like the opioids and
stimulants like cocaine, with neither of which it share properties, serves no
useful taxonomic purpose and serves merely to remind us of the legacy of the
uninformed writings of Emily Murphy. Not the best antecedents for a
social policy.
In terms of bad
sociology, it can be argued that the present control regime not only does not
have the deterrent effect that is one of its aims – it also has a number of
unintended and adverse effects – the resulting lack of respect for the law,
its creation of rifts in credibility between the adult and the adolescent
world views and the undermining of more evidence based prevention messages are
three.
The economics are bad in that the present regime inflates prices and profits and has created the incentives for vertical integration by organized crime families to enter the illicit market. Profits are high, prices are low and quality is improved. It may also be that the economic drivers have served to bring the markets for so-called “hard drugs” and “soft drugs” together.
Bad
law – briefly the present legal framework does not discourage use, it
encourages disrespect for the law and it has the undesirable effect of mixing
drug markets and undermining preventive and educational programs. The law is
not uniformly enforced between and within jurisdictions,
(in BC in 1999 only 17% of those caught were charged vs 78% in PEI), is
widely viewed as being susceptible to social and ethnic prejudice on the part
of enforcing officers and has marginal support from top law enforcement
officers as represented by the Canadian Association of Chiefs of Police.
Under the
present regulatory regime, possession remains a criminal offence under the
CDSA. The CDSA itself was introduced as a “housekeeping” bill and its
passage was accompanied by the promise of a subsequent full-scale review of
Canada’s drug laws. A review that is only now underway.
As a compromise
to objections raised during the lengthy passage of the predecessors to the
CDSA, some attempt is made within the CDSA to diminish the criminal impact of
cannabis convictions and to distinguish between personal and commercial
possession. Leniency can be exercised on small amounts and the conviction for
possession of small amounts does not automatically carry a criminal record
with entry into CPIC. Nevertheless it is reported that in excess of 26,000
charges for cannabis possession were laid by police in 1999. Subsequent
convictions carry severe consequences for job searches and international
travel.
What is it about
cannabis that warrants this treatment?
The objective,
scientific assessment of harms – both individual and societal, that result
from cannabis use has been hampered by the inflationary-deflationary dialectic
that accompanies cannabis discussion.
That is, those who oppose any liberalization of the law have a tendency
to inflate the hazards, and, where these are not known, to assume the worst.
Conversely those who favour liberalization or legalization, in their turn
minimize or ignore all evidence or suggestion of harms.
Of course it may
also be that an actual metric of harm is irrelevant to the social or political
aspects of the debate. I would not like to think that this was the case, but
clearly, for many, the cannabis debate has enormous symbolic overtones.
In any event we
are talking about plant derivatives that contain a number of psychoactive
alkaloids. The psychoactive effects are predominantly of mild euphoria and
time distortion, though disorientation and panic attacks may occur, the
appreciation of music and art are said to be enhanced as is appetite. This
latter function seems important to one of its claimed medical benefits in
ameliorating the effects of chronic wasting syndrome in AIDS and the prolonged
nausea that accompanies chemotherapy.
There are
natural ligands of cannabis produced within the human body and cannabis
receptors have been found in the brain and peripheral lymphatic system. A
naturally occurring cannabinoid has been identified – anandamide.
Cannabis, in
contradistinction to alcohol or nicotine, has little acute toxicity. There is
no known lethal acute dose, and the other physiological effects on heart rate
and blood pressure are similar to nicotine and generally well tolerated,
though recent reports have suggested that in older men, cannabis consumption
may have a slightly higher risk than sex, in precipitating myocardial
infarction.
Because the drug
is usually smoked, it has acute and chronic effects that are shared with
tobacco and include airway irritation, cough and probably, with chronic use
bronchitis, COPD and lung cancer.
Its impact on
the immune system is generally to impair its function, but the impact on human
health is probably minor. The effects of cannabis consumption on reproductive
health are negative in animal studies, disrupting male and female reproductive
hormonal systems and increasing chromosomal anomalies.
This is
obviously relevant to human health, but human studies have yet to show
measurable adverse impacts beyond some evidence of adverse behavioural and
developmental impacts in the children of mothers who smoked cannabis during
pregnancy. Because of the usual route of administration, low birth weight and
prematurity may be associated with cannabis use during pregnancy.
The impact of
cannabis on cognition is well documented, short-term memory is adversely
affected and chronic use may lead to chronic, measurable defects in cognitive
functioning – though this may be the result of persistent chronic
intoxication rather than impairment to the substance of the brain.
Psychomotor
skills are adversely affected by cannabis and driving or operating heavy
machinery when intoxicated is contraindicated. Again, in contradistinction to
alcohol, cannabis intoxication tends to slow drivers down rather than increase
their speed. Similarly cannabis smokers tend not to be involved in acts of
physical aggression and violence when intoxicated is reportedly rare.
Cannabis use may
provoke schizophrenic symptoms in those with active schizophrenia or
schizophreniform tendencies, panic attacks and dysphoria are also mentioned in
the literature, the “amotivational syndrome” that cannabis was said to
induce has been discredited by most researchers, as has its role as a gateway
drug.
The issue of
dependence has been disputed, but there is good evidence that a cannabis
dependence syndrome can occur in chronic heavy users. It is of lesser severity
than withdrawal from alcohol or opiates, though given the prevalence of
cannabis use it may be one of the more common dependency syndromes in Western
societies, though few individuals seek treatment.
Concerns have
legitimately been raised about the effects of cannabis consumption on
adolescent development. As use tends to peak in late adolescence this is an
important consideration. Adverse effects that have been noted include an
association with risk of discontinuation of high school, job instability, and
progression to the use of “harder” drugs. The degree to which these
associations are causal remains controversial. Alternative hypotheses are that
cannabis use, like adolescent alcohol use, early onset of sexual activity and
tobacco smoking are in fact markers for other risks or adverse social
conditions.
Research
undertaken by the ARF in 1997, in Ontario (a series of focus groups of high
school students across the province) seemed to show that the occasional use of
cannabis by well integrated middle class white youth carries few if any harms.
It was in fact associated with high performing, socially well adapted
adolescents. In contradistinction, solitary, school day use was clearly (and
probably accurately) perceived to be a “loser activity”.
All researchers
agree however that intoxication interferes with academic prowess, (recent
study seems to demonstrate measurable – though reversible – drops in IQ
associated with heavy persistent cannabis use) and that the engagement in
illicit activities carries substantial risks, especially perhaps for youth
whose connections to the school community are tenuous at best.
There remains
the fear that cannabis acts as a “gateway drug”. Consumption of marijuana,
it has long been argued, is the first step on a slippery slope to
experimentation and later habituation, with hard drugs. And while it is true
that it is rare to find a heroin or cocaine user who did not first use
cannabis, the vast majority (>98%) of cannabis smokers do not progress to
harder drug use. For drug progression, the hypothesis that the sequence to use
of drugs like ecstacy, speed, cocaine or heroin, reflects a direct effect of
cannabis on the brain is the least compelling.
A more likely
explanation is that cannabis use may be one of many social and cultural
factors – including family relationships, peer influences, social attitude
and beliefs, youthful rebelliousness – associated with a higher likelihood
of the use of other substances as well. In other words the same factors that
contribute to cannabis use may lead a smaller number of individuals to
experiment with other illicit drugs. This may also explain the link between
cannabis use and lower professional and academic achievement and other
personal and social problems. An additional factor may be the fact that
cannabis is illegal – a dealer who sells cannabis may also offer other
drugs.
In addition we
should note use of both tobacco and alcohol usually precedes use of cannabis.
Public health practitioners have claimed that tobacco is in fact the
“gateway drug”.
In a summation
of effects then, while there is little doubt that consumption of cannabis has
adverse affects on the health of Canadians – however, and it is a
significant qualifier, a document commissioned by the WHO concludes that
intermittent use of cannabis is probably less hazardous than use of tobacco
and alcohol, and at present levels of consumption, less of a public health
problem than are alcohol or tobacco with which it shares certain
characteristics.
Table 1 shows
how the “experts “ rate cannabis against a variety of other psychoactive
substances.
TABLE 1 |
|||||||
Comparing Adverse Effects on Health for heavy Users of the Most Harmful common Form of each Substance: A first Approximation |
|||||||
Marijuana |
Alcohol |
Tobaco |
Heroin |
||||
Traffic and other accidents |
* |
** |
* |
||||
Violence and suicide |
** |
||||||
Overdose death |
* |
** |
|||||
HIV and liver infections |
* |
** |
|||||
Liver cirrhosis |
** |
||||||
heart disease |
* |
** |
|||||
Respiratory diseases |
* |
** |
|||||
Cancers |
* |
* |
** |
||||
Mental Illness |
* |
** |
|||||
Dependance/addiction |
** |
** |
** |
** |
|||
Lasting effects on the fetus |
* |
** |
* |
* |
|||
* Less common or less well-established effect |
If social and
legal strictures against the use of cannabis are justified mainly by the
health risks and the costs to society we must ask why we treat cannabis so
differently from alcohol and tobacco?
When the metric of harms so clearly weighs against the latter legal
substances. There
is a very valid point that as a society we do not wish to add additional
harmful substances to our list.
We should therefore ask whether our regulatory framework is effective
in discouraging use and whether it is proportionally fair in its application
as a deterrent. While we are also determined to discourage underage alcohol
consumption and the smoking of tobacco we do not inflict the same degree of
criminal sanctions on youth who are found imbibing the latter two substances.
This despite the fact that on the evidence we have, that at present levels of
use, the risks to health and the costs to society from misuse of alcohol and
the use of tobacco far exceed those from cannabis.
One way of
assessing the deterrent effect of the law is to look at trends in cannabis
use. Consistent provincial or national data are lacking, but longitudinal
surveys in Ontario are consistent with findings from the U.S. and some
Canadian provinces in showing a 20 year trend of increasing use, during the
‘60’s and‘70’s, with peak use in 1979 (31.7%). This occurred despite a
670 fold increase in cannabis related convictions between 1965 and 1980. This
peak in use was followed by over a decade of steadily decreasing use, the
lowest levels of use being recorded in 1991 (11.7), after which time use has
risen (to 25% in 1998) although not to the level noted in the late 70’s. The
most recent data show that among school age respondents, use is highest in
grade 11 and in Ontario was reported to be at 42% and at 57% in a sample of
Vancouver grade 11’s. It is important to note however that the majority of
users in Canada use the drug sporadically or experimentally. Only 2% of
students report weekly use in surveys asking for use in past 4 weeks.
In concert with
this rise in use is a reported drop in the perceived harms of cannabis, an
increasing public tolerance of personal cannabis use and a “softening” of
attitudes towards the compassionate use of cannabis in the medical setting.
Indeed this populist view has been reinforced by a series of court decisions
affirming the right of access to cannabis for medical use and the development
of both a research framework and a legal supply.
There is
little evidence to support the contention that a more liberal framework for
cannabis results in increased use or increased costs. Indeed in jurisdictions
that have relaxed the legal frameworks enforcement costs have decreased. This
lack of demonstrated pent up demand is a critical point to note as the
most cogent argument against any relaxation of our present framework is that
it would lead to increased levels of consumption and increased harms to
individuals and to society.
In addition to
the costs of law enforcement, the policy of cannabis prohibition entails other
social costs. Large numbers of predominantly young citizens are arrested and
prosecuted each year. Many would otherwise not have criminal records or the
associated negative impacts on schooling, employment and family discord. An
additional consideration that applies not only to cannabis offenders, but to
society as a whole is the encroachment on individual rights and freedoms in
order to facilitate drug enforcement.
If we conclude
as did the Le Dain Commission some 25-30 years ago, that we can achieve the
social goals of constraining use and avoiding harms without the need for
including cannabis within a criminal law framework, what then would be a
reasonable alternative?
I
would submit that there is a model for the Committee to examine. A model that
can be extended to include a societal response for a number of psychoactive
drugs, licit and illicit, that will provide options for reducing the harms,
not only from the drugs but also from the regimes of control. Many analysts
assert that the collateral damage from our present regimes of drug control now
cause more harm than they prevent. The explosive epidemics of HIV and HCV in
injection drug users is frequently cited as one example.
The framework
for examining possible regulatory regimes, owes its origins in 1984 to a
British Psychiatrist named Marks. It’s a simple framework – he titled it
“The Paradox of Prohibition” and essentially it suggests that the harms
from a drug can be graphed out as a “U” shaped curve when plotted against
demand on the vertical axis and regulatory regime along the horizontal axis.
See the Paradox
of Prohibition figure below.
The harms at the
prohibition end of the regulatory continuum include not only the direct
effects of the drug, or its adulterants, but also the harms that result from
unsafe consumption patterns – (infections, overdose deaths), crimes
committed to access drugs, social costs from courts and jails, personal costs
from criminal records, the costs associated with corruption of police forces
and the opportunity costs of law enforcement. Marks cited the era of
prohibition in North America as an example. Other writers cite the present
“War on Drugs” in the United States as an even more compelling case.
At the other end
of the regulatory scale we have the absolutely free market, with no
constraints on the commercial production and distribution of the product. The
gin mills and epidemic intoxication of Hogarth’s England probably come
closest to meeting Marks description on “epidemic intoxication”, “drunk
for a penny, dead drunk for a tuppence” being the marketing slogan of
the time.
In the centre,
at the bottom of the “U” Marks postulated was a place where the extremes
of prohibition or the full free market play were modulated and yet where
access consumption could be moderated and harms from both consumption and
control minimized. We have come to call this the “Public Health Approach”.
At this centre point at the bottom of the “U”, in today’s regulatory
environment, you will find the most regulated of legal drugs, those that are
controlled and prescribed by health professionals through the means of
prescription. Our legal psychoactives-tobacco and alcohol occupy niches to the
right of the curve.
Tobacco has
slowly been moving from the right hand side and a completely free market, back
to the centre over the last two decade, while alcohol, having escaped from the
prohibition of the extreme left of the curve has moved through the strictly
regulated, controlled state monopoly that characterized the Canadian alcoholic
beverage market of the 60’s and was almost akin to prescription, and is now
steadily moving to the right hand end as governments and the “drinks
industry” seek more and more to normalize it. Advertising restrictions are
being lifted, Sunday and late night sales are permitted, some provinces have
privatized their previous provincial monopolies and others have moved to put
beer and wine into corner stores.
At the same time
harms from consumption are arguably decreasing and we have come to acknowledge
that for adults in the 5th decade and older, the health benefits metric has
swung in favour of moderate consumption.
It remains to be
seen however whether or not the increased access has been as favourable to the
young and to the dysfunctional drinker.
Dr. Harold
Kalant, who presented to you earlier on in the hearings has written much on
psychoactive substances, one treatise investigated whether or not it would be
possible to devise a regulatory schema based solely on the pharmacologic and
physiologic effects of the drugs themselves. He concluded that our knowledge
base was insufficient, but that even if we had the knowledge, cultural values
and symbolism played as much a part in what we bless and what we curse, that
it might be futile even
The Senate,
however, has given us the opportunity to have another shot at bringing
rationality to the irrational world of intoxicants and even if we may not
achieve perfect rationality I propose that we can do better than the
inconsistent and ineffectual regulatory regime that we have in place today.
Returning to
Marks continuum I cite the work of a colleague in Addictions Services back in
B.C. – Mark Haden, who has proposed that there are a number of options along
the continuum. He has cited seven, but it would be possible to either contract
or expand on this number.
At one end we
have:
1.
Legalization and promotion without restriction. As we move across the
spectrum we encounter.
–
2.
Legalization with product restrictions e.g. packaging, marketing,
methods of sale, advertising etc, then
–
3.
Legalization with product and customer restrictions, e.g. age of
purchaser, volume of purchase, proof of residency etc, then
–
4.
Availability on prescription basis only, then
–
5.
Decriminalization – maintain illicit status but remove criminal
sanctions e.g. move to “ticketable offense”, then
–
6.
De facto criminalization e.g. ignore the existing laws, then
–
7.
At the other end of the continuum maintain the present criminalized
status.
In a more
focused proposal and narrower scope, the Canadian Centre on Substance
Abuse National Working Group on Addictions Policy in 1998 examined the
regulatory requirement
for cannabis
proposed a series of “liberalized” alternatives for cannabis control yet
which retained its illegal status – these included;
1.
A “fine only” option under the CDSA.
2.
A “Civil Offense” option.
3.
A “Diversion” option.
4.
A “Devolution to the Provinces” option.
Following this
analysis the Group made a series of recommendations; the first of which was,
“The
severity of punishment for a cannabis possession charge should be reduced.
Specifically cannabis possession should be converted to a civil violation
under the Contraventions Act.”
The group also
recommended that diversion of offenders to treatment should be available for
heavy users or those experiencing problems from the use of other illicit
drugs, that any change in the law should be accompanied by an evaluation on
subsequent levels of use and harms, and any change in the law that reduced
consequences for cannabis users should be accompanied by strong messaging that
this does not signal reduced concerns with the potential problems caused by
cannabis use.
This seems a
sensible if conservative package of recommendations (decriminalization and
evaluation as opposed to legalization) and one that would sit well with the
majority of Canadians, including the policing and public health communities.
However, a
cautionary note should be sounded. If Canada adopted this recommendation we
should be concerned and take steps to avoid repeating the situation in
Australia, where the imposition of a “cannabis expiation program” actually
led to a “net widening effect” as police ticketed individuals whom earlier
they had ignored, many ticketed failed to pay their fines and significant
numbers entered the criminal justice systems and subsequently received
criminal convictions – with the unintended result that Single reports that
the number of persons thus criminalized is as large or perhaps larger than
before the measure was implemented.
One might
legitimately ask whether in view of what we know about cannabis in comparison
to alcohol, a similar but stricter regime might be justified? That is –
state control of production and retailing, strict limits on access – age
restrictions, geographic restrictions, temporal restrictions, quantity
restrictions, etc, would provide a more rational approach and one that also
allowed the government to collect taxes – which could, if desired be
directed to education and treatment.
While this might
be eminently sensible, my judgment is that it would not be acceptable at the
present time. Among other considerations are Canada’s obligations under the
international treaties although I note that the UN International Drug Control
programme noted that “None of the Conventions requires a party to convict or
punish those who commit such offenses, even when they have been established as
punishable; alternative measures may always substitute for criminal
prosecution”
(UNDCP, World
Drug Report, New York: Oxford University Press 1997:185).
So it is with
some reservations therefore that I support the recommendations from the CCSA
Policy Advisory Working Group.