Public Health Approach to Psychoactive Substances

Using cannabis as an example

February 3 2015

Dr. Brian Emerson

Chair, Health Officers Council of BC Psychoactive Substances Committee;

Medical Consultant, BC Ministry of Health

brian.emerson@gov.bc.ca

250-952-1701

Disclaimer – This presentation and my comments DO NOT represent the position of the Government of BC.

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Disclosure - None of the information in this presentation has been

supported by commercial sources.

Participants in this session will be able to:

1. Describe a public health approach to psychoactive substances.

2. Identify the main determinants of benefits and harms of psychoactive substances.

3. Discuss how a public health approach could be applied to the management of cannabis.

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Learning Objectives

Acknowledgements/References

Health Officers Council of BC Canadian Public Health Association

CPHA Alcohol and Tobacco Papers

1. Key Concepts 2. Public Health Approach

I. Directional Elements II. Strategies 3. Application to Cannabis 4. Concluding Remarks 5. Discussion

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Outline

Control approaches developed in the early 20th century.

Based on racism, fear, political and economic agendas.

Limited scientific and medical knowledge or considerations.

Bewley-Taylor, D., Blickman, T., Jelsma, M., The Rise and Decline of Cannabis Prohibition. Transnational Institute, Amsterdam, Global Drug Policy Observatory, Swansea, March 2014, http://www.tni.org/rise-and-decline?context=595

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Key Concepts

History Prohibition

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Key Concepts – Morbidity & Mortality Canada 2002 Rehm, J et al, “The Costs of Substance Abuse in Canada”, 2002. Canadian Centre on Substance Abuse.

% of Total Acute

Care Days

Deaths % of Total

Tobacco 10.8 16.6

Alcohol 7.2 4.1

Illegal Drugs 1.5 0.7

Total (excludes

pharmaceuticals)

19.5 21.4

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Key Concepts - Deaths % of Total Canada 1992 - 2002 Rehm, J et al, “The Costs of Substance Abuse in Canada”, 2002. Canadian Centre for Substance Abuse.

Deaths % of

Total

1992 2002

Tobacco 17.0 16.6

Alcohol 3.4 4.1

Illegal Drugs 0.4 0.7

Total (excludes

pharmaceuticals)

20.8 21.4

Key Concepts - Acute Care Days % Total Trends Rehm, J et al, “The Costs of Substance Abuse in Canada”, 2002. Canadian Centre for

Substance Abuse

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% of Total

Acute Care

Days

1992 2002

Tobacco 7.3 10.8

Alcohol 2.8 7.2

Illegal

Drugs

0.1

1.5

Total (excludes

pharmaceuticals)

10.2 19.5

Key Concepts - Costs by substance (Billions $) Rehm, J et al, “The Costs of Substance Abuse in Canada”, 2002. Canadian Centre for

Substance Abuse

$ Billions % Per Capita

Tobacco 17.0 43 541

Alcohol 14.6 37 463

Illegal Drugs 8.2 21 262

Total (excludes

pharmaceuticals)

39.8 100 1,267

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Key Concepts

Spectrum of Psychoactive Substance Use (Adapted From: BC Ministry of Health Services. ”Every Door is the Right Door: a British Columbia planning

framework to address problematic substance use and addiction” 2004)

Drug “use” is an indicator; “use” is not necessarily the problem, reducing drug use is not necessarily the objective.

Focus on “use” over-emphasizes personal responsibility and choice; tends to target, blame and stigmatize people who use drugs.

Focus on “use” distracts from systemic issues, risk conditions and risk behaviours that determine benefits and harms. 14

Key Concepts - “Use”

Approach

Definition

Prohibition and Criminalization

Criminal law to denounce, deter, punish, and rehabilitate - to reduce harms.

State Control Government monopolies or partial monopolies.

Commercialization Free market - managing substances as commodities.

Prescription Health professional gatekeepers

Social/Sacred Control Social norms –wine with food, no alcohol with breakfast Social rituals – Japanese tea ceremony, coca leaf ritual Sacred rituals – tobacco, peyote, ayahuasca

Self-Control Self imposed controls on use 15

Key Concepts – Control Approaches

Prohibit possession, production, import/export and trafficking through criminal law.

Criminal law purposes - reduce harms

Strategies - denounce, deter, punish, and rehabilitate.

Tactics - arrests, criminal trials, fines, imprisonment, probation orders and criminal records.

Limited to ineffective deterrent to substance use.

Results in many harms. 16

Key Concepts

Prohibition and Criminalization

Key Concepts

Harms of Prohibition/Criminalization Organized crime, illegal markets,

corruption, gangs ,crime, violence.

Accelerated spread HIV, hepatitis.

Enforcement drives users away from prevention and care services.

Increase potency, overdoses deaths.

Expending personal resources on substances, to detriment of basic needs.

Forced involvement in criminal activities.

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Key Concepts

Harms of Prohibition/Criminalization Stigmatization and discrimination.

Crowding and slowing criminal justice.

Marginalization of people with difficult health, psychological, social problems.

Damaged houses, community disruption.

Substance displacement, users move to more hazardous products.

Restricted research on therapeutic and beneficial use. 18

Population levels of use and substance risk determine population levels harm.

E. g. Widespread use but limited risk of harm can result in as much adverse consequences as limited prevalence of use but higher risk of harm.

Benefits need to be considered, which complicates this assessment.

From a public health perspective ideal is low harm/benefit ratio, without unintended effects of control measures.

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Key Concepts

Population Health Impact

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The Paradox of Prohibition H

eal

th a

nd

So

cial

Pro

ble

ms

Market Regulation

Public Health

Illegal Market Gangsterism

Corporate Profit

Heroin Cocaine

Prohibition Defacto

Depenalization

Decriminalization Prescription

Legalize Many Restrictions

Legalize Few Restrictions

Cannabis

Methamphetamine

Medical Cannabis

Tobacco

Alcohol

Canadian Drug Policy Coalition www.drugpolicy.ca (from John Marks)

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Key concepts - Determinants of Harms and Benefits

Availability – The probability of being able to encounter or be exposed to the option of obtaining a substance. For example, availability may be determined by numbers of outlets, restrictions on density of retail outlets, or hours of operation.

Accessibility – The ease with which one may obtain a substance. It is a function of availability and other control measures that limit or facilitate purchase such as price, age requirements, and social networks that may be a source.

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Concepts Definitions

Advertising

Branding/naming

Sponsorship

Gifting

Product association with films

Leading personality recruitment

Associating use with attractive activities such as sporting, socialization, sex, and vacations;

Pricing reductions (i.e., loss leaders);

Labelling suggestive of pleasure, enhanced performance, over stated benefits;

Associations with pleasant activities;

Creating similar products for children (i.e., chocolate cigarettes) or youth-attractive products (e.g., alco pops, flavoured cigarettes, and cigars).

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Key concepts - Product Promotion

I. Directional Elements Assumptions, Principles, Vision, Goal,

Objectives (by sector – Health, Social Welfare, Education, Safety, Public Order and Justice, Agriculture, Environment, Business and Finance)

II. Strategies Health Promotion Health Protection Prevention Harm-reduction Health Assessment and Surveillance Emergency Preparedness and Response Research Services for people who are at risk or develop

problems with substances

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Public Health Approach

Consumption for both medical and non-medical purposes has long history and will continue in the future.

New substances will continue to be produced, and the consequences will need to be effectively managed.

Substantial, positive differences can be made with evidenced-based, coordinated, multi-sectoral, public health oriented strategies.

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Directional Elements - Explicit Assumptions

Promotion and protection of life, health, security, human rights and freedoms.

Empowerment through evidence based information, education, and support for self determination.

Informed consent about harms and benefits.

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Directional Elements - Explicit Principles

Emphasizes social justice, equity, respect for human rights, efficiency, and sustainability.

Includes perspectives of people who use and are affected by substances.

Respect for spiritual, traditional and therapeutic use.

Attentive to benefits and harms, as well unintended effects.

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Directional Elements – Explicit Principles (continued)

Public health approach addresses

determinants of health (i.e. physical, biological, psychological, and social e.g. income distribution, education, housing)

determinants of social and health inequities (i.e. power imbalance, racism, classism, ageism, sexism).

Recognizes that problematic use is often symptomatic of underlying biological, psychological, social or health issues.

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Directional Elements – Explicit Principles (continued)

Protection against false claims, unsafe products.

Respect for autonomy in making decisions about ones body.

Individuals held responsible, accountable for actions that harm others.

Criminal sanctions limited to harm to others (i.e. crimes of force, bodily harm, fraud and public safety).

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Directional Elements – Explicit Principles (continued)

Evidence informed, incremental implementation and rigorous evaluation; not ideology.

Regulation intensity based on harm potential.

Variations that pose the least risk should be most accessible. E.g. incentives for oral or vapourized products vs smoked, incentives for low vs high concentration.

Easy and readily available access to help for people who do experience problems. 30

Directional Elements – Explicit Principles (continued)

Pragmatism

Compassion for people directly or indirectly adversely affected.

Non-stigmatization and non-discrimination of consumers and providers.

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Directional Elements – Explicit Principles (continued)

Rational, respectful discussion, consensus. Inclusivity. Involve and gain support of affected people

and communities. Access to information and transparency. Where evidence is lacking, encouraging pilot

projects and evaluation. Where policies and strategies made without

evidence, make explicit and evaluate. Be prepared and willing to change course

based on evaluation.

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Directional Elements – Process Principles

Vision – Aspirational description of future to guide decision making.

See CPHA paper for “A Vision for 2025”.

Goal - Maximize the health and wellness of population, minimize harms, and ensure that the harms associated with interventions are minimized and not disproportionate to the harms of the substances themselves.

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Directional Elements

Benefits Harms

Physical Pain relief

Assistance with sleep

Decreased risk of

cardiovascular disease

Increased endurance,

stimulation or diminution of

appetite

Toxicity

Injury or death

Infectious and chronic diseases

Neurological damage and fetal alcohol

spectrum disorder

Aggravation of existing physical

disorders

Psychological Relaxation

Relief of stress and anxiety

Increase alertness

Assistance in coping with daily

life

Mood alteration

Pleasure

Performance or creativity

enhancement

Depression

Impaired thinking

Psychosis

Maladaptive coping behaviours

Dependency

Addiction

Aggravation of existing mental

disorders

Social Facilitation of social interaction

Religious, spiritual or

ceremonial use

Family violence

Financial hardship

Crime

Driving crashes

Stigmatization and discrimination

Economic Business and industrial activity

Wealth generation

Employment creation

Agricultural development

Tax revenue generation

Lost productivity

Costs of health, social, and criminal

justice services

Property damage

Fueling an illegal economy that avoids

taxation and distorts/impairs legal

markets

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1. Health promotion

2. Health protection

3. Prevention

4. Harm-reduction

5. Emergency preparedness and response

6. Population health assessment

7. Disease, injury, and disability surveillance

8. Services to help people at risk or who develop problems.

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Public Health Strategies

Over arching

Universal initiatives which apply to the entire population i.e. population wide social marketing campaigns.

Targeted initiatives such as providing harm reduction supplies i.e. needles, crack pipes, supervised consumption services.

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Strategies

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Health promotion as the process of enabling people to increase control over and improve their health,

Ottawa Charter for Health Promotion outlines prerequisites for health as peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. A key theme is “coordinated action by all concerned”.

defines the five components as: Building healthy public policy; Creating supportive environments for health; Strengthening community action; Developing personal skills; and Reorienting health services.

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Strategies

Prevention measures include low barrier blood testing and immunization programs, screening and brief intervention, evidence based education, and social marketing

Harm reduction reduces adverse consequences without necessarily reducing drug use i.e. needle, crack pipe and other harm reduction supply distribution programs, take home naloxone programs to prevent overdose fatalities, substitution maintenance therapies, supervised consumption services, and street drug testing programs

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Strategies

Health protection include policies and legal tools that control the supply chain to minimize the potential for harms from substances to individuals and those secondarily affected, and includes rules about governance of the system, production, manufacture, wholesale, distribution, retail, product promotion, purchase and consumption.

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Strategies

Emergency preparedness and response

Population health assessment

Disease, injury, and disability surveillance

Services to help people at risk or who develop problems

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Strategies

Application to Cannabis

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Crude Estimates of Annual Cannabis-attributable Morbidity and Mortality (Fischer, B. et al, Journal of PH, 2015)

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Mortality

MVA

Lung Cancer

Total

Low

89

130

219

High

267

280

547

MVA Injury 6,825 20,475

Incident

Schizophrenia

106 186

Cannabis Substance

Use Disorders

Treatment

Population

(Total = 380,000)

76,000 95,000

A for profit, free market approach can produce significant health and social harms.

Companies that sell products, which have potential for harm, prioritize profits over public health.

Production, distribution, sales, marketing, and consumption need to be carefully controlled.

Public health strategies have had some success, more is needed.

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Application to Cannabis Lessons learned from Alcohol and Tobacco

International – Framework Convention Tobacco Control, WHO Global Alcohol Strategy, Proposed Framework Convention Cannabis Control (Room R, et al Cannabis policy: Moving beyond stalemate. http://www.beckleyfoundation.org/cannabis-policy-moving-beyond-stalemate/)

UN General Assembly Special Session 2016 on “World Drug Problem (http://www.unodc.org/ungass2016/)

Other Countries - Shift from strong state control alcohol to private system increases harms. Plain packaging tobacco in Australia and proposed for Britain.

Federal – Tobacco: national advertising limits, warning labels, national strategy, product constituents i.e. flavour restrictions, support research, coordinate with provinces. - Alcohol: Control with provinces, product

promotion controls 45

Learning from alcohol or tobacco

Other Countries

Uruguay, Mexico, Jamaica

Netherlands – coffee shops

Portugal – decriminalized all drugs, health based approach

Spain - collective cultivation

USA

Legalization - Colorado, Washington State, Washington DC, Alaska, Oregon

Medical marijuana states (21)

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Cannabis Policy Context

Cannabis Legalization in the USA (Courtesy of Mark Haden) Washington

Oregon

Colorado Washington DC

Alaska

California

Nevada

Minnesota

Maine New Hampshire Vermont

New York

Massachusetts

Connecticut

Rhode Island

Maryland

Montana

Arizona New Mexico

Illinois

Michigan

Nebraska Ohio

North Carolina

Mississippi

Federal - Prohibition

– Medical Cannabis

Marihuana for Medical Purposes Regulation

Patients obtain authorization from physician, submit authorization to a licensed commercial producer

Categories of conditions or symptoms eliminated

Supply and distribution system of licensed producers

Patients no longer permitted to grow their own cannabis or designate others to grow it– injunction set aside – trial 2015. 48

Cannabis Policy Context Canada

Government regulation of consumer products to reduce risk and prevent harm is well established:

Food and water protection legislation

Consumer product legislation i.e. paint, cleaning products, toys etc.

Pharmaceutical and medical device legislation

Motor vehicle safety legislation 49

Health Protection e.g. Regulation

Health protection include policies and legal tools that control the supply chain to minimize the potential for harms from substances to individuals and those secondarily affected, and includes rules about governance of the system, production, manufacture, wholesale, distribution, retail, product promotion, purchase and consumption.

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Strategies

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Determinants of Harms and Benefits

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June 9, 2014 http://www.openmedicine.ca/article/view/630/552

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CAMH Policy Framework Link

Availability control – e.g. Governance - government monopoly; production controls; licensed retailers/lounges; regulation of density, locations, hours of operation; no co-sale with alcohol or tobacco.

Accessibility control - e.g. Retailers check age if appearance < 25 yrs; minimum pricing and taxation to influence price; required retailer/server training.

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Public Health Oriented Regulation for Cannabis

Supply control – e.g. allow some home production; strictly regulate commercial production; product standards; quotas; encourage small-scale production; track production and sales; bulk product only i.e. not pre-made joints; processing controls.

Demand reduction - e.g. require provision of factual information on harms and benefits; labelling constituents and warnings; bans on product promotion such as advertising, branding, and sponsorship.

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Public Health Oriented Regulations for Cannabis

Purchase, consumption, use controls - e.g. legal age of purchase, purchase quantity limits, public use limitations, impaired driving laws.

Revenue – Government monopoly mandate explicitly guided by public health vision, principles, goals and objectives; revenue generation explicitly not a primary function; revenue generated funds regulatory, public health related and other health and social initiatives.

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Public Health Oriented Regulations for Cannabis

Public support for cannabis “legalization” is growing, in part because of increasing recognition of the lack of effectiveness and the harms of cannabis prohibition.

There is a pressing need for proactive action based on a public health approach.

Otherwise, a commercial exploitation model may result, such that public health and social problems similar to those associated with alcohol and tobacco may be repeated.

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Closing Remarks

Provides opportunities to move away from prohibition/criminalization of opioids, stimulants, psychedelics to reduce harms of these substances and of the associated policies, and creates opportunities to realize benefits:

Psychedelics - MDMA and cannabis studies on PTSD, substance disorders

Stimulants maintenance therapy – ADHD

Opioids – public health approach to pain, less addiction and mortality

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Implications of public health approach for managing other illegal drugs

Values and principles

Economics

Infrastructure

Canadian laws and international conventions

Programs and projects

Leadership

Evaluation

Research

Barriers and Facilitators to a Public Health Shift – CPHA Paper

Responses Available under Prohibition (Courtesy City of Vancouver)

Enforcement

Education and

awareness

Socially stigmatized

through criminalization

Treatment and

Harm Reduction

Responses Available under Public Health Approach (Courtesy City of Vancouver)

Age

Degree of intoxification

Volume rationing

Limited places to use

Required training prior to use

Registration of purchasers

Licensing of users

Tracking of consumption habits

Drug consumed on location of sale

Prescription only

Maximum volumes for purchase and possession

Training of supplier

Monitoring of use with driving

Illegal dealers pursued by enforcement

Retail outlets licensed and limited

Appearance of retail outlets

Pharmacy specialist required

Price and profit controls

Taxed

Licensing, location and opening hours of consumption facilities

Social controls

Prevention programs

Treatment available

Plain packaging

Concentration of product is restricted and labeled

Warning labels

No advertising or event sponsorships

Clean needles and health information provided with purchase Required membership in users group

Stop purchase orders

Previously negotiated limits

Acknowledgements/References Health Officers Council of BC “Public Health Perspectives for

Regulating Psychoactive Substances: What we can do about alcohol, tobacco, and other drugs” http://healthofficerscouncil.net/positions-and-advocacy/regulation-of-psychoactive-substances/ or http://www.phabc.org/modules.php?name=Contentpub&pa=viewdoc&cid=11

Canadian Public Health Association “A New Approach to Managing Psychoactive Substances in Canada” http://www.cpha.ca/en/default.aspx

Haden, Mark; Emerson, Brian. “A vision for cannabis regulation:

a public health approach based on lessons learned from the regulation of alcohol and tobacco” http://www.openmedicine.ca/article/view/630/552

Centre for Mental Health and Addiction “Cannabis Policy

Framework” http://www.camh.ca/en/hospital/about_camh/newsroom/news_releases_media_advisories_and_backgrounders/current_year/Pages/CAMH-releases-new-Cannabis-Policy-Framework.aspx

Rolles, S. How to Regulate Cannabis: A Practical Guide http://www.tdpf.org.uk/resources/publications/how-regulate-cannabis-practical-guide

Canadian Centre on Substance Abuse: Marijuana Policy Briefs http://www.ccsa.ca/Eng/topics/Marijuana/Pages/default.aspx

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Thank you ! Questions and Comments

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1. The negative public health and social impacts of both use of and policies related to alcohol, tobacco, prescription and illegal substances are substantial, and largely preventable.

2. Use the evidence from the alcohol and tobacco free market experiences and associated harms when developing a public health oriented regulation of all substances.

3. The prohibition of a number of substances is ineffective and causing much harm. As a result, many jurisdictions are moving away from criminalization to more public health oriented approaches.

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Main Messages from HOC Paper

4. A public health oriented approach for all psychoactive substances is needed, together with appropriate health care, social, and criminal justice services

5. The effects of any changes in substance legality and regulation will need to be carefully monitored and evaluated. Local, provincial, and federal government innovation needs to be supported and encouraged.

6. A comprehensive public health approach is needed. All steps in the supply and demand chain should be under careful societal control.

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Main Messages from HOC Paper