IN PRACTICE
POSITION STATEMENT

 

Position statement on cannabis

 

 

D J Stein; Executive Committee of the Central Drug Authority

FRCPC, PhD Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa

Correspondence

 

 

---

ABSTRACT

There is an ongoing national debate around cannabis policy. This brief position statement by the Executive Committee of the Central Drug Authority outlines some of the factors that have contributed to this debate, delineates reduction strategies, summarises the harms and benefits of marijuana, and provides recommendations. These recommendations emphasise an integrated and evidence-based approach, the need for resources to implement harm reduction strategies against continued and chronic use of alcohol and cannabis, and the potential value of a focus on decriminalisation rather than the legalisation of cannabis.

---

 

 

Why now?

A national debate on cannabis has gathered momentum for several reasons. First, the introduction of a bill that focuses on the use of cannabis for medical purposes has raised issues about the access to and the efficacy of the psychoactive ingredients of the cannabis plant for the management of medical conditions. Second, there have been changes in the legal status of cannabis in several countries around the world, including Uruguay and the USA. Third, in South Africa (SA), the abuse of alcohol, tobacco, cannabis and other psychoactive substances or drugs continues to be a major problem, causing immense suffering to individuals, families and communities and costing the national economy severely.^[1-3]

 

Brief history

Cannabis is subject to several international and national conventions and laws. The International Drug Convention of 1961 agrees that states should not commercialise cannabis, but allows states to decide for themselves the extent to which laws and policies should focus on the different strategies of supply, demand and harm reduction. The Prevention of and Treatment for Substance Abuse Act 70 of 2008 speaks to The National Drug Master Plan, which emphasises all three of these strategies for combating the abuse of alcohol, tobacco, cannabis and other psychoactive substances.

 

Reduction strategies

Supply reduction refers to policing efforts to curb the manufacture and distribution of alcohol, tobacco, cannabis and other psychoactive substances. Demand reduction refers to preventive efforts to decrease demand for such substances. Harm reduction refers to policies and interventions aimed at reducing the harmful consequences of alcohol, tobacco, cannabis and other psychoactive substance use. A focus on harm reduction does not intend to send a message to the community that risky behaviours and the use of psychoactive substances or drugs are acceptable. Rather, such policies are formulated based on the scientific evidence regarding what works to improve public health and reduce social harms when tobacco, alcohol, cannabis and other psychoactive substances are already being used.^[4-6]

 

Harms of marijuana

Scientific research has established that cannabis is associated with a range of potential harms to individuals and to society. Data on smoking cannabis indicate that this practice is linked to cardiovascular and respiratory disorders, as well as to cognitive impairment and mental disorders.^[7] Exposure to cannabis in adolescence, a time of significant neurodevelopment, is associated with a higher risk for psychotic disorders in later life. The risk is dose related.^[8] Highly potent cannabis represents a significant public health problem. Acute cannabis use, for example, is associated with increased risk of motor vehicle collisions, including fatal crashes.^[9] Cannabis use should therefore be prevented, and its continued use treated, using evidence-based approaches.

 

Benefits of marijuana

Medications such as dronabinol and nabilone consist of psychoactive ingredients of the cannabis plant, and are available in a number of countries for the treatment of medical conditions, such as nausea after chemotherapy, pain and spasticity. There is ongoing interest in the use of psychoactive ingredients of the cannabis plant in various other medical contexts, including for weight gain in HIV-positive patients. However, there are relatively few rigorous data in this area, and little is known about safe dose limits.^[10] In the SA setting, there is a need for greater health research in general, including work on cannabis. This needs to be balanced against national health research priorities, which have highlighted the importance of additional research on several aspects of mental health that are relevant to SA's burden of disease, including mortality and morbidity.^[11]

 

Recommendations

• The National Drug Master Plan emphasises the importance of an integrated approach to supply reduction, demand reduction, and harm reduction strategies for combating alcohol, tobacco, cannabis and other psychoactive substance use and abuse in SA. For any particular substance, the balance between these three strategies, and the precise nature of the approach taken, should be evidence based.

• An assessment of currently available data in other countries indicates that alcohol is the substance that causes the most individual and societal harm,^[12] and it is therefore key to put particular efforts into implementing the most evidence-based policies and interventions for combating such harm. This would encompass addressing a range of upstream drivers of alcohol use, as well as prevention and intervention efforts.^[13]

• Efforts at harm reduction have been particularly poorly resourced in SA, and given the enormous profits made by the liquor industry there is a need and obligation for this industry to be substantively more involved in evidence-based harm-reduction efforts.

• In terms of cannabis, local school survey data suggest high rates of experimentation during early adolescence;^[14] hence, evidence-based interventions that include a strong focus on harm reduction are also needed in this population, which comprises a large proportion of South Africans.

• There are few data to indicate that supply reduction via criminalisation is effective in reducing cannabis abuse. At the same time there are insufficient data to indicate that the legalisation of cannabis will not be harmful. The immediate focus should therefore be decriminalisation rather than legalisation.

• With regard to medical marijuana, products based on ingredients of the cannabis plant should undergo standard evaluation by the Medicines Control Council to assess their benefits and risks for the treatment of particular medical conditions.

• Evidence-based approaches that reduce harm from continued and chronic use of alcohol and cannabis (particularly among vulnerable groups such as adolescents and people with mental disorders) deserve greater attention and additional resources.

• Mental, neurological, and substance use disorders contribute significantly to SA's burden of disease. Proportionally and quantitatively, more research attention and resources need to focus on this area.

Acknowledgement. We thank Prof. Bronwyn Myers of the SA Medical Research Council for her inputs.

The Executive Committee of the Central Drug Authority: Carol du Toit, Dan Stein, David Bayever, Eva Manyedi, Johlene Ntwana, Lethiwe Ndlovu, Mogotsi Kalaemodimo, Moses Gama, Pelmos Mashabela, Peter Ucko.

 

References

1. Van Niekerk JP. Medical marijuana and beyond. S Afr Med J 2014;104(6):387. DOI:10.7196/SAMJ.8335        [ Links ]

2. Parry CD, Myers BJ. Legalising medical use of cannabis in South Africa: Is the empirical evidence sufficient to support policy shifts in this direction? S Afr Med J 2014;104(6):399-400. DOI:10.7196/SAMJ.8135        [ Links ]

3. Matzopoulos RG, Truen S, Bowman B, Corrigall J. The cost of harmful alcohol use in South Africa. S Afr Med J 2014;104(2):127-132. DOI:10.7196/SAMJ.7644        [ Links ]

4. Anderson P, Chisholm D, Fuhr DC. Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 2009;373(9682):2234-2246. DOI:10.1016/S0140-6736(09)60744-3        [ Links ]

5. Jones L, Hughes K, Atkinson AM, Bellis MA. Reducing harm in drinking environments: A systematic review of effective approaches. Health Place 2011;17(2):508-518. DOI:10.1016/j.healthplace.2010.12.006        [ Links ]

6. Babor TF. Linking science to policy: The role of international collaboration and problem-focused integrative reviews. Addiction 2015;110(2):40-46. DOI:10.1111/add.12911        [ Links ]

7. Karila L, Roux P, Rolland B, et al. Acute and long-term effects of cannabis use: A review. Curr Pharm Des 2014;20(25):4112-4118. DOI:10.2174/13816128113199990620        [ Links ]

8. Radhakrishnan R, Wilkinson ST, D'Souza DC. Gone to pot - a review of the association between cannabis and psychosis. Front Psychiatry 2014;22(5):54. DOI:10.3389/fpsyt.2014.00054        [ Links ]

9. Asbridge M, Hayden JA, Cartwright JL. Acute cannabis consumption and motor vehicle collision risk: Systematic review of observational studies and meta-analysis. BMJ 2012;344:e536. DOI:10.1136/bmj.e536        [ Links ]

10. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA 2015;313(24):2456-2473. DOI:10.1001/jama.2015.6358        [ Links ]

11. Stein DJ. Psychiatry and mental health research in South Africa: National priorities in a low and middle income context. Afr J Psychiatry 2012;15(6):427-431. DOI:10.4314/ajpsy.v15i6.54        [ Links ]

12. Nutt DJ, King LA, Phillips LD. Independent Scientific Committee on Drugs. Drug harms in the UK: A multicriteria decision analysis. Lancet 2010;376(9752):1558-1565. DOI:10.1016/S0140-6736(10)61462-6        [ Links ]

13. Ferreira-Borges C, Dias S, Babor T, Esser MB, Parry CD. Alcohol and public health in Africa: Can we prevent alcohol-related harm from increasing? Addiction 2015;110(9):1373-1379. DOI:10.1111/add.12916        [ Links ]

14. Parry CD, Myers B, Morojele NK, et al. Trends in adolescent alcohol and other drug use: Findings from three sentinel sites in South Africa (1997 - 2001). J Adolesc 2004;27(4):429-440. DOI:10.1016/j.adolescence.2003.11.013        [ Links ]

 

 

Correspondence:
D J Stein
dan.stein@uct.ac.za

Accepted 11 April 2016.