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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.106 no.9 Pretoria Set. 2016

http://dx.doi.org/10.7196/samj.2016.v106i9.11222 

DEBATE

 

Position statement on cannabis: A step forwards

 

 

Dr Scott's response[1] to our position statement[2] enables us to clarify our views to health professionals and the public.

We agree with Dr Scott on several points. There is an increasing evidence-based consensus that policy on alcohol, tobacco, cannabis and other substances should move from the 'war on drugs' towards a science-based public health approach (as was successful locally in addressing tobacco use).[3] We agree that various substances differ in their associated costs and harms and that globally alcohol is a far more harmful substance than cannabis.[4] We also agree that an approach to substances that emphasises harm reduction and human rights is also key, and that new local policies and programmes are urgently needed, given the enormous burden of disease caused by alcohol, tobacco, cannabis and other substance use.[5] Our position statement was developed with these in mind! We have also submitted to this journal a position statement on harm reduction[6] to emphasise the importance of this approach to alcohol, tobacco, cannabis and other substance use from a public health perspective.

Nevertheless, important clarifications on questions of science, substance use regulation and local politics are also needed.

Dr Scott claims that our scientific view has 'confirmation bias' in that we selectively present evidence on the harms of cannabis. However, we drew on rigorous published systematic reviews in discussing its harms and benefits. While we accept that alcohol is a harmful agent and that cannabis may have health benefits, systematic reviews routinely confirm that cannabis use is harmful for certain aspects of health. Research on its health benefits remains sparse to date, with more research needed to establish safe dosages. Health professionals and the public must understand what the scientific literature indicates and the individual and public health problems associated with the use of tobacco, alcohol, cannabis and other psychoactive substances. Awareness of the potential medicinal uses of psychoactive agents is also important, as is the need for further research in this area. Our position statement made these points and we trust that health professionals will be persuaded by the relevant systematic reviews.

Dr Scott starkly contrasts prohibition and legal regulation and argues that decriminalisation is merely a form of prohibition. Our more nuanced view is that a broad spectrum of legislation is consistent with the harm reduction approach. The evidence base indicates that decriminalisation can contribute to improved public health (Dr Scott mentions Portugal, but does not mention this finding in that context) and that legal regulation does not necessarily stamp out criminal activity (consider the illegal trade of alcohol in South Africa (SA)). [7] Decriminalisation may be an achievable step locally for cannabis but does not preclude additional types of regulation for a range of drugs over time, based on evidence of what works to improve public health and to reduce harm. We hope that policy allows research on cannabis and other drugs for medicinal purposes, that when people use psychoactive substances measures are made available to prioritise safety (e.g. needle exchange), and that medication-assisted treatment is made widely available. At the same time, we are cognisant of not wanting policy to lead simply to 'Big Tobacco' being joined by 'Big Marijuana'[8] - there is insufficient evidence this would be a gain for public health.

Regarding politics, it is important to emphasise that our position statement was authored by members of the Executive Committee of the Central Drug Authority (CDA). The broader CDA contains many civil servants representing different government departments and reporting to their ministers, each of whom may have different positions on aspects of policy related to alcohol, tobacco, cannabis and psychoactive substance use. For example, some departments are focused on adhering to the international agreements that SA has signed to outlaw drugs. We also know that there may be different positions within government about the value of putting more pressure on the liquor industry to support harm reduction efforts and of doing so from a public health perspective. As advisors to government, our goal is to emphasise an evidence-based and balanced approach. We hoped that a public position statement would be welcomed by health professionals and the public as a progressive and pragmatic step to address SA's massive public health problem from alcohol, tobacco, cannabis and other psychoactive substance use.

We did not expect that our position statement would be accepted by those wishing to continue a 'war on drugs', or by those who support immediate commercialisation of all psychoactive substances in SA. Our science-based public health approach attempts to take a balanced and pragmatic step forward. As more data become available and political will is found to develop new policies and programmes to improve public health and advance harm reduction with respect to the use of alcohol, tobacco, cannabis and other psychoactive substances, we hope that the CDA Executive Committee will reassess its position on the best way forward. In the interim, we call on health professionals, civil society and the public to join the move away from the 'war on drugs' and towards a public health approach. While our position statement could lead to a focus on the issue of cannabis decriminalisation, in line with a public health approach and the profile of our burden of disease, we request health professionals and civil society to also focus on the urgency for harm reduction measures in the area of alcohol, tobacco and opioid use.

 

Dan J Stein

Department of Psychiatry and Mental Health, Faculty of Health Sciences, University of Cape Town, South Africa dan.stein@uct.ac.za

Eva Manyedi

School of Nursing, Faculty of Agriculture, Science and Technology, North-West University, Mahikeng, South Africa

For 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. Scott K. Comment on the Central Drug Authority's position statement on cannabis. S Afr Med J 2016;106(6):545-546. DOI:10.7196/SAMJ.2016.v106i6.1103        [ Links ]

2. Stein D, for the Executive Committee of the Central Drug Authority. Position statement on cannabis. S Afr Med J 2016;106(6):569-570. DOI:10.7196/SAMJ.2016.v106i6.10863        [ Links ]

3. Reddy P, James S, Sewpaul R, et al. A decade of tobacco control: The South African case of politics, health policy, health promotion and behaviour change. S Afr Med J 2013;103(11):835-840. DOI:10.7196/samj.6910        [ Links ]

4. 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 ]

5. Ellis GFR, Stein DJ, Thomas KGF, Meintjes EM. Substance Use and Abuse in South Africa: Insights from Brain and Behavioural Sciences. Cape Town: University of Cape Town Press, 2012.         [ Links ]

6. Stein D, Manyedi E, for the Executive Committee of the Central Drug Authority. Psychoactive substances: Position statement on harm reduction. S Afr Med J 2016;106(9):836. DOI:10.7196/SAMJ.2016.v106i9.11223        [ Links ]

7. Goncalves R, Lourenco A, Silva SN. A social cost perspective in the wake of the Portuguese strategy for the fight against drugs. Int J Drug Policy 2015;26(2):199-209. DOI:10.1016/j.drugpo.2014.08.017        [ Links ]

8. Richter KP, Levy S. Big marijuana - lessons from big tobacco. N Engl J Med 2014;371(5):399-401. DOI:10.1056/NEJMp1406074        [ Links ]

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