Special Session – Cannabis

Solomon Rataemane, University of Limpopo, South Africa and President, African Association of Psychiatry and Allied Professions

Professor Rataemane explained that South Africa is not in position or willing to legalize cannabis, in part because of the nature of Africa and the lack of current drug controls in place. Policy element – speak as government rep, NGos, and professor/university.

He reviewed the epidemiology of cannabis use. Worldwide cannabis is most widely used illicit drug, used by about 3.9% of the world’s adult population. Its use is more prevalent among males, but that is changing.

In sub-Saharan Africa, the general position on cannabis is that it is illicit, it harms young users, and that its use leads to other drugs. Additionally, its use is increases likelihood of academic failure in school, contributes to crowing prisons with teenagers and contributes to violence in society.

The United Kingdom reclassified cannabis to the status of a “softer” drug; after negative consequences resulting from that policy change, cannabis was reclassified as a “hard” drug.

There are no formal studies of cannabis use and its effects in South Africa. Among adolescents, 5-10% self-report cannabis use whereas 2% of adults report use. Cannabis use is higher among men, urban areas, and in certain provinces, specifically Western Cape and Gauteng.

Professor Rataemane reported on a number of harmful drug combinations used in South Africa which combine cannabis and cheap heroin (NYAOPE), methaquolone (“white pipe”, methamphetamines, alcohol and use in conjunction with cocaine.

These combinations often result in serious consequences, including explosive short-lived psychosis. One of the difficulties is that hospitals when they admit acute psychotic states in patients, they do not conduct quantitative analyses about the levels of drugs used and identified.

Linkages have been made to drug use and unprotected sex and related consequences; increase in fatal road crashes; domestic violence (mainly child and women abuse); academic failure and general apathy; workplace accidents and drop in productivity; increase in cardiac, liver and other problems.

Due to a number of incidents in schools related to drugs, South Africa is currently investigating the possible use of random drug testing for students to discourage drug use. It is being debated today but there has been strong resistance from parents. They would prefer that testing be reserved for only students suspected of use, not random testing.

In terms of treatment demand, alcohol is the most prevalent primary drug of abuse; however, he noted that cannabis use is common among individuals with alcohol abuse.

He noted that the nation of Malawai has a very high treatment demand for cannabis. The problems that Malawi has with cannabis are also seen in Uganda and South Africa, among other African countries.

In Africa there is new controversy about cannabis given the recent changes in other countries related to the medical use of cannabis, and legalization of cannabis in two US states. These policy changes elsewhere have impacted South Africa. In February 2014, a medical innovations bill was introduced.

Professor Rataemane noted that changes in cannabis laws send the message that drug use is acceptable socially. He stressed that once use occurs, it opens the door for lifelong illness, which is why prevention is so important. Drugs impact the brain at different points with the greatest impact on the frontal lobe. Moreover, the psychological effects are long-lasting.

He reviewed the criteria of cannabis withdrawal disorder published in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) which can include in the diagnosis: induced anxiety disorder, induced psychotic disorder with delusions; induced psychotic disorder with hallucinations; intoxication; intoxication delirium; sleep disorder; and unspecified cannabis related disorder.

Professor Rataemane concluded his remarks by reviewing that the sub-Saharan position on cannabis reinforces that its use is harmful and negatively affects health and achievement. The view is that it should remain illegal. There is interest in connecting drug users to treatment through the criminal justice system, including interest in the use of Drug Courts. More must be done to educate communities in South Africa about the drug and its harm, and to appeal to other countries to continue tight control on cannabis.

Martien Kooyman, MD, PhD began his presentation with a brief review of cannabis laws in The Netherlands where 300,000 persons are alcohol dependent and 50,000 are cannabis dependent.

In 1960s, the book “Soft Drugs” was published. He had been working in Uganda and did not see psychosis related to cannabis use. There alcohol was the drug of choice. In The Netherlands, it was other way around for young people; young people used cannabis. In The Netherlands, no one cared if cannabis is smoked in public, on the streets.

In the 1970s there were no known long-term effects of cannabis. Cannabis users were not viewed as being nuisance to others. In 1976 the use of cannabis was no longer a crime. Possession of 5 grams was permitted for personal use. An individual could grow 5 plants for personal use. The intention of the policy was to avoid the expected shift of the cannabis user to hard drugs. However, The Netherlands has not legalized cannabis; although its sale is limited to “coffee shops”. The sale of other drugs remains illegal.

The first coffee shop was opened in 1978. In 2010 The Netherlands had 650 coffee shops nationwide, with 214 in Amsterdam. Since 2010 several coffee shops have been closed due to new regulations regarding where they may be placed (e.g. proximity to schools) and because some were selling hard drugs. Some of the coffee shops near the border with Belgium were closed.

The unintended impacts of this cannabis policy include the fact that 80% of cannabis collected in The Netherlands is exported to other countries in Europe; the profits of exported cannabis is estimated at €3 billion each year. The Netherlands has become the largest exporter of cannabis seeds. Lastly, many cannabis nurseries producing cannabis use illegally obtained/diverted electricity.

The Netherlands is a drug tourism destination. Upwards of 80% of clients of coffee shops were foreigners. In 2008, over one fifth of foreign tourists in Amsterdam bought cannabis in coffee shops.

As a result of these problems, a 2012 court decision determined that coffee shop owners are limited to having 500 grams of cannabis in store. For commercial exploitation of the coffee shops, more than 500 mg of stock is necessary.

The large majority of cannabis users in Europe are young, between the ages of 15 and 24 years. There are important differences in the way in which cannabis is used today by young people as compared to use in the past. Rather than a shared group experience, cannabis is used by individuals alone. The drug itself has changed dramatically. The THC content has increased to more than 15%. This increase in the THC content of cannabis grown in nurseries is enhanced by the use of stronger light and growing “skunk.”

More people using cannabis today are looking for treatment. There was an increase by 40% of individuals seeking treatment between 2004 and 2009; that figure is stabilizing now. The average age of cannabis users entering treatment today is 25 years. In The Hauge, half (50%) of patients in detoxification units for adolescents are now solely addicted to cannabis.

In The Netherlands, cannabis can be used for medical use for relieving pain related to multiple sclerosis. Most people if using for medical purposes do not get cannabis from physicians because it is easier and cheaper to purchase the drug in shops.

Under the passed 2012 “wietpas” law, coffee shops were to have clubs with a maximum number of 2,000 members. This policy was implemented in some provinces. About three quarters of clients refused to be registered. After protests from mayors of large cities that rely on tourism, many did not introduce the policy. It was decided by the government that each city could determine its own policy on coffee shops.

Through police activities in The Netherlands, 5,962 cannabis nurseries destroyed; only professional growers with lamps and ventilators were arrested.

One of the unintended consequences of The Netherlands drug policy of allowing coffee shops to sell cannabis has led to an easy way of selling illegally grown cannabis. There is much opportunity for criminal organizations to take over the market.

The Netherland’s attempt to divide markets into soft vs. hard drugs by allowing coffee shops to sell cannabis did not result in lower consumption of hard drugs. Overall it has been a social disaster.

The cannabis grown and sold today is not same drug as was available in the 1970s. The average THC has increased to more than 15%. Cannabis issue can clearly lead to addiction. The damage to the brain from chronic use is worse compared with chronic use of heroin. Among the negative effects of long-term cannabis use in adolescence include neuropsychological dysfunction, decline in IQ, short memory, among others.

Dr. Kooyman concluded his presentation by reinforcing the message that cannabis can no longer be labeled a “soft” drug. There is no justification to have different laws for cannabis than other drugs (labeled as “hard”). The legalization of cannabis reinforces already existing opinion among youth that there are no risks in using cannabis.

Kat Belendiuk, PhD presented her research findings from an adolescent drug treatment program in Colorado in the United States.

In 2000, the state of Colorado allowed the sale of cannabis for medical uses, known as “medical marijuana” to persons with a physician’s recommendation for use of the drug. Physicians could recommend the drug for up to five patients.

In 2009 marijuana became commercialized in the state. The previous restriction regarding the number of patients physicians could recommend cannabis to was eliminated. At the same time, cannabis dispensaries opened. The number of dispensaries increased over time. Dr. Belendiuk noted that for one of her patients, there exist 31 marijuana dispensaries within a 2-mile radius of the patient’s home.

In 2012 Colorado passed full legalization of marijuana which went into effect on January 1, 2014. There is much interest in the impact of these changing laws.

Investigation has shown that the residents of states with medical marijuana laws are more likely to use marijuana; however, it has been argued that those states with greater use are the most likely to pass such laws.

What do these changes in laws mean for adolescents? There have been many concerns particularly related to diversion of marijuana and the increased potency of the drug.

Dr. Belendiuk’s study included 560 adolescents in the largest addiction treatment program for adolescents in Colorado. These adolescents have dual-diagnosis for substance use disorders and co-occurring mental health disorders. They participate in weekly individual, cognitive behavioral sessions. The study included over 6,000 urine drug screens collected (though these were not observed samples).

The study focused on the biological exposure of these adolescent patients to cannabis, examining the THC-to-creatinine ration (THC/Creatinine or THC/Cr), a quantitative measure of the drug screen results. Creatinine helps identify whether samples were contaminated.

The drug test results were shared with the patients. Clean, drug-free urines were positively reinforced with an incentive (i.e. prize). Dr. Belendiuk compared adolescents who entered the treatment program prior to commercialization of cannabis, between 2007 and 2009, to adolescents who entered treatment after cannabis commercialization, between 2010 and 2013.

The research findings indicate that adolescents who entered treatment after commercialization had higher initial THC/Cr ratios but no differences in final THC/Cr level before discharge. However, these patients had more positive urine drug tests, more treatment visits overall and more treatment visits before producing the first negative urine drug test result.

Patients who entered treatment prior to commercialization were 2.8 times more likely to be sober upon leaving treatment than patients who entered treatment post-commercialization. Overall adolescents that entered treatment post-commercialization had poorer treatment outcomes. The higher THC/Cr ratios suggest may indicate greater dependence on marijuana. These findings were present when accounting for higher initial THC/Cr levels among post-commercialization group, indicating that increased marijuana availability may be an important factor.

Future study is needed on the cohort of adolescents who enter treatment for following the implementation of full legalization of marijuana.

Other areas of interest for research include examining the features of the environment (i.e. density and proximity of marijuana dispensaries) to understand the effects of marijuana potency and the availability of marijuana on influencing adolescent marijuana use and treatment outcomes. Finally, new research is needed to evaluate the role of marijuana policy on other substance use and treatment.