An Examination of Marijuana Use Among a Vulnerable Population in Canada

Social Norms for Cannabis Use After Nonmedical Legalization in Canada

INTRODUCTION

Social norms play an important role in cannabis use; however, there is little evidence on how social norms change in jurisdictions that legalize cannabis. This study examined trends in social norms before and after legalization of nonmedical cannabis in Canada in 2018.

METHODS

Data are from the International Cannabis Policy Study, a series of cross-sectional surveys conducted annually with Canadian respondents aged 16-65 years. Analyses were conducted in 2023 and included data from 58,045 respondents across 4 waves: the year immediately before legalization (2018) and 3 post-legalization waves (2019-2021). Regression models examined trends in injunctive norms (perceived approval of cannabis) and comfort in using cannabis in six different social contexts, adjusting for cannabis use frequency, medical authorization, and sociodemographic covariates.

RESULTS

Perceived social approval of cannabis use and comfort using cannabis in different social contexts was highest among males, frequent cannabis consumers, and those who reported medical authorization (p<0.05 in all cases). No changes in perceived approval were observed across years, except a temporary decrease in 2020 versus 2018 (OR=0.87, 95% CI=0.80, 0.95). Modest increases in comfort of using cannabis in 6 different social contexts were observed in 2019 (ß=0.10, p=0.001), 2020 (ß=0.10, p=0.001), and 2021 (ß=0.12, p<0.001) versus in 2018.

CONCLUSIONS

Social norms have remained relatively stable after nonmedical legalization in Canada, with only modest increases in comfort of using cannabis in different social settings. The findings may reflect widespread cannabis use in Canada prior to nonmedical legalization in 2018 as well as comprehensive restrictions on promotion and advertising.

Trauma and Substance Use among Indigenous Peoples of the United States and Canada: A Scoping Review

Substance use has been identified by Indigenous populations as contributing to health disparities facing their communities. Rates of trauma exposure and post-traumatic stress disorder are higher in Indigenous, compared to non-Indigenous, populations and have been linked to substance use. Historical trauma is thought to be one mechanism underlying substance use and related disorders. The purpose of the present study is to summarize the current state of the literature focusing on the association between trauma (historical and lived) and substance use among Indigenous populations in the United States and Canada. Databases were systematically searched using the preferred reporting items for systematic reviews and meta-analyses statement. The search strategy initially yielded 4,026 articles. After exclusion of ineligible articles, 63 articles remained for synthesis. Results of the present review provide evidence for a positive link between substance use and both historical trauma (i.e., 86.4% of studies) and lived trauma (i.e., 84.7% of studies). Indigenous participants reported that historical trauma and pain related to loss of cultural identity contributed to substance use in their communities. Indigenous participants also consistently described an association between lived trauma and substance use. Despite heterogeneity among Indigenous communities, findings suggest a significant association between trauma and substance use across many different tribes and settings (e.g., reservation/reserve, rural/urban). Indigenous participants identified healing from trauma and reconnecting with culture as necessary components for reducing substance use and maintaining sobriety. With this, the development and implementation of interventions should partner with Indigenous communities in a manner that promotes and enhances cultural values for healing.

Cannabis-Impaired driving: ethical considerations for the primary care practitioner

Background: Widespread cannabis consumption and recreational cannabis legalization is thought to have led to an increase in motor vehicle accidents, although there currently lacks ethical guidance for primary care practitioners on cannabis-impaired driving.Objective: The aim was to develop an ethical framework for primary care providers on cannabis-impaired driving.Methods: An ethical analysis in the form of a critical interpretive review was undertaken, using a systematic approach to determine the appropriate action to a given situation with evidence to substantiate its claims. The search strategy was designed to answer the research question: What are some ethical concerns for primary care providers to consider when cannabis-impaired driving is suspected? Four databases were searched in December 2021 using keywords related to cannabis, impaired driving, ethics, and primary care. The resulting evidence was synthesized as recommendations for primary care practice.Results: The ethical approach for primary care practitioners in addressing cannabis-impaired driving can be summarized as the duty to always inform, provide care through prevention and harm reduction strategies, and report when necessary. The prevention of cannabis-impaired driving should not fall on the sole responsibility of primary care practitioners. As this review offers a high-level discussion of the ethical considerations in cannabis-impaired driving, specific recommendations will depend upon the legal and policy designations of individual jurisdictions.Conclusion: Ultimately, the practitioner should manage cannabis-impaired driving in a way that fosters the therapeutic relationship in patient-centered care, through motivational discussions, collaboration with specialists, skills for self-management, patient empowerment, and support. KEY MESSAGES  Take-Home Points for Primary Care Practitioners in Cannabis-Impaired Driving  •  For patients who report driving frequently and using cannabis, the frequency of use, dosage, form of cannabis, tolerance levels, and withdrawal symptoms should be discussed, while informing the patient of the risks, harms, and legal consequences associated with cannabis-impaired driving.  •  The practitioner's primary responsibility in the cannabis-impaired driving context is to provide care to patients who drive and consume cannabis, which may include referring patients to mental health care to manage addictive or problematic behaviors associated with cannabis use.  •  Practitioners may have a duty to report cannabis-impaired driving to legal authorities (such as law enforcement) when the user engages in harmful behavior to themselves or others.

Trauma, historical trauma, PTSD and suicide in an American Indian community sample

AIMS

To study the associations between perceived historical trauma, current traumatic events, diagnoses of post-traumatic stress disorder (PTSD), and suicidal behaviors in an American Indian community sample.

METHODS

Participants were American Indians recruited from reservations who were assessed with the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA), as well as the Historical Loss Scale, Historical Loss Associated Symptoms Scale, and Stressful Life Events Scale.

RESULTS

In data from 447 American Indian adults (mean age = 33 years), twenty percent reported lifetime experiences of suicidal thoughts (ideation and/or plans) and 14% reported suicidal acts, (including either a suicide attempt history or verified death by suicide (n = 4)). Diagnosis of PTSD and experience of assaultive trauma were each significantly associated with suicidal thoughts and acts, although assaultive trauma did not remain significant in models adjusting for gender and PTSD. High endorsement of symptoms associated with historical trauma was significantly associated with suicidal acts, and this remained significant when adjusting for gender and PTSD.

CONCLUSIONS

PTSD and historical trauma have an association with suicide and suicidal attempts in this American Indian community. Although further research is needed to evaluate the causal nature of these relations, these findings suggest treatment and prevention programs for American Indian suicide may benefit from addressing issues related to feelings of historical losses, PTSD, and their associated symptomatology.

Non-medical cannabis use among Indigenous Canadians: A systematic review of prevalence and associated factors

BACKGROUND

Indigenous Canadians may be at an increased risk of non-medical cannabis use. The aim of this review was to synthesize the prevalence of non-medical cannabis use and its associated factors among Indigenous Canadians.

METHODS

We systematically searched MEDLINE, EMBASE, Web of Science, and Scopus from inception to January 29th, 2020 for publications reporting the prevalence of non-medical cannabis use among Indigenous Canadians. We included studies published in English after January 1st, 2000. Included publications were hand-searched for potentially relevant peer-reviewed and gray literature publications. Results were synthesized descriptively.

RESULTS

We identified 16 peer-reviewed and 7 gray literature publications which met our inclusion criteria. All data were collected prior to cannabis legalization in Canada (October 17th, 2018). The most recent estimates of prevalence of use in the past year were 27% among on-reserve First Nations adults, 50% among off-reserve First Nations adults, and 60% among Nunavik Inuit. In youth, they were 45% among all Indigenous youth grades 9-12, 27% among on-reserve First Nations youth aged 12-17, and 69% in Nunavik Inuit aged 16-22. Direct comparisons indicated a 1.2-15 times higher prevalence of use in Indigenous compared to non-Indigenous youth. Factors associated with cannabis use in adults included younger age and male sex. In youth, factors included older age, poorer mental and physical health, and a poorer relationship with school.

CONCLUSION

Results suggest that Indigenous Canadians are at a higher risk for non-medical cannabis use than the general Canadian population. Further research is warranted to inform the development of targeted interventions.

A community-driven and evidence-based approach to developing mental wellness strategies in First Nations: a program protocol

BACKGROUND

Mental health, substance use/addiction and violence (MSV) are important issues affecting the well-being of Indigenous People in Canada. This paper outlines the protocol for a research-to-action program called the Mental Wellness Program (MWP). The MWP aims to increase community capacity, promote relationship-building among communities, and close gaps in services through processes that place value on and supports Indigenous communities' rights to self-determination and control. The MWP involves collecting and using local data to develop and implement community-specific mental wellness strategies in five First Nations in Ontario.

METHODS

The MWP has four key phases. Phase 1 (data collection) includes a community-wide survey to understand MSV issues, service needs and community strengths; in-depth interviews with individuals with lived experiences with MSV issues to understand, health system strengths, service gaps and challenges, as well as individual and community resilience factors; and focus groups with service providers to improve understanding of system weaknesses and strengths in addressing MSV. Phase 2 (review and synthesis) involves analysis of results from these local data sources and knowledge-sharing events to identify a priority area for strategic development based on local strengths and need. Phase 3 (participatory action research approach) involves community members, including persons with lived experience, working with the community and local service providers to develop, implement, and evaluate the MWP to address the selected priority area. Phase 4 (share) is focused on developing and implementing effective knowledge-sharing initiatives. Guidelines and models for building the MWP are shared regionally and provincially through forums, webinars, and social media, as well as cross-community mentoring.

DISCUSSION

MWP uses local community data to address MSV challenges by building on community supports and resilience factors. Drawing on local data and each community's system of formal and informal supports, the program includes sharing exemplary knowledge-to-action models and wellness strategies developed by and for First Nations people that can be used by other First Nations to identify shared wellness priorities in each community, and determine and execute next steps in addressing areas of main concern.