Uruguay's middle-ground approach to cannabis legalization

Effects of Recreational Cannabis Legalization on Mental Health: Scoping Review

OBJECTIVE

Recreational cannabis legalization (RCL) is expanding rapidly. RCL's effects on mental health issues are of particular concern because cannabis use is more frequent among people receiving psychiatric care and is associated with several psychiatric disorders. The authors conducted a scoping review to examine the evidence and discern gaps in the literature concerning the effects of RCL on mental health and to assess the factors responsible for an observed heterogeneity in research results.

METHODS

This scoping literature review followed PRISMA guidelines. Five databases-MEDLINE, CINAHL, Embase, APA PsycInfo, and Web of Science-were searched for English- or French-language reports published between January 1, 2012, and April 30, 2023.

RESULTS

Twenty-eight studies from the United States and Canada were found. The studies were classified by category of the study's data (patients receiving psychiatric care [k=1], death records [k=4], emergency department or hospital records [k=10], and the general population [k=13]) and by the diagnosis (schizophrenia or psychoses, mood disorders, anxiety disorders and symptoms, suicide or suicidal ideation, or other mental health issues) examined. The review findings revealed a paucity of research and indicated mixed and largely inconclusive results of the studies examined. Research gaps were found in the examination of potential changes in cannabis use patterns among people receiving psychiatric care and in the availability of longitudinal studies.

CONCLUSIONS

Clinicians, researchers, and policy makers need to collaborate to address the research gaps and to develop evidence-based policies that reflect a thorough understanding of the effects associated with RCL.

[Legalization of Recreational Cannabis use in Germany - Implications Based on Experiences in Uruguay, Canada und USA: a Narrative Review]

The current government of Germany has agreed on legalizing the recreational use of cannabis in their coalition agreement. Legalization will be implemented in 2023. This issue has continuously been a subject of controversial discussion including most parts of society, executive authorities and science. This article refers to the experiences of other countries (Uruguay, Canada, USA) yet having legalized Cannabis in the past and tries to discuss implications for Germany.

Cannabis Social Clubs in Contemporary Legalization Reforms: Talking Consumption Sites and Social Justice

There is ongoing debate about what policy approaches to cannabis use might best address health and social related harm. Profit-driven, adult-use cannabis markets have been introduced in the United States and Canada, where legalization reform has had mixed effects to date in terms of public health and has made limited progress in achieving social justice aims. Meanwhile, several jurisdictions have seen an organic evolution of alternative cannabis-supply regimes. Cannabis social clubs (CSCs), the focus of this commentary, are nonprofit cooperatives that supply cannabis to consumers with the goal of harm reduction. The peer and participatory aspects of CSCs may have positive effects on health-related outcomes of cannabis use, such as through encouraging the use of safer products and responsible use practices. The nonprofit objectives of CSCs may diminish the risk for increasing cannabis consumption in wider society. CSCs have recently made an important transition from grassroots organizations in Spain and elsewhere. In particular, they have become key players in top-down cannabis legalization reform in Uruguay and, most recently, Malta. The history of CSCs in reducing harm from cannabis use is an important advantage, but there might be concerns around the grassroots origins, low taxation opportunities, and capacity to sustain social objectives. Also, the CSC model might not seem unique, as contemporary cannabis entrepreneurs have absorbed some features of their community-based predecessors. CSCs can play an important role in future cannabis legalization reform due to their unique strengths as cannabis-consumption sites and can be effective in advancing social justice by giving people affected by cannabis prohibition agency and direct access to resources.

Cannabis policy in The Netherlands: Rationale and design of an experiment with a controlled legal ('closed') cannabis supply chain

Since the Dutch tolerance policy, allowing the purchase of cannabis in 'coffeeshops', is associated with problems of public order and safety as well as health risks, there has been a long debate about legalisation of cannabis production and supply. It was therefore decided to conduct an experiment with a controlled legal ('closed') cannabis supply chain for recreational use. This is of international relevance in view of the current illegal cannabis exports from the Netherlands, the importance of sharing knowledge about the effectiveness of cannabis policies, and the accumulation of evidence needed to evaluate and update international treaties. Here we describe and discuss the background, general approach and design of the experiment. An independent expert committee elaborated how the closed chain will operate and be evaluated, based on the experience with the medicinal cannabis chain, and round table discussions with stakeholders (mayors, coffeeshop owners, cannabis consumers, growers, regulators, scientists, and addiction experts). Ten trusted cannabis growers are contracted to produce and supply cannabis to the coffeeshops in intervention municipalities, with product quality control, law enforcement against criminal interference, and preventive efforts to reduce health risks being implemented. No changes will be made in the cannabis supply to the coffeeshops in participating control municipalities. A process evaluation will assess whether the chain from production to sale in the intervention municipalities was really closed. In a quasi-experimental study comparing intervention and control municipalities, the chain's effects on public health, cannabis-related crime, safety and public nuisance will be estimated. The fieldwork period is expected to start early 2024 and will take four years, including reporting to the government and parliament. These will then decide whether and what further steps towards legalisation of the production and supply of cannabis will be taken.

Cannabis-Legalisierung in Deutschland

Zusammenfassung: Zielsetzung: Die deutsche Bundesregierung hat beschlossen, den nicht-medizinischen Cannabis-Gebrauch und -Vertrieb zu legalisieren, und Kernpunkte des vorgesehenen Regelwerks vorgelegt. Einige dieser Kernpunkte werden aus der Sicht internationaler Erfahrungen und wissenschaftlicher Evidenz zur Legalisierung – insbesondere mit Blick auf Massnahmen und Ziele öffentlicher Gesundheit – eingeschätzt und kommentiert. Methodik: Selektive Zusammenfassung und policy-analytische Anwendung wissenschaftlicher Evidenz. Ergebnisse: Ein erheblicher Anteil von Cannabis-bezogenen Gesundheitsproblemen hängt mit dem Konsum von Hochpotenz- (THC) Produkten zusammen; allerdings würden kategorische THC-Grenzwerte für legal verfügbares Cannabis diese im Gesamten wahrscheinlich nicht reduzieren sondern primär Hochrisiko-Konsumenten weiter in der Illegalität belassen. Die Mindestalter-Grenze von 18 Jahren für legales Cannabis macht primär politischen Sinn und repräsentiert nicht unbedingt optimalen Gesundheits- oder sozialen Schutz für junge Konsumenten; allerdings wird der Cannabis-Konsum bei Minderjährigen wahrscheinlich weiter hoch blieben. Eine substanz-übergreifende, gesundheits-orientierte Angleichung mit den Gesetzesregelungen für andere Substanzen (z. B. Alkohol) wäre sinnvoll. Das Fahren unter Cannabis-Einfluss ist relativ häufig, und kann zu Verletzungs- und Todesfällen, und damit erheblicher Gesundheitsbelastung führen; seine Kontrolle braucht gezielte Aufklärungs- und Abschreckungs-Maßnahmen. Cannabis-Legalisierung ist mit einschlägigen internationalen (z. B. UN) Konventionen generell schwierig zu vereinbaren, sollte aber dazu genutzt werden, diese grundsätzlich auf der Basis von Prinzipien des Gesundheitsschutzes zu erneuern. Schlussfolgerungen: Für die Cannabis-Legalisierung in Deutschland gibt es kein perfektes Regelwerk; einige Kern-Ziele werden nur über Kompromiss-Ansätze zu erreichen sein, die im Zweifelsfall angepasst werden müssen. Wenn implementiert, wird Deutschland wichtige Daten zur Cannabis-Legalisierung als Politik-Option bieten können, wozu ein systematisches und umfassendes Prozess- und Ergebnis-Monitoring durchgeführt werden muss.

'We never thought this would be considered drug trafficking': International finance rules, policy space and Uruguay's regulation of recreational cannabis

ABSTRACTFollowing landmark legislation in 2013, Uruguay became the first country to regulate the legal production, distribution and sale of recreational cannabis. While broader debates anticipated the significance of the UN drug conventions, the extent to which Uruguay's drug treaty obligations shaped regulation is unclear and the relevance of finance norms has been neglected. Drawing on institutionalist and governance theories, this study explores how international drug and finance regulations limited Uruguay's policy space to implement cannabis regulation, and how this was perceived by policy actors. Policy documents and 43 semi-structured interviews were thematically analysed. The analysis demonstrates how Uruguay's drug treaty obligations were less directly constraining to policy space compared to international finance norms, including the US Patriot Act, anti-money laundering standards and financial inclusion practices. Such norms exerted powerful influence over Uruguay's ability to implement aspects of cannabis supply that interact with broader financial systems, allowing banks to terminate business relationships with clients deemed as high risks for money laundering. The Uruguayan case suggests that financial regulations at diverse levels are likely to constrain policy space in other contexts where the market-based policies of cannabis regulation raise tensions with a narrowly constructed risk management principle in approaches to financial supply.

Does recreational cannabis legalization change cannabis use patterns? Evidence from secondary school students in Uruguay

BACKGROUND AND AIMS

In 2013, Uruguay became the first country to legalize and regulate the production and distribution of cannabis for recreational use. We measured whether Uruguay's non-commercial model of recreational cannabis legalization was associated with changes in the prevalence of risky and frequent cannabis use among secondary school students.

DESIGN

We used data from repeated cross-sectional surveys of secondary students in Uruguay and Chile (2007-2018). Using a difference-in-difference approach, we evaluated changes in the prevalence of past-year, past-month, any risky and frequent cannabis use following enactment (2014) and implementation (2016) of cannabis legalization among the full sample of secondary students and among students who reported past-year/month use. We examined changes separately for students ages 12 to 17, and students for whom cannabis became legally accessible, ages 18 to 21.

SETTING

Uruguay and Chile (2007-2018).

PARTICIPANTS

Secondary school students in 8th, 10th and 12th grade (n = 204 730).

MEASUREMENTS

Past-year and past-month cannabis use; any risky cannabis use measured with the Cannabis Abuse Screening Test (CAST); and frequent cannabis use (10+ days in the past-month).

FINDINGS

We found a decrease in past-year and past-month use following enactment or implementation. Among students ages 18 to 21, post-enactment, we observed a transitory increase in 2014 that decreased thereafter for: any risky use among those who reported past-year use (prevalence difference [PD] = 13.5%; 95% CI: 2.0, 24.9), frequent use in the full sample (PD = 4.5%; 95% CI: 1.0, 8.1), and frequent use among those who reported past-month use (PD = 16.8%; 95% CI: 1.9, 31.8).

CONCLUSION

The legalization of recreational cannabis in Uruguay was not associated with overall increases in either past-year/past-month cannabis use or with multi-year changes in any risky and frequent cannabis use among young people.

How High-Frequency Users Embraced Cannabis Regulation in Uruguay

How cannabis legalization affects users’ behaviors? In this paper, we describe changes in the way users access cannabis in Uruguay before and after the implementation of cannabis regulation. We explore the differences between users that access through the legal, black, and gray markets. To do so, we rely on two face-to-face surveys of high-frequency users using the Respondent Driven Sample technique. The first survey was conducted at the beginning of the regulation implementation in 2014, and the second one in 2017. Results indicate that cannabis users gradually moved to the legal market, and most switched to the gray market. Furthermore, users kept acquiring cannabis from the black market even when using legal mechanisms. Considering these results, we argue that the strict regulations imposed in Uruguay may have operated as barriers for consumers to abandon the black market completely. These findings show that the specifics of each legalization policy matter.

Trends in cannabis or cocaine-related dependence and alcohol/drug treatment in Argentina, Chile, and Uruguay

BACKGROUND

In the context of changing cannabis and other drug policy and regulation, concerns may arise regarding drug treatment access and use. We assessed cannabis/cocaine-related dependence and treatment in Argentina, Chile, and Uruguay.

METHODS

Nationally representative cross-sectional household surveys of people ages 15-64 in Argentina (4 surveys, 2006-2017), Chile (7 surveys, 2006-2018), and Uruguay (4 surveys, 2006-2018) were harmonized. We estimated weighted prevalences of cannabis or cocaine-related (cocaine or cocaine paste) dependence, based on meeting 3+ past-year ICD-10 dependence criteria. We estimated weighted prevalences of past-year alcohol/drug treatment use (Argentina, Chile) or use/seeking (Uruguay) among people with past-year cannabis/cocaine-related dependence. We tested model-based prevalence trends over time and described individual-level treatment correlates by country.

RESULTS

Cannabis/cocaine dependence prevalence increased in the region starting in 2010-2011, driven by cannabis dependence. Adjusted cannabis dependence prevalence increased from 0.7% in 2010 to 1.5% in 2017 in Argentina (aPD=0.8, 95% CI= 0.3, 1.2), from 0.8% in 2010 to 2.8% in 2018 in Chile (aPD=2.0, 95% CI= 1.4, 2.6), and from 1.4% in 2011 to 2.4% in 2018 in Uruguay (aPD=0.9, 95% CI= 0.2, 1.6). Cocaine-related dependence increased in Uruguay, decreased in Argentina, and remained stable in Chile. Among people with past-year cannabis/cocaine dependence, average alcohol/drug treatment use prevalence was 15.3% in Argentina and 6.0% in Chile, while treatment use/seeking was 14.7% in Uruguay. Alcohol/drug treatment prevalence was lower among people with cannabis dependence than cocaine-related dependence. Treatment correlates included older ages in all countries and male sex in Argentina only.

CONCLUSION

Alcohol/drug treatment use among people with cannabis/cocaine-related dependence remained low, signaling an ongoing treatment gap in the context of growing cannabis dependence prevalence in the region. Additional resources may be needed to increase treatment access and uptake. Future studies should assess contributors of low treatment use, including perceived need, stigma, and service availability.

Trends in the sequence of initiation of alcohol, tobacco, and marijuana use among adolescents in Argentina and Chile from 2001 to 2017

BACKGROUND

Variation in drug policies, norms, and substance use over time and across countries may affect the normative sequences of adolescent substance use initiation. We estimated relative and absolute time-varying associations between prior alcohol and tobacco use and adolescent marijuana initiation in Argentina and Chile. Relative measures quantify the magnitude of the associations, whereas absolute measures quantify excess risk.

METHODS

We analyzed repeated, cross-sectional survey data from the National Surveys on Drug Use Among Secondary School Students in Argentina (2001-2014) and Chile (2001-2017). Participants included 8th, 10th, and 12th grade students (N = 680,156). Linear regression models described trends over time in the average age of first use of alcohol, tobacco, and marijuana. Logistic regression models were used to estimate time-varying risk ratios and risk differences of the associations between prior alcohol and tobacco use and current-year marijuana initiation.

RESULTS

Average age of marijuana initiation increased and then decreased in Argentina and declined in Chile. In both countries, the relative associations between prior tobacco use and marijuana initiation weakened amid declining rates of tobacco use; e.g., in Argentina, the risk ratio was 19.9 (95% CI: 9.0-30.8) in 2001 and 11.6 (95% CI: 9.0-13.2) in 2014. The relative association between prior alcohol use and marijuana initiation weakened Chile, but not in Argentina. On the contrary, risk differences (RD) increased substantially across both relationships and countries, e.g., in Argentina, the RD for tobacco was 3% (95% CI: 0.02-0.03) in 2001 and 12% (95% CI: 0.11-0.13) in 2014.

CONCLUSION

Diverging trends in risk ratios and risk differences highlight the utility of examining multiple measures of association. Variation in the strength of the associations over time and place suggests the influence of environmental factors. Increasing risk differences indicate alcohol and tobacco use may be important targets for interventions to reduce adolescent marijuana use.

Assessing the impact of a cannabis course on pharmacy students' understanding, beliefs and preparedness regarding medical and recreational cannabis

Background

With the legalization of cannabis in Canada in 2018, pharmacists are increasingly likely to encounter patients using this substance. The primary objective of this pre-post questionnaire study was to evaluate the impact of an accredited cannabis course on the understanding, beliefs, perceptions and knowledge of undergraduate PharmD students.

Methods

A 38-question, web-based survey generated in REDCap was administered to third-year PharmD students at the University of Waterloo, prior to and right after taking an accredited cannabis course. The pre- and postsurvey data were analyzed using SPSS version 25. Pearson chi-square tests were performed on questions in which answers consisted of qualitative categorical data. Two-sided t tests were performed to test the significance of mean differences of questions measuring continuous variables.

Results

In a class of 120 students, 110 completed the presurvey and 79 students completed the postsurvey. After the course, students were more likely to report being knowledgeable and prepared for patient encounters dealing with medical and recreational cannabis, understanding that medical cannabis should be prescribed for select (vs all) medical conditions, rating the quality of evidence as poor to moderate for medical use of cannabis, understanding that medical documents should be more prescriptive and understanding that cannabis should not be sold in pharmacies (p < 0.05).

Interpretation

With cannabis education a part of their curriculum, pharmacy students felt more prepared to engage patients using cannabis both medically and recreationally. Furthermore, students were more cautious regarding the potential use of cannabis therapeutically and indicated that more oversight should be in place. Can Pharm J (Ott) 2021;154:xx-xx.

Changes in cannabis policy and prevalence of recreational cannabis use among adolescents and young adults in Europe-An interrupted time-series analysis

Background

Cannabis policy varies greatly across European countries, but evidence of how such policy impacts on recreational cannabis use among young people is conflicting. This study aimed to clarify this association by investigating how changes in cannabis legislation influenced cannabis use.

Methods

Available data on self-reports of recreational cannabis use among individuals aged 15–34 years was retrieved from EMCDDA. Information on cannabis policy changes was categorized as more lenient (decriminalisation or depenalisation) or stricter (criminalisation, penalisation). Countries that had implemented changes in cannabis legislation or had information on prevalence of use for at least eight calendar years, were eligible for inclusion. We used interrupted time-series linear models to investigate changes in country-specific trajectories of prevalence over calendar time and in relation to policy changes.

Results

Data from Belgium, Czech Republic, Germany, Italy, Netherlands, Norway, Portugal, Slovakia, Spain, Sweden and United Kingdom, for 1994–2017 was available for analyses. Cannabis use varied considerably over the study period and between countries. On average, use was stable or weakly increasing in countries where legislation was not changed or changed at the extremes of the study period (+0.08 percent per year [95% CI -0.01, 0.17 percent]). In contrast, the pooled average use decreased after changes in legislation, regardless of whether it had become more lenient (-0.22 [-1.21, 0.77]) or stricter (-0.44 [-0.91, 0.03]).

Conclusions

Our findings do not support any considerable impact of cannabis legislation on the prevalence of recreational cannabis use among youth and young adults in Europe.

Legalization of recreational cannabis: Facilitators and barriers to switching from an illegal to a legal source

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Limiting surveillance, quantity limits, and preserving anonymity is a facilitator.

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Competitive pricing from the illicit market and heavy regulation are barriers.

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Loyalty to current illicit suppliers is a barrier to switching to a licit market.

Illicit markets persist in places where recreational cannabis has been legalized. This study aimed to identify perceived facilitators/barriers of switching from an illicit to a licit cannabis source. Using a cross-sectional qualitative approach, 529 students, from one New Zealand university, completed a survey investigating the facilitators/barriers to switching through two open-ended questions. Perceived facilitators for switching included: safety (63.1%); price (42.7%); legal, no risk of convictions (35.3%); increased accessibility (32.3%); product diversity (14.2%). Perceived barriers included: price (66.4%); judgement (36%); regulation (28.9%); loyalty to current supplier (27.2%); reduced accessibility (13.2%). The findings provide recommendations for policies aimed at tipping people in favor of a licit over an illicit source. Avoiding arrest/convictions, and easier access, were not primary facilitators for switching. Thus, providing a licit market might be insufficient in the absence of other competitive factors, such as communicating improved product safety. Competitive pricing and regulation (tetrahydrocannabinol strength/quantity limits) were also barriers. Given legal markets aimed at minimizing harm are constrained with competing in these areas, it is significant that our findings identified other barriers which could be overcome, including limiting surveillance and quantity limits and positioning stores to preserve anonymity. The findings also highlight that loyalty to current illicit suppliers will be a significant barrier.

It is time for us all to embrace person-centred language for people in prison and people who were formerly in prison

The use of person-centred language is well accepted regarding substance use and infectious disease healthcare and research, and appropriate acronyms have become commonplace, e.g., "people who inject drugs (PWID)" has mostly replaced phrases like "injecting drugs users". However, the use of the term's 'prisoner' or 'prisoners' remains common. Although less common, terms such as 'offenders' and 'inmates' are also still used on occasion. This persists despite calls from people with lived experience of incarceration, and fellow academics, to stop using these terms. Given the considerable overlap between substance use, infectious diseases, and incarceration, in this commentary we discuss how they interact, including the stigma that is common to each. We propose that using person-centred language (i.e., people in prison or people formerly in prison) needs to become the default language used when presenting research related to people in prison or people formerly in prison. This is a much-needed step in efforts to overcome the continued stigma that people in prison face while incarcerated from prison officers and other employees, including healthcare providers. Likewise, overcoming stigma, including legalised discrimination, that follows people who were formerly in prison upon gaining their freedom is critical, as this impacts their health and related social determinants, including employment and housing.

A cross-national examination of cannabis protective behavioral strategies' role in the relationship between Big Five personality traits and cannabis outcomes

Background: Problematic cannabis use is common among young adults across the world. However, limited research has examined whether etiological models predicting negative consequences are universal.Objective: The present study examined whether the Five-Factor Model of personality (openness, conscientiousness, extraversion, agreeableness, and neuroticism) relates to cannabis outcomes via use of cannabis protective behavioral strategies (PBS) in a cross-national sample of college student cannabis users (i.e., used cannabis in the last 30 days).Method: Participants were 1175 university students (63.27% female) across five countries (United States, Argentina, Spain, Uruguay, and the Netherlands) recruited to complete an online survey.Results: PBS use mediated the associations between personality traits and cannabis consequences, such that higher conscientiousness (β = .20), agreeableness (β = .11), and lower emotional stability [i.e., higher neuroticism] (β = -.14) were associated with more PBS use. Higher PBS use was, in turn, associated with lower frequency of cannabis use (β = -.32); lower frequency of use was then associated with fewer cannabis consequences (β = .34). This sequential pathway was invariant across sex, but not countries. Notably, there were a number of differences in links between PBS and cannabis outcomes when comparing countries (e.g., negative associations in the US sample, but positive associations in the Argentina sample).Conclusions: Cannabis PBS mediates the relationship between personality traits and cannabis outcomes, but there are nuanced differences across countries (i.e., relationship between PBS and cannabis outcomes). Overall, students that are low in conscientiousness, agreeableness, and neuroticism and/or report low rates of PBS use may benefit from cannabis PBS-focused interventions that promote utilization of PBS.

Assessment of the impact of implementation of a zero blood alcohol concentration law in Uruguay on moderate/severe injury and fatal crashes: a quasi-experimental study

BACKGROUND AND AIMS

Debates regarding lowering the blood alcohol concentration (BAC) limit for drivers are intensifying in the United States and other countries, and the World Health Organization recommends that the limit for adults should be 0.05%. In January 2016, Uruguay implemented a law setting a zero BAC limit for all drivers. This study aimed to assess the effect of this policy on the frequency of moderate/severe injury and fatal traffic crashes.

DESIGN

A quasi-experimental study in which a synthetic control model was used with controls consisting of local areas in Chile as the counterfactual for outcomes in Uruguay, matched across population counts and pre-intervention period outcomes. Sensitivity analyses were also conducted.

SETTING

Uruguay and Chile.

CASES

Panel data with crash counts by outcome per locality-month (2013-2017).

INTERVENTION AND COMPARATOR

A zero blood alcohol concentration law implemented on 9 January 2016 in Uruguay, alongside a continued 0.03 g/dl BAC threshold in Chile.

MEASUREMENTS

Per-capita moderate/severe injury (i.e. moderate or severe), severe injury and fatal crashes (2013-2017).

FINDINGS

Our base synthetic control model results suggested a reduction in fatal crashes at 12 months [20.9%; P-value = 0.018, 95% confidence interval (CI) = -0.340, -0.061]. Moderate/severe injury crashes did not decrease significantly (10.2%, P = 0.312, 95% CI = -0.282, 0.075). The estimated effect at 24 months was smaller and with larger confidence intervals for fatal crashes (14%; P = 0.048, 95% CI = -0.246, -0.026) and largely unchanged for moderate/severe injury crashes (-9.4%, P = 0.302, 95% CI = -0.248, 0.058). Difference-in-differences analyses yielded similar results. As a sensitivity test, a synthetic control model relying on an inferior treatment-control match pre-intervention (measured by mean squared error) yielded similar-sized differences that were not statistically significant.

CONCLUSIONS

Implementation of a law setting a zero blood alcohol concentration threshold for all drivers in Uruguay appears to have resulted in a reduction in fatal crashes during the following 12 and 24 months.

Evolving Global Perspectives of Pharmacists: Dispensing Medical Cannabis

Introduction: Different countries have employed a variety of methods for their populace to access medical cannabis. Objectives: The purpose of this literature review was to assess the international literature on pharmacists' beliefs and attitudes towards medical cannabis. Methodology: This literature review summarized the various countries that utilize pharmacies and pharmacists to dispense medical cannabis. The countries included in this review were: Australia, Canada, Denmark, Finland, Germany, Israel, Italy, Netherlands, Poland, Serbia, Switzerland, USA, and Uruguay. Discussion: The pharmacist perspective has been of key importance within the medical landscape, as they are the ones who not only dispense medication but also counsel and monitor patients and it is this perspective that is lacking. Conclusion: Overall, this review found that even though pharmacists are generally comfortable with dispensing medical cannabis; they still require further education to do so as safely and effectively as possible.

Young and under the influence: A systematic literature review of the impact of cannabis on the driving performance of youth

BACKGROUND

Young drivers ages 15-24 continue to constitute a high-risk population for fatal motor vehicle collisions (MVCs) compared to all other age groups. Driving under the influence of cannabis is an important contributor to the high rates of MVCs among youth. Understanding the specific impact of cannabis on the driving performance outcomes of young drivers can inform injury prevention, education, and intervention strategies.

OBJECTIVES

This systematic literature review (SLR) aims to determine the Class (I- highest to IV-lowest) of evidence and level of confidence (A-high to U-insufficient) in the effects of cannabis on the driving performance of young drivers.

METHODS

Registered in PROSPERO (#CRD42020180541), this SLR searched seven data bases and appraised the quality and confidence in the evidence using an established research methodology.

RESULTS

Class II evidence suggests that THC is likely to reduce mean speed, headway distance, and reaction time; and increase lane and steering wheel position variability among young drivers (Level B, moderate confidence).

CONCLUSIONS

This study shows that there is a moderate to low level of confidence on the impact of cannabis on the specific driving performance outcomes of young drivers. A need remains for Class I and II studies that focus on the specific effects on young drivers, distinguish between the biological and socially constructed variables of sex and gender, and includes larger and more representative samples.

Implications of the 2018 Canadian Cannabis Act: Should regulation differ for medicinal and non-medicinal cannabis use?⋆

The regulatory framework for access to medical cannabis has been established in Canada since 2001, with the number of patients seeking access growing substantially over the years. With the novel enactment of the Cannabis Act in October 2018, Canada now maintains two distinct mechanisms for accessing cannabis - one for medical cannabis and the other for non-medical cannabis. With two regulatory access mechanisms in place, questions have arisen in the country as to the necessity of maintaining regulatory separation and the integrity of the medical access framework. A single framework would remove the gate-keeping function that the medical profession currently holds, streamlining processes and simplifying the current regulatory landscape. This approach has been advocated for by the Canadian Medical Association, despite objections from multiple stakeholders. Critical questions arise should the medical access framework be dissolved into a single, non medical-based regulatory framework. Insurance coverage, control mechanisms, market incentives, and patient obligations represent some examples of these issues. This paper will expand upon these considerations and highlight why maintaining two separate access mechanismss best serves the Canadian public. As medicinal cannabis continues to be liberated in international jurisdictions, this paper can help to illuminate the current status of medical cannabis in Canada, and provide insights to those from other countries on our current approach and domestic challenges.

Trends in marijuana use in two Latin American countries: an age, period and cohort study

BACKGROUND AND AIMS

Uruguay and Chile have the highest levels of marijuana use in Latin America, and have experienced consistent increases during the last two decades. We aim to calculate separate age-period-cohort (APC) effects for past-year marijuana use in Uruguay and Chile, which have similar epidemiologica, and demographic profiles but diverging paths in cannabis regulation.

DESIGN

APC study in which period and cohort effects were estimated as first derivative deviations from their linear age trend, separately by country and gender.

SETTING

Uruguay and Chile.

PARTICIPANTS

General population between 15 and 64 years.

MEASUREMENTS

Past-year marijuana use from household surveys with five repeated cross-sections between 2001 and 2018 in Uruguay (median n = 4616) and 13 between 1994 and 2018 in Chile (median n = 15 895).

FINDINGS

Marijuana use prevalence in both countries peaked at 20-24 years of age and increased consistently across calendar years. Period effects were strong and positive, indicating that increases in use were evident across age groups. Relative to 2006 (reference year), Chilean period effects were approximately 48% lower in 1994 and approximately four times higher in 2018; in Uruguay, these effects were approximately 56% lower in 2001 and almost quadrupled in 2018. We observed non-linear cohort effects in Chile and similar patterns in Uruguay for the overall sample and women. In both countries, marijuana use increased for cohorts born between the mid-1970s and early 1990s, even in the context of rising period effects. Prevalence was consistently larger for men, but period increases were stronger in women.

CONCLUSIONS

Age-period-cohort effects on past-year marijuana use appear to have been similar in Chile and Uruguay, decreasing with age and increasing over time at heterogeneous growth rates depending on gender and cohort. Current levels of marijuana use, including age and gender disparities, seem to be associated with recent common historical events in these two countries.

Controlled administration of cannabis to mitigate cannabis-attributable harm among recreational users: a quasi-experimental study in Germany

Background: New approaches are required to slow down or reverse increasing trends of levels of delta-9-tetrahydrocannabinol (THC) and cannabis-attributable hospitalizations in Germany. Legal access to cannabis may constitute one viable effective policy response; however, available evidence does not suffice to inform a regulation model for Germany. The proposed study aims to reduce harm for cannabis users through legal access to herbal cannabis through pharmacies.

Protocol: A quasi-experimental study comparing cannabis users with legal access to herbal cannabis (Berlin, intervention group) to those without legal access (Hamburg, control group) (total N=698). As the primary outcome, we hypothesize that: 1) illegal THC consumption will reduce by at least 50% in the intervention group and 2) total THC exposure in the intervention group will be reduced by at least 10% lower than that of the control group, taking into account baseline values. Secondary outcomes comprise measures of frequency of use, THC-impaired driving, and mode of administration. Paired t-tests and multilevel regression models will be performed for statistical analyses.

Discussion: This study proposal is currently being reviewed by the ‘Federal Institute for Drugs and Medical Devices’ – the body responsible for approving research studies on classified substances, including cannabis. Upon approval and prior to the start of the study, a full ethical review will be undertaken. Results may inform a regulation model for Germany and other jurisdictions and are expected to deepen the understanding of the effects of legal access to cannabis.

Pre-registration: German Clinical Trials Register (DRKS), DRKS00020829

The association between recreational cannabis commercialization and cannabis exposures reported to the US National Poison Data System

BACKGROUND AND AIMS

Recreational cannabis has been legalized in 11 states and District of Columbia (DC) in the United States. Among these, 10 states further permitted retail sale to provide a legal supply to adults. This study examined the associations of cannabis exposures with recreational cannabis legalization and commercialization.

DESIGN

Secondary data analysis of state-quarter level cannabis exposures during 2010-17 in the United States. Linear regressions with a difference-in-differences design were used to compare pre- and post-legalization trends in states that legalized recreational cannabis to contemporaneous trends in states that did not legalize recreational cannabis.

SETTING

United States, including all 50 states and DC.

CASES

Cannabis exposures reported to the US National Poison Data System.

MEASUREMENTS

The primary outcome was state age-adjusted cannabis exposures reported to the US National Poison Data System per 1 000 000 population per quarter. The two policy variables of interest included (1) the enactment of recreational cannabis legalization (i.e. removing penalties for adults' possession of cannabis in a small amount for recreational use) and (2) the initiation of recreational cannabis commercialization (i.e. providing a legal supply of cannabis to adults through licensed dispensaries).

FINDINGS

The association between a state's enactment of recreational cannabis legalization and its changes in cannabis exposures was statistically non-significant overall. After controlling for recreational cannabis legalization, however, the initiation of recreational cannabis commercialization was associated with 5.06-5.80 more exposures per 1 000 000 population per quarter (67-77% increase relative to the pre-legalization average), depending on the composition of comparison states. The increase associated with commercialization was higher among minors than adults (7.97-9.53 versus 3.83-4.21 more exposures), higher among males than females (6.16-7.56 versus 3.76-3.91 more exposures) and higher among exposures with medical consequences than those without medical consequences (4.09-4.79 versus 0.97-1.01 more exposures).

CONCLUSION

An increase in cannabis exposures reported to the US National Poison Data System was observed following recreational cannabis commercialization in the United States.

Facing the option for the legalisation of cannabis use and supply in New Zealand: An overview of relevant evidence, concepts and considerations

ISSUES

Non-medical cannabis policies are changing, including towards legalisation-with-regulation frameworks. New Zealand will hold a public referendum on cannabis legalisation in 2020. We reviewed data on cannabis use and health/social harms; policy reform options; experiences with and outcomes of reforms elsewhere; and other relevant considerations towards informing policy choices in the upcoming referendum.

APPROACH

Relevant epidemiological, health, social, criminal justice and policy studies and data were identified and comprehensively reviewed.

KEY FINDINGS

Cannabis use is common (including in New Zealand) and associated with risks for health and social harms, mainly concentrated in young users; key harms are attributable to criminalisation. 'Decriminalisation' reforms have produced ambivalent results. Existing cannabis legalisation frameworks vary considerably in main parameters. Legalisation offers some distinct advantages, for example regulated use, products and user education, yet outcomes depend on essential regulation parameters, including commercialisation, and policy ecologies. While major changes in use are not observed, legalisation experiences are inconclusive to date, including mixed health and social outcomes, with select harms increasing and resilient illegal markets. It is unclear whether legalisation reduces cannabis exposure or social harms (e.g. from enforcement) for youth.

IMPLICATIONS/CONCLUSIONS

No conclusive overall evidence on the outcomes of legalisation elsewhere exists, nor is evidence easily transferable to other settings. Legalisation offers direct social justice benefits for adults, yet overall public health impacts are uncertain. Legalisation may not categorically improve health or social outcomes for youth. Legalisation remains a well-intended, while experimental policy option towards more measured and sensible cannabis control and overall greater policy coherence, requiring close monitoring and possible adjustments depending on setting-specific outcomes.

Assessing the public health impact of cannabis legalization in Canada: core outcome indicators towards an 'index' for monitoring and evaluation

The legalization of non-medical cannabis use and supply is impending in Canada. This constitutes a major policy change with the declared objective of improving public health outcomes, which requires rigorous monitoring and evaluation. While numerous different aspects associated with legalization will be examined, a focused perspective is required for effective policy evaluation purposes. To these ends, we have identified a set of 10 core indicators associated with cannabis-related risk/harm outcomes-based on current best evidence-that are expected to measure the primary impacts of legalization on public health outcomes. We briefly review these indicators, and their respective data availability in Canada. As ideally an integrated outcome assessment of cannabis legalization's impact on public health will be available, we further propose options to merge the individual indicators into an integrated, weighted 'index', considering their expected relative impact for public health. One possible approach to undertake this is 'multi-criteria decision analysis' as a method to weight the relative indicator impact on public health; alternative approaches are proposed. The integrated 'public health index' for cannabis legalization will allow for scientifically comprehensive, while focused, monitoring and evaluation of the effects of legalization in Canada for the benefits of science and evidence-based policy alike.

Assessing the public health impacts of legalizing recreational cannabis use: the US experience

The sale of cannabis for adult recreational use has been made legal in nine US states since 2012, and nationally in Uruguay in 2013 and Canada in 2018. We review US research on the effects of legalization on cannabis use among adults and adolescents and on cannabis-related harms; the impact of legalizing adult recreational use on cannabis price, availability, potency and use; and regulatory policies that may increase or limit adverse effects of legalization. The legalization of recreational cannabis use in the US has substantially reduced the price of cannabis, increased its potency, and made cannabis more available to adult users. It appears to have increased the frequency of cannabis use among adults, but not so far among youth. It has also increased emergency department attendances and hospitalizations for some cannabis-related harms. The relatively modest effects on cannabis use to date probably reflect restrictions on the number and locations of retail cannabis outlets and the constraints on commercialization under a continued federal prohibition of cannabis. Future evaluations of legalization should monitor: cannabis sales volumes, prices and content of tetrahydrocannabinol; prevalence and frequency of cannabis use among adolescents and adults in household and high school surveys; car crash fatalities and injuries involving drivers who are cannabis-impaired; emergency department presentations related to cannabis; the demand for treatment of cannabis use disorders; and the prevalence of regular cannabis use among vulnerable young people in mental health services, schools and the criminal justice system. Governments that propose to legalize and regulate cannabis use need to fund research to monitor the impacts of these policy changes on public health, and take advantage of this research to develop ways of regulating can-nabis use that minimize adverse effects on public health.

The impact of cannabis legalization in Uruguay on adolescent cannabis use

BACKGROUND

In 2013, Uruguay became the first country in the world to legalize recreational cannabis, instituting a non-commercial state regulatory model of production and supply. This study provides the first empirical evidence on its impacts on adolescent use of cannabis and related risks.

METHODS

We use a generalization of the synthetic control method (SCM) to estimate the impact of legalization in Uruguay on adolescent past year and month cannabis use, perceived availability of cannabis and perceived risk of cannabis use. We compare biennial high school student self-reported survey data from Montevideo and regions in the interior of Uruguay post-legalization (2014-2018) and post initial implementation (2015-2018) to a synthetic counterfactual constructed using a weighted combination of 15 control regions in Chile.

RESULTS

We find no evidence of an impact on cannabis use or the perceived risk of use. We find an increase in student perception of cannabis availability (58% observed vs. 51% synthetic control) following legalization.

CONCLUSION

Our findings provide some support for the thesis that Uruguay's state regulatory approach to cannabis supply may minimize the impact of legalization on adolescent cannabis use. At the same time, our study period represents a period of transition: pharmacy access, by far the most popular means of access, was not available until the summer of 2017. Additional study will be important to assess the longer-term impacts of the fully implemented legalization regime on substance use outcomes.

Genome-wide DNA methylation analysis of heavy cannabis exposure in a New Zealand longitudinal cohort

Cannabis use is of increasing public health interest globally. Here we examined the effect of heavy cannabis use, with and without tobacco, on genome-wide DNA methylation in a longitudinal birth cohort (Christchurch Health and Development Study, CHDS). A total of 48 heavy cannabis users were selected from the CHDS cohort, on the basis of their adult exposure to cannabis and tobacco, and DNA methylation assessed from whole blood samples, collected at approximately age 28. Methylation in heavy cannabis users was assessed, relative to non-users (n = 48 controls) via the Illumina Infinium® MethylationEPIC BeadChip. We found the most differentially methylated sites in cannabis with tobacco users were in the AHRR and F2RL3 genes, replicating previous studies on the effects of tobacco. Cannabis-only users had no evidence of differential methylation in these genes, or at any other loci at the epigenome-wide significance level (P < 10^-7). However, there were 521 sites differentially methylated at P < 0.001 which were enriched for genes involved in neuronal signalling (glutamatergic synapse and long-term potentiation) and cardiomyopathy. Further, the most differentially methylated loci were associated with genes with reported roles in brain function (e.g. TMEM190, MUC3L, CDC20 and SP9). We conclude that the effects of cannabis use on the mature human blood methylome differ from, and are less pronounced than, the effects of tobacco use, and that larger sample sizes are required to investigate this further.

Cannabis Legalization and Acute Harm From High Potency Cannabis Products: A Narrative Review and Recommendations for Public Health

Legalization and commercial sale of non-medical cannabis has led to increasing diversity and potency of cannabis products. Some of the American states that were the first to legalize have seen rises in acute harms associated with cannabis use, e.g. Colorado has seen increases in emergency department visits for cannabis-related acute psychological distress and severe vomiting (hyperemesis), as well as a number of high-profile deaths related to ingestion of high doses of cannabis edibles. Over-ingestion of cannabis is related to multiple factors, including the sale of cannabis products with high levels of THC and consumers' confusion regarding labelling of cannabis products, which disproportionately impact new or inexperienced users. Based on our review of the literature, we propose three approaches to minimizing acute harms: early restriction of cannabis edibles and high-potency products; clear and consistent labelling that communicates dose/serving size and health risks; and implementation of robust data collection frameworks to monitor harms, broken down by cannabis product type (e.g. dose, potency, route of administration) and consumer characteristics (e.g. age, sex, gender, ethnicity). Ongoing data collection and monitoring of harms in jurisdictions that have existing legal cannabis laws will be vital to understanding the impact of cannabis legalization and maximizing public health benefits.

From prohibition to regulation: A comparative analysis of the emergence and related outcomes of new legal cannabis policy models (Colorado, Washington State and Uruguay)

An effective approach to drug regulation is a growing concern. Since 2012, 10 US States and Uruguay have taken the step to revoke prohibition and legalize the recreational cannabis market. Based on the findings from a study ('Cannalex') carried out in 2015-2017 in Colorado, Washington and Uruguay by the French Monitoring Centre for Drugs and Drug Addiction (OFDT) and the Institute of Security and Justice (INHESJ), relying on a hundred of in-depth interviews analyzed in line with the existing official statistics and studies, this paper shows heterogeneous policy-making models and contexts for reform. It also examines the early outcomes of the cannabis policy change. A mixed picture is emerging from the regulatory regimes currently implemented. This paper discusses the reform processes and their early outcomes, with a specific focus on the less documented area: the political processes that led to legalizing cannabis, analyzed with qualitative data. It argues that the different outcomes reported across Colorado, Washington and Uruguay are framed by the regulatory options that were taken, depending on specific dynamics of reform. The discussion focuses on some hot topics raised by the effective regulations, stressing that the array of cannabis regulatory options is a public debate that has just begun.

Using the pharmacy retail model to examine perceptions and biases of a UK population sample towards regulation of specific psychoactive drugs

Background:

Contemporary research indicates that the legal classifications of cannabis (Schedule 2, Class B), 3,4-methylenedioxymethamphetamine (MDMA) (Schedule 1, Class A) and psilocybin (Schedule 1, Class A) in the United Kingdom are not entirely based on considerations of harm and therapeutic utility. The legal classifications of the substances discussed are typically determined by legislators such as Parliament and, therefore, may be a reflection of the views or perceived views of the general public.

Objective:

The aim of the study was to provide an indication of the underlying psychology regarding the legislated sale of alcohol, tobacco, cannabis, MDMA and psilocybin in pharmacies according to a UK general population sample.

Methods:

A sample of 105 UK nationals was selected for the survey. Participants were asked questions on perceived relative harm of the five substances. After viewing contemporary information on reported relative harm and therapeutic applications, the participants were asked questions related to using the pharmacy retail model for the sale of the substances discussed. Participants who opposed the substances being sold primarily in pharmacies were asked to explain their rationale according to a predetermined list of options for each of the five drugs. Participants were also asked whether they consider it a human right to be legally permitted to consume the substances.

Results:

The participants' perceptions of relative harm (tobacco > MDMA > psilocybin > alcohol > cannabis) were not in agreement with the relative harm reported in the literature (alcohol > tobacco > cannabis > MDMA > psilocybin). Principal objections to the currently illicit substances being legally available in pharmacies include it sending the wrong message; it feels wrong; it is too dangerous; disliking the smell of cannabis; disapproval of the people; and not liking the idea of people using psychoactive drugs for entertainment or to have mystical/religious experiences. Overall, the participants determined that being legally permitted to consume the substances discussed is an issue of relevance to human rights. A majority of the male participants concluded that being legally permitted to consume alcohol, tobacco, cannabis and Psilocybe mushrooms is a human right in contrast to the majority of female participants who solely considered alcohol consumption to be a human right.

Conclusions:

The data suggest that the legal classifications may not simply be based on considerations of harm. Misperceptions of the dangers, biases and non-health-related aversions likely contribute to the continuation of policies that do not reflect the state of scientific research.

Trends In Substance Use And Related Disorders: Analysis of the Epidemiological Survey of Substance Abuse 1995 to 2018

BACKGROUND

Changes in the use of psychoactive substances and medications and in the occurrence of substance-related disorders enable assessment of the magni- tude of the anticipated negative consequences for the population.

METHODS

Trends were analyzed in the consumption of tobacco, alcohol, cannabis and other illegal drugs, analgesics, and hypnotics/sedatives, as well as trends in substance-related disorders, as coded according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The data were derived from nine waves of the German Epidemiological Survey of Substance Abuse (Epidemiologischer Sucht- survey, ESA) from 1995 to 2018. The data were collected in written form or by means of a combination of paper and internet-based questionnaires or telephone interviews.

RESULTS

The estimated prevalence rates of tobacco and alcohol consumption and the use of hypnotics/sedatives decreased over time. On the other hand, increasing prevalence rates were observed for the consumption of cannabis and other illegal drugs and the use of analgesics. The trends in substance-related disorders showed no statistically significant changes compared to the reference values for the year 2018, except for higher prevalence rates of nicotine dependence, alcohol abuse and dependence, analgesic dependence, and hypnotic/sedative dependence in the year 2012 only.

CONCLUSION

Trends in tobacco and alcohol consumption imply a future decline in the burden to society from the morbidity, mortality, and economic costs related to these substances. An opposite development in cannabis use cannot be excluded. No increase over time was seen in the prevalence of analgesic dependence, but the observed increase in the use of analgesics demands critical attention.

Investigating how perceived risk and availability of marijuana relate to marijuana use among adolescents in Argentina, Chile, and Uruguay over time

AIMS

Amid changing marijuana policies in the Southern Cone, we examined relationships between marijuana-related risk factors and marijuana use among adolescents in Argentina, Chile, and Uruguay from 2001 to 2016.

METHODS

Using cross-sectional surveys from 8^th, 10^th, and 12^th graders and weighted time-varying effect models, we estimated associations between perceived risk (no/low risk versus moderate/great risk) and perceived availability (easy/very easy versus difficult/very difficult/not able to obtain) of marijuana, and any past-month marijuana use.

RESULTS

In all countries, marijuana use increased over time and adolescents who perceived no/low risk and easy availability had higher odds of use. In Argentina, the bivariate risk/use association weakened from 2001 (OR = 15.24, 95%CI = 9.63, 24.12) to 2004 [OR = 3.86 (2.72, 5.48)] and strengthened until 2011 [OR = 8.22 (7.56, 10.30)]; the availability/use association strengthened from 2005 [OR = 5.32 (4.05, 6.98)] to 2009 [OR = 20.77 (15.57, 27.70)] and weakened until 2014 [OR = 11.00 (9.11, 13.27)]. In Chile, the risk/use association weakened from 2001 [OR = 7.22 (6.57, 7.95)] to 2015 [OR = 5.58 (4.82, 6.48)]; the availability/use association weakened from 2001 [OR = 5.92 (4.96, 7.06)] to 2015 [OR = 4.10 (3.15, 5.34)]. In Uruguay, the risk/use association weakened from 2003 [OR = 34.22 (22.76, 51.46)] to 2016 [OR = 6.23 (4.96, 7.83)]; the availability/use association weakened from 2005 [OR = 29.13 (13.39, 63.39) to 2007 [OR = 9.42 (3.85, 23.07)], and strengthened until 2016 [OR = 22.68 (12.03, 42.76)].

CONCLUSIONS

Overall, the association between risk and use weakened in all countries, suggesting risk perceptions became a weaker determinant of marijuana use. Perceived availability remained strongly associated with use and may become an increasingly important driver of use (particularly in Uruguay and Argentina).

Cannabis use in Switzerland 2015-2045: A population survey based model

BACKGROUND

Alternative cannabis regulation models are discussed and implemented worldwide. A baseline scenario under the assumption of no policy or market changes may prove useful to forecast cannabis use and treatment demand and evaluate changes in legislation.

METHODS

Based on data of the Continuous Rolling Survey of Addictive Behaviours and Related Risks on cannabis use, age, gender and nationality from 2011 to 2015, we used general estimating equation analysis to model lifetime and 30-days prevalence from 2015 to 2045 in Switzerland accounting for demographic trends.

RESULTS

Lifetime prevalence of cannabis use is projected to grow from 28.3% (CI 95% 27.8-28.8) in 2015 to 42.0% (CI 95% 41.0-43.0) in 2045. 30-days prevalence would increase slightly from 2.70% (CI 95% 2.53-2.88) to 3.39% (CI 95% 3.11-3.66). Due to population growth, absolute numbers with past 30-day cannabis use are estimated to increase from 202,784 (CI 95% 189,534-216,035) to 314,302 (CI 95% 288,504-340,100). Among those aged under 30 years no substantial change in lifetime and 30-days prevalence of cannabis use is projected. Larger changes are estimated to occur in the age group 30+. The mean age of past 30-day cannabis users would increase for men with Swiss nationality from 30.3 to 38.7 years.

DISCUSSION

Population-based survey data and demographic projections can be used to develop baseline scenarios of future cannabis use. Assuming no changes in cannabis legislation, growing absolute numbers of users will likely increase treatment demand. Cannabis use is estimated to increase among the group aged >30 years, which is currently underrepresented in clinical treatment and research. Our findings highlight the need for prospective baseline scenarios to evaluate the impact of legislative changes on cannabis use. Moreover, in Switzerland effective prevention and treatment interventions for cannabis use disorders are required even if cannabis legislation remains unchanged.

The effect of cannabis exposure on pubertal outcomes: a systematic review

Purpose

Several countries are legalizing the use of medicinal cannabis and easing restrictions on its recreational use. While adults have been the primary target of these initiatives, expanding access to cannabis will likely lead to increased use by children. While the effects of cannabis on pediatric neuropsychological and mental health outcomes have been broadly studied, there are limited data on the physical health effects of cannabis, including endocrine health. Animal studies have shown that chronic cannabis use leads to delayed sexual maturation; however, its effects on pubertal outcomes in children are not well studied. This systematic review aimed to assess the effect of cannabis use on pubertal timing and tempo in children.

Methods

We conducted a systematic review with literature searches in MEDLINE, Embase, Cochrane Database of Systematic Reviews, Central, PsycINFO, CINAHL, Web of Science, and SPORTDiscus from inception to February 2018. A gray literature search was also completed in Clinicaltrials.gov and ProQuest Dissertations and Theses A&I. The primary outcome was pubertal timing, while secondary outcomes included pubertal tempo and final height and weight. We had no restrictions on date or language of publication of papers. Two reviewers independently assessed records for eligibility, with a third reviewer resolving disagreements.

Results

Our database and gray literature searches identified 759 records. A total of 29 full-text papers were assessed for eligibility. However, all studies were ultimately excluded as they did not meet the eligibility criteria.

Conclusion

Our results highlight a significant gap in existing literature regarding the effects of cannabis use on puberty. Adequately powered longitudinal studies are urgently needed to provide pediatricians and other health care providers with high-quality information on the potential effects of cannabis on the physical health of children.

Prospective Registrar of Systematic Reviews Registration

PROSPERO no.: CRD42018089397.

Cannabis decriminalization: A study of recent policy change in five U.S. states

BACKGROUND

A number of public health professional organizations support the decriminalization of cannabis due to adverse effects of cannabis-related arrests and legal consequences, particularly on youth. We sought to examine the associations between cannabis decriminalization and both arrests and youth cannabis use in five states that passed decriminalization measures between the years 2008 and 2014: Massachusetts (decriminalized in 2008), Connecticut (2011), Rhode Island (2013), Vermont (2013), and Maryland (2014).

METHODS

Data on cannabis possession arrests were obtained from federal crime statistics; data on cannabis use were obtained from state Youth Risk Behavior Survey (YRBS) surveys, years 2007-2015. Using a "difference in difference" regression framework, we contrasted trends in decriminalization states with those from states that did not adopt major policy changes during the observation period.

RESULTS

Decriminalization was associated with a 75% reduction in the rate of drug-related arrests for youth (95% CI: 44%, 89%) with similar effects observed for adult arrests. Decriminalization was not associated with any increase in the past-30 day prevalence of cannabis use overall (relative change=-0.2%; 95% CI: -4.5%, 4.3%) or in any of the individual decriminalization states.

CONCLUSIONS

Decriminalization of cannabis in Massachusetts, Connecticut, Rhode Island, Vermont, and Maryland resulted in large decreases in cannabis possession arrests for both youth and adults, suggesting that the policy change had its intended consequence. Our analysis did not find any increase in the prevalence of youth cannabis use during the observation period.

Cannabis Use and Supply Patterns Among Belgian Cannabis Social Club Members

Cannabis Social Clubs (CSCs) constitute a noncommercial model for the supply of cannabis among registered, adults users, which is present in several countries—including in Belgium. This analysis provides a first descriptive examination of a sample of Belgian CSC members’ patterns of use and supply, as well as their sociodemographic features. According to a new voluntary survey of 190 Belgian CSC members, more than three quarters are male, Belgian, and more than half work full- or part-time. About 44% of respondents have completed university studies. Securing cannabis was the primary reason to adhere to a CSC, and most are (near-)daily users. Our results revealed that the CSC was the sole supplier for most respondents of cannabis-producing CSCs, who obtained almost exclusively (dried) herbal cannabis. The presence of (self-declared) medical users in our sample is noteworthy. This analysis advances our knowledge of the segment of the market served by this noncommercial model.

The trajectories of cannabis and tobacco policies in the United States, Uruguay, Canada and Portugal: is more cross-substance learning possible outside the United States?

Commentary to: The diverging trajectories of cannabis and tobacco policies in the United States: reasons and possible implications