Black Sheep

3. Turning on the Light

 

Supporting problematic cannabis use requires a two stage approach: reforming existing public health measures to appropriately prioritise the needs of problematic cannabis users and the introduction of a regulatory framework that links these public health measures to their intended audience.

 

More research is needed to investigate the social costs of cannabis.

Prioritisation

Since the dissolution of the National Treatment Agency, commissioners have been given more freedom to mould public services around the needs of the Local Authority and purchase services which cater to those needs. As 21% of clients are citing cannabis as a problematic substance,1 commissioners have a responsibility to commission services which are attentive to those needs. Moreover, as cannabis is most commonly consumed with tobacco, commissioners cannot draw providers attention to smoking cessation without also focusing on cannabis, unless they choose to wilfully ignore cannabis consumption. Some Local Authorities are already recommending that smoking cessation and cannabis treatment should be considered as joint initiatives2 and the EMCDDA has advised a synergy between cannabis control and tobacco control policies.3 FWD, a young people’s drug and alcohol service in Camden, highlighted that they will use smoking cessation as an entry point for initiating conversations about cannabis.

To ensure that cannabis is appropriately prioritised, more research is needed to investigate the social costs of cannabis, as has been done for heroin, crack cocaine and alcohol. Current publications which explain why commissioners should invest in drug and alcohol treatment make no reference to cannabis.4

With commissioner prioritisation of problematic cannabis use, would come an incentive for drug and alcohol providers to pay greater attention to problematic cannabis use, challenge perceptions that cannabis cannot be a problematic substance, and make better use of existing resources.

Providers would also be incentivised to innovate and improve cannabis interventions to stay competitive in the market. The EMCDDA have highlighted that digital interventions are a promising area for further development,5 with a review from Hoch et al. concluding that digital interventions can effectively reduce problematic cannabis use and can be used as a resource to overcome barriers to treatment.6

A concern raised by some contributors was providers not sharing innovation, in a bid to remain competitive in the market.

“One provider is not going to approach another with an amazing group intervention, they’ll want to keep it secret to keep themselves competitive.”

This concern was not shared by other contributors, including providers, who asserted that any learning and innovation which benefited service users would always be made publicly available. Whether or not information sharing is a concern, the chances of useful learning being confined to small pockets of services has declined owing to a greater practice of large scale commissioning under one service provider. For example, Change, Grow, Live (CGL) is contracted to deliver all drug and alcohol services in Birmingham.7

While utilisation of the competitive market may risk untended consequences, if there is purchaser expectation that services should meet the needs of problematic cannabis users, providers have an incentive to innovatively supply services which meet this need.

Holistic Provision and Promotion

No Wrong Door

Supporting problematic cannabis users requires a transition away from the traditional treatment centre model, where clients would expect to access a specifically ‘drug’ treatment service and the treatment centre is the only place they could go to receive that support.

 

Many people will not need to enter formal treatment to overcome their problematic use of cannabis and should be able to receive brief, informal interventions from non-substance specific community services. If a problematic cannabis user is presenting to a mental health service, their primary need may be mental health and it may be more appropriate for their key worker to offer low level support around cannabis rather than refer them to a treatment centre. A GP may be in the best position to offer holistic brief interventions as they can support the person around a range of needs and will likely be the first point of contact.

“It can be better for a GP to support in house rather than refer to a specialist.”

The EMCDDA offers a case study of how more holistic service provision is being offered in Finland:

‘In addition to the units providing specialised services for those with substance use problems, increasing numbers are treated within primary social and healthcare services, including social welfare offices, child welfare services, mental health clinics, health centre clinics, hospitals and psychiatric hospitals.’8

We want to empower other professional agencies so any service can respond to cannabis.

An initiative which started in North Yorkshire children’s services was for there to be a ‘no wrong door’ policy, where a range of support was brought under one umbrella.9 Under the ethos of ‘no wrong door’, Change, Grow, Live (CGL) and the West Lothian Drug and Alcohol service have implemented outreach programmes to train other professional agencies to deliver initial interventions relating to cannabis, thus diversifying and dispersing skills sets.

“We want to empower other professional agencies so any service can respond to cannabis.”

Drug and alcohol service provider Forward Leeds and mental health service Aspire have also both signed up to the Leeds Dual Diagnosis project. The project offers access to training and networking events, where mental health workers can become skilled in offering interventions relating to cannabis and drug and alcohol workers can become skilled in delivering mental health interventions.

A wider use of ‘no wrong door’ would aim to enhance professionals’ confidence in delivering low-level interventions and increase the amount of people interacting with support and guidance.  Public Health England are soon to release a briefing on brief psychosocial interventions for problematic cannabis use which will better support professionals’ deliverance of brief interventions.

There is the concern that even after receiving training, professionals will not deliver brief cannabis interventions as it is not considered part of their ‘core business’. For example, despite significant attention being given to alcohol Identification and Brief Advice (IBA), the extent of effective routine implementation has been questionable.10 A response to this implementation barrier has been the planned adoption of CQUIN contracts within primary care services, where a percentage of the total value of an NHS contract with a provider will be allocated in accordance of the sufficient delivery of a specified activity.11 If this measure effectively moves people away from ‘core business’ thinking, it may be policy which can be appropriately transferred to brief interventions relating to cannabis.

Marketing

For those who require more formal treatment, contributors reported that clients would prefer to receive support from specialist cannabis services rather than present to existing general treatment centres. However, there is no evidence that specialist services produce better outcomes than general treatment.12

There has been a trend towards providers offering support which targets support towards the behaviour, rather than the drug,13 with all drug and alcohol service providers contributing to this report highlighting that they are offering support which is grounded in building resilience and positive coping mechanisms.

Any support centre should look at the whole person and why they are using drugs.

Rather than syphon problematic cannabis users into separate services, providers would be best placed to ensure their marketing reflects the holistic service provision which is being offered. Turning Point advised that a move towards ‘hiding in plain sight’, where marketing language is grounded in skills sharing, resilience, wellbeing and positive coping mechanisms, and away from directly referring to substances, would challenge the perception that treatment centres are only places for people seeking support for opiates and crack cocaine, and lessen the attached stigma of attending a treatment centre. Excluding the 16 who skipped the question, half of the survey respondents agreed that they would be more likely to attend a treatment centre if it was advertised that they would receive support around a range of needs rather than just drug use.

“I would prefer a more general approach to my health, then to specifically focus on cannabis use.”

“Any support centre should look at the whole person and why they are using drugs.”

By moving beyond the constraints of the traditional treatment centre model, a public health response can be adopted which interacts and engages with a broader range of people.

Move Towards an Appropriately Regulated Market

A move towards a regulated market would offer a targeted dialogue with people experiencing problematic cannabis use, providing opportunities for harm reduction advice to be delivered at point of purchase and any person in need of support relating to their cannabis use to be linked into reformed public health measures. There would also be the emergence of wider opportunities for more public guidance, packaging controls, products which vary in potency, and research into cannabis culture and consumption to improve interventions.

I think advice from a professional is far better than advice from a dealer.

Targeted Interventions

Similar to initiatives such as the needle exchange, points of purchase would offer opportunities for harm reduction advice and support services to be directly targeted to their intended audience.

However, direct comparisons should not be made between the former and the latter. Needle exchange programmes rely on service users not being criminalised so that they may offer them services which mitigate against high risk harms like blood borne viruses.  Decriminalisation would not offer this same opportunity for cannabis use because common problems associated with cannabis do not pose an immediate or acute risk which needs to be mitigated against.

A regulated market is the most effective model because the purchase of cannabis offers an incentive for consumers to interact with guidance and different public health measures, with those who consume the most having the most interaction. When respondents to Volteface’s survey on problematic cannabis use were asked if they thought cannabis should be regulated so that it can be sold legally, 12 skipped the question, 3 were undecided and 26 agreed. No respondents disapproved of cannabis being a regulated substance.

“I think advice from a professional is far better than advice from a dealer.”

“I believe the policy of prohibition is more harmful than any drug or use of them.”

Regulatory public health models have been published that envision how a public health framework would be adopted if cannabis became a regulated substance. Transform’s framework for the regulation of cannabis has laid out mandatory, enforced, responsible vendor guidelines which ensure vendors act as gatekeepers to a controlled substance and deliver public health interventions and education during the customer interaction period.14 Volteface’s report on the online regulation of cannabis expands on this blueprint by mapping out a framework of age restrictions, health questionnaires, limits on users’ monthly purchase, and helplines and chatbots to direct those who felt their use was becoming problematic to local support services.15

When respondents to Volteface’s survey were asked if they would have managed their cannabis use better if advice and information had been available on point of purchase, 12 skipped the question, 3 were undecided, 18 approved of the initiative, with the remaining 8 feeling they did not want or need guidance, they would have preferred more choice instead, or that the advice would not have made a difference.

There is research from Burton et al.,16 who after undertaking a rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies, concluded that providing information and education does not produce sustained behavioural changes. However, due to contextual reasons, direct comparisons between alcohol and cannabis should be undertaken cautiously. Firstly, Burton et al. clarified that any attempts to inform or educate may have been overshadowed by marketing from the alcohol industry. Comparisons may not apply, as Transform have highlighted that ‘cannabis regulation offers a unique opportunity to build a regulated market model from the start, making decisions in the public interest’ and ensuring the mistakes from the past are not repeated.17 Secondly, the normalised and benign image of cannabis among regular users, reported by practitioners and survey respondents,18 indicates there is a need for more information on the harms that cannabis can pose and how they can be managed.  Thirdly, it is challenging to measure the effectiveness of an intervention in isolation when considering Michie, Atkins and West’s theory that behaviour change is a complex process that depends on interactions between necessary conditions for change: capability, motivation and opportunity.19

Wider Opportunities

The first of these wider opportunities is that regulation increases attention relating to cannabis and encourage more balanced, accessible, quality resources to be made available to the public. Volteface’s survey respondents highlighted that more guidance would only be useful if it was driven by evidence and suggested that useful guidance would be to avoid mixing tobacco with joints and consuming cannabis which is low in CBD and high in THC, recommendations which have been approved by established or emerging literature.20

There are also greater opportunities for consumers making informed purchases relating to strength and content and being able to chose from a broader range of greater quality products.21 Survey respondents highlighted concerns that ‘street’ cannabis is highly potent yet there is often little else to choose from.

“Do you think customers should buy super strength skunk made on the streets or organically, safely grown cannabis with varying strengths, allowing the consumer to make a healthy choice?”

Curran et al. have recommended that ‘if handled carefully from a harm‑reduction standpoint, a regulated market might…inform accurately about dosage and increase the availability of more balanced cannabis (that is, with lower levels of Δ9‑THC and higher levels of CBD) to maintain desired effects while reducing the incidence of harms’.22

A regulated market would also aim to reduce the stigma surrounding cannabis consumption by removing the association with criminality. The social stigma that can be attached to cannabis was a reason why some people were reluctant to access support from professionals.

Finally, the emergence of new points of contact with cannabis users could be used as opportunities for research into cannabis culture and consumption, thus improving the quality of interventions. Contributors highlighted that the current legal state of cannabis has limited how much research has been undertaken into brief interventions.

Illegal growers only ‘care for quantity and profit.’

Regulation Concerns

Within the context of the regulation of cannabis, there is the concern that ‘the increased availability that will accompany a regulated market, will lead to increased use and increased harm amongst those least able to cope’.23 These concerns are grounded in alcohol and tobacco being legal substances which have the highest consumption among those in lower socioeconomic groups and those who are experiencing a mental health illness.24  Moreover, as problematic consumers are likely to be heavy users there would be an incentive for firms to target their product towards problematic users.25

Yet in the current illegal market, there is already a high consumption of cannabis among certain disadvantaged groups,26 who criminal individuals and organisations have an incentive to target. One survey respondent highlighted that illegal growers only ‘care for quantity and profit.’ The difference between cannabis and regulated substances such as alcohol and tobacco,  is that there is not a targeted public health infrastructure in place which regulates supply and purchasing.

There is also international evidence from regulatory models which suggests that increased consumption need not inevitably lead to increased harm. When considering cannabis regulation in Vermont, Caulkins et al.27 state that in most cases the likelihood is that use will rise if sanctions are lifted, but this does not equate to harm and should not be a benchmark of policy failure.

Compton et al.’s 2002-2014 analysis of annual cross sectional surveys highlighted that though consumption has increased across the US, cannabis use disorders have remained relatively stable among adults in the general population and have even decreased among regular users of cannabis.28 Hasin et al’s analysis of two nationally representative samples found similar results, with the prevalence of cannabis use disorder among cannabis users decreasing significantly from 2001-2002 to 2012-2013.29 This data should however be treated cautiously, as the reports were not able to assess the impact of state level regulatory cannabis laws.

When considering regulation we should be cautious; of course a move towards a regulated market poses risks, and it would negligent to claim otherwise but it is worth considering that ‘our relationship with risk is frequently restrictive, driven more by the fear of getting things wrong. While this approach is a rational response…. it denies us many positive opportunities’.30 Certain groups who are least well served by the current system have the most to gain from an appropriately regulated market, regulation is a risk which needs to be taken.