- Black Sheep
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Black Sheep: An Investigation into Existing Support for Problematic Cannabis Use
- It has been estimated that 2.6% of the adult population (aged 16 or over) showed signs of cannabis dependence, which is up to 1,150,000 people, though it is expected that the actual number of people who meet the threshold for clinical dependence will be far lower
- 21% of adults going through treatment are citing cannabis as a problematic substance
- 79.7% of adults listing cannabis as a problematic substance are entering treatment voluntarily
- New presentations among adults for cannabis treatment increased by 55.2% between 2005-2014
- Among adult non-opiate clients accessing treatment, cannabis users were the most likely to have unchanged use at the 6 month review, which equates to 42% of those who entered treatment
- Among people showing signs of cannabis dependence, only 14.6% had ever received treatment, help or support specifically because of their drug use, and 5.5% had received this in the past six months
Cannabis is a neglected drug in public health discourses, a reality which is at odds with the growing number of people in England who are now seeking support for problematic cannabis use. The disparity of how cannabis is prioritised by drug and alcohol service providers, wider community services, local authority commissioners and public health bodies has limited the amount of support available and impeded quality.
- Among people experiencing problematic cannabis use, there is a perception that their needs will not be effectively met at treatment centres.
- Some drug and alcohol service providers and commissioners are being attentive to cannabis but overall, cannabis has not been appropriately prioritised.
- One to one interventions relating to cannabis are mostly confined to drug and alcohol treatment centres. Wider community services reported that they do not have the capacity or the ability to offer brief, initial interventions.
- There are limited amounts of public resources available, some of which are lacking in levels of quality and accessibility.
A wider structural barrier is that the sector does not have a clear strategy for linking people experiencing problematic cannabis use into support and guidance. With the current illegal and unregulated market reducing the visibility of cannabis use, practitioners reported that ‘we’re just fumbling around in the dark trying to find them’.
Responsibility for change does not just fall to drug and alcohol service providers, and a unified, multi-faceted approach is needed. Evidence of good practice within the sector and contributions from stakeholders and experts has been used to formulate sensible, innovative policy options tailored to the needs of people experiencing problematic cannabis use.
- Research into the social costs of problematic cannabis use by Public Health England would provide justification for commissioners to appropriately prioritise cannabis within treatment. Commissioner specification of cannabis would incentivise providers to utilise existing resources and supply innovations targeted towards people experiencing problematic cannabis use.
- A shift towards holistic service provision and promotion by drug and alcohol service providers and wider community services, would aim to increase interaction and engagement with support.
- 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 persons 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, research into cannabis culture and consumption to improve interventions, and reduced stigma to enable access to services.
Effective support requires public health measures which appropriately prioritise the needs of people experiencing problematic cannabis use and a regulated market which targets these measures to their intended audience.
2.6% of the adult population (aged 16 or over) showed signs of cannabis dependence.
It should be emphasised that cannabis is not as dangerous as many other drugs,1 with treatment centres historically focusing on opiates and crack cocaine which have higher associated harms.2 As with many other substances with a potential for dependence and misuse, most people do not develop a problematic relationship with their cannabis use,3 but for a proportion of people, usage can become problematic and may stop them from living meaningful and fulfilling lives. It is these people who are the focus of this report.4
The most recent Adult Psychiatric Morbidity Survey has estimated that 2.6% of the adult population (aged 16 or over) showed signs of cannabis dependence,5 which is estimated to be up to 1,150,000 people.6 Caution should be taken with this figure, however, as the Adult Psychiatric Morbidity Survey defines signs of dependence as responding positively to any one of the five criteria for dependence it lists. The survey notes that responding to three or more of these criteria is closer to the threshold for drug dependence defined in ICD-10. Volteface have issued a Freedom of Information request to establish the figure corresponding to this tighter definition of dependence from the Adult Psychiatric Morbidity Survey, which is expected to be substantially lower than the survey’s definition for signs of dependence. The 2015 England and Wales Crime Survey estimates 3.7% of 16-59 year olds in England and Wales are frequent cannabis users, which corresponds to 800,000 people, and only a subset of these will fit ICD-10 criteria for cannabis dependence.7 This gives an indication of the smaller number of people likely to fit a tighter definition of cannabis dependence.
Explaining Problematic Cannabis Use
The most The International Statistical Classification of Diseases and Related Health Problems provide widely used clinical definitions of cannabis use disorders and cannabis withdrawal which have been integrated into the diagnostic criteria for substance misuse (DSM-5).8 However, problematic cannabis use can be more widely defined as ‘use leading to negative consequences on a social or health level, both for the individual user and for the larger community’,9 with various other concepts encompassed within it such as misuse, abuse, and dependence.10
The guide on the assessment and management of problematic cannabis use in primary care by Winstock et al.11 highlights that the patient will likely be a long term, heavy daily user, who may experience:
- Respiratory problems, such as exacerbation of asthma, chronic obstructive airways disease, wheeze or prolonged cough, or other chest symptoms
- Mental health symptoms, such as anxiety, depression, paranoia, panic, depersonalisation, exacerbation of an underlying mental health condition
- Problems with concentration while studying or with employment and relationships
- Difficulties stopping cannabis use
- Legal or employment problems (arising from use of cannabis)
The exacerbation of schizophrenia,12 has been the most widely reported adverse effect of cannabis but less attention has been paid to the less severe mental health problems associated with problematic cannabis use, such as anxiety and depression, which are far more common.13
Taylor et al. have also concluded that after controlling for tobacco, ‘significant respiratory symptoms and changes in spirometry occur in cannabis-dependent individuals at age 21 years, even though the cannabis smoking history is of relatively short duration’.14 The physical health impacts then become more pronounced when considering that the majority of cannabis users consume cannabis with tobacco.15
The are also wider social difficulties associated with problematic cannabis use, with international evidence cautiously indicating that people who are dependent on cannabis are also at greater risk of downward social mobility and financial difficulties when compared to those who use cannabis but are not dependent. The NZ Dunedin Longitudinal Study16 studied participants from birth to age 38 and found that those with regular cannabis use and persistent dependence experienced downward socioeconomic mobility, more financial difficulties, workplace problems, and relationship conflict in early midlife. It should be noted that this finding was modelled on a small sub-sample as only 23 participants were assessed as being dependent at all study waves.
All drug taking has risk and cannabis is no different.
“For me drugs are all about how a person is brought up. Growing up my parents didn’t set boundaries and they didn’t educate me to build resilience needed for adulthood. So, like many other of my mates I got drunk for the first time when I was 12, and smoked cannabis at the age of 13.
I was smoking cannabis during my time at the navy as there was plenty of trips ashore where you would be able to smoke, but it was just recreational. It wasn’t really till I left the navy that I became a habitual smoker but I would never have considered it a problem, it was just part of the smoking culture.
But it was having a problem on my life. I was smoking and inhaling for longer so in terms of my health it was having an effect and I knew the quantities I was using wasn’t good.
I was using cannabis to calm down the other drugs I was taking and I was blocking out the negative consequences of those drugs. It became a substance within all those other substances I had to deal with.
Your life revolves around getting up in the morning and playing cards and having a big spliff with your flatmate. There are other people that can wake up in the morning and take a spliff, but that didn’t work for me. All drug taking has risk and cannabis is no different.”
Rising Demand for Treatment
Between 2005-2014, new treatment presentations where cannabis was the primary drug of use have increased by 55.2% (see Figure 1.1).17
Figure 1.1 New cannabis treatment presentations in England from 2005 to 2014.
There has been no clear agreement on why cannabis referrals have increased in recent years, and though many reasons have been espoused, none have been fully substantiated. Firstly, there is the ‘build it and they shall come’ explanation, with the argument that additional funding given under the Blair government and a declining number of opiate users in treatment has allowed services to accept more referrals for people experiencing problematic cannabis use.
However, though there was substantial funding given during the Blair government, the rise in referrals continued despite subsequent reductions in funding for cannabis related treatment. Moreover, even though there are fewer opiate users entering treatment, the ageing heroin cohort have higher levels of complexities and require more resource and innovation from services to engage in treatment.18
The second commonly cited argument is that high potency cannabis use is associated with increased incidences of harm,19 with a correlation emerging between prevalence of high potency cannabis and numbers in treatment, as illustrated by Figure 1.2.20 However, this evidence is not conclusive as there have only been three recorded data points on cannabis potency,21 and criticisms have been made of the data collection practices.22
Figure 1.2 Prevalence of high potency cannabis and number of adults in cannabis treatment over time.
79.7% of adults listing cannabis as a problematic substance are entering treatment voluntarily.
What is known is that the 79.7% of adults listing cannabis as a problematic substance are entering treatment voluntarily. An FOI request showed that among the clients who cited cannabis as a problematic substance, the majority of referrals came from the client, family and friends,23 with recently released statistics from the National Drug Treatment Monitoring System also confirming that non-opiate users were most likely to enter treatment voluntarily.24
It is worth considering that the proportion of self referrals may be over estimated, as contributors reported that some clients may have been told by probation that they must seek treatment or other action would be taken. However, it was also noted that this example would only reflect a very small number of cases and it was rare for services to receive a referral for non-problematic use. Furthermore, a combined referral source of self, family, and friends does leave unanswered the question of whether significant numbers of clients are coerced by family or friends. While it is possible that some clients are being pressured into treatment, the client group are adults who are ultimately free to make their own decisions. Moreover, even if a person were coerced into treatment, this does not mean that there is no problem, nor that meaningful work cannot take place.
Proportion of Client Group
Though the increase in clients citing cannabis as a problematic substance is worthy of further investigation, the data which is perhaps of most interest is simply the proportion of people who are citing cannabis as a problematic substance in treatment centres. NDTMS data shows that cannabis accounts for 21% of all problematic substances cited in treatment centres (Public Health England et al, 2016).25 Contributors highlighted that many clients will be citing other substances such as alcohol, opiates, or crack cocaine, and their cannabis use (even though deemed problematic) might be incidental to them being in treatment. Even though cannabis may not be the primary need for many clients, it is being cited as a problematic substance by a significant proportion of clients and should not be disregarded even if it is a secondary need.
This paper will examine the public health response to cannabis and identify the barriers and opportunities for effective support.
Volteface undertook unstructured interviews with a broad range of stakeholders and experts to better understand the public health response these trends. Interviewees were asked how current public health measures were engaging people experiencing problem cannabis use and whether the measures were addressing the full spectrum of need. This paper reports on the key themes emerging from these discussions and consultations. Interviewees were selected through Volteface’s network of contacts, including stakeholders who were not engaged with drug policy reform. A limitation to the research is that drug and alcohol service providers are operating in a competitive market and may have been reluctant to disclose information which could be viewed negatively by their commissioners or risk their reputation. To encourage interviewees to speak candidly, contributions have not been attributed to individual persons. Providers who offered specific examples of good practice have been named to enable information sharing within the sector.
After conducting an initial consultation with professionals and identifying key themes, a public survey of open questions was launched, asking people who had experienced a problematic relationship with cannabis, for their opinion on the validity of these findings. The survey received 41 responses.26
Drawing from these consultations and wider literature, this paper will examine the public health response to cannabis and identify the barriers and opportunities for effective support. Stakeholders who we believe will find this report useful include drug and alcohol service providers, commissioners, GPs, Public Health England, the Home Office, the Department of Health and the ACMD, with different sections of the report relevant for different audiences. The conclusions of this report are not intended as guidelines for clinicians but rather aim to highlight policies which would improve the public health response to problematic cannabis use. Though wider structural problems, such as cuts to service provision, do impede effective support, only findings which specifically relate to cannabis will be included in the paper. The first section will address how well the current system engages and supports adults experiencing problematic cannabis use, whilst the second section will make practical policy recommendations.
- Black Sheep
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