Street Lottery

1. Reframing Mental Health

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Chapters

A Combination of Confusion

Cannabis is a complex substance capable of inducing a vast spectrum of experiences, from enjoyable euphoria to distressing anxiety. This complexity is exacerbated when the impact it can have on someone’s mental health is considered. ‘Mental health’ might be a term we think we all understand, but, just like cannabis, it is far more complicated than many would imagine. Unfortunately, many people, consumers of cannabis included, see mental health as something that is ‘black and white’ – you either have a mental health problem or you are okay. The debate around cannabis can, at times, fall into the same trap – cannabis is seen as either safe or causing psychosis. The reality is that, mental health, just like physical health, is a spectrum. To progress the debate around cannabis and mental health, we need to reframe our understanding and recognise the complexity of the issue, rather than accepting simple labels and diagnoses.

The latest Government Drug Strategy placed more emphasis on enforcement, which has thus far not proved to be effective, and provides no solution for those who with ongoing dependency.

Gaps in Policy and Perception

Despite the growing number of cannabis presentations in drug treatment services and increased hospital admissions for drug-related psychosis, the 2017 Government Drug Strategy, published in July, makes no attempt to address the issue. Vast reductions and cuts to drug treatment services instead reveal an ignorance of the problem. While the Prime Minister Theresa May recognised that cannabis could impact negatively on someone’s mental health1 in the 2017 general election campaign, no clear plan has been outlined on how to tackle the issue.

The latest Government Drug Strategy placed more emphasis on enforcement, which has thus far not proved to be effective, and provided no solution for those who with ongoing dependency. The strategy also brought harm reduction back onto the agenda and recognised the importance of gendered experience, which was mentioned little in the previous strategy. The issue, however, is finding the funding for any new ideas or ways of working.

The Government’s official mental health strategy is now six years out of date and therefore unable to respond to the emerging picture around problematic cannabis use. While the Government has said that mental health is a priority, no new strategy has been forthcoming.

As this report will discuss, mental health is too often seen as a ‘black or white’ issue, which severely limits our understanding and response to it. We will now explore a more productive way of thinking about it before returning to the role cannabis plays on a consumer’s mental health, both positively and negatively.

A Spectrum Rather Than a Label

“Our current system [of mental health service provision] was designed from the wrong end of the telescope, focusing on provision, funding, demarcations and organisation of a particular set of professional services for one in twenty people, regardless of how they became ill. The design ignored the fact that one hundred per cent of people have mental health and that, as with physical health, they are on a spectrum from the super-fit, through to the healthy, the unhealthy and the moderately ill to the severely ill.” – Paul Kirby2

As Paul Kirby notes, everyone has a level of mental health that can fluctuate from moment to moment, day to day, and year to year. Just like physical health, our mental health can improve or deteriorate based upon our experiences and biology. Although this concept seems easy to relate to, the fact that mental health cannot be seen in the same way as physical health, or understood as simply, makes the matter more complex. The problem with mental ill health is that its treatment relies upon the diagnosis or labelling of a specific condition, such as anxiety, depression, or schizophrenia. While this may assist in the administration of medicines, insurance and disability benefits, it can create the impression in society that you either have one of these conditions or are completely well.

Issue 1 – People Do Not Always Notice a Deterioration in Mental Health

If we view anxiety or depression as a purely singular condition, without progressive deterioration, then we miss out on the chance to get help early on or change patterns of behaviour. The gradual decline of someone’s psychological well being presents opportunities for intervention throughout, but if the individual does not see it as such they may wait for far too long before seeking help. This keeps people away from services and treatment, leaving them out in the community, unaccounted for and without support.

This becomes a key issue when the impact of cannabis on someone’s mental health is considered. As the debate has focused so heavily on episodes of psychosis, many consumers of the drug do not consider that they could be experiencing mental health problems that fall lower down on that same spectrum. Should someone’s mental health be gradually deteriorating (or even remain stable at a problematic level), the regular consumption of cannabis will make this harder to recognise. The relationship between such a problem and the consumption of a drug can also become entwined as the experience of consuming cannabis can mask, create, amplify or suppress the problem itself.

The debate is misleading and serves to reinforce a simplistic way of discussing mental health.

“I didn’t realise something was wrong until I couldn’t leave the house. I ended up just being a complete recluse who couldn’t even walk to the shop without someone going with me. The mad thing is I was a confident guy and used to play in front of people at gigs all the time. But slowly this fear just started to set in… when I look back I can see I was slowly getting worse and worse, but I was just smoking all day and escaping from stuff so it was pretty hard to notice at the time.” – Michael, cannabis consumer for 15 years.

“I have no doubt that people presenting for cannabis-induced psychosis are the ‘tip of the iceberg’ of people adversely affected by heavy cannabis use. In our study in Dunedin (Arseneault et al 2002), cannabis use increased not only psychotic disorder but also minor subclinical psychotic symptoms such as paranoia among people in the community.” – Professor Robin Murray, Institute of Psychiatry, King’s College London.

We need to educate consumers of cannabis that mental health, just like physical health, can fluctuate. While conditions such as psychosis or schizophrenia are higher up on this spectrum in terms of severity, they are not the only type of problematic experience.

Issue 2 – Academic Debate Focuses Heavily on Psychosis

The subject of cannabis and mental health is hotly debated both in and outside of academia. Its focus, however, seems to be on the most severe psychological conditions and their labelling, rather than on exploring issues that are more common in the cannabis consuming population as a whole. By looking only at the more serious conditions – the tip of the iceberg – the debate is misleading and serves to reinforce a simplistic way of discussing mental health. If the debate instead discussed a wider range of conditions and viewed such problems as on a spectrum, there could be several benefits. As outlined earlier, it could help to educate those consuming cannabis to be aware of changes in their mental health and would also push academia to look beyond the easily accessible group of hospital admissions and groups seeking treatment.

“Researchers try their best to access cannabis users but it is too convenient to recruit from treatment centres. The majority of people don’t make it into a treatment centre, they sort things out on their own and find their own way. We are almost blind to the largest number of people who don’t get into treatment. Research has shown again and again the vast majority, almost 90%, who do develop a problem don’t make it into treatment for a whole variety of reasons.” – Ian Hamilton, Lecturer in Mental Health, University of York

Issue 3 – The Media are Missing the Bigger Story

Media reports focus heavily on the relationship between street cannabis and psychosis, with readers being provided with accounts of the most alarming stories. Regardless of the relationship between cannabis and schizophrenia, by reporting solely on this upper tier of mental health conditions, the general population is left with a message that cannabis is either safe or sends you into a psychotic episode.

We need to create a dialogue and raise awareness with the media that it should be discussing far more than simply schizophrenia or psychosis when it comes to cannabis and mental health as the scale of the problem might be going under the radar. The issue should also be handled with more subtlety and nuance by the press to reflect its complexities.

Issue 4 – Physical Health and Mental Health are Linked

The World Health Organisation states that ‘there is no health without mental health’.3 Poor physical health can cause pain, discomfort and create limitations on someone’s ability to function. This lack of functioning and discomfort can then impact on how a person feels about themselves and, in some cases, leads to a deterioration in mental health. This becomes especially relevant when discussing cannabis and mental health. Even if cannabis has no impact whatsoever on a consumer’s mental health from a biological perspective, if it was to contribute to physical limitations, or to a change in their social integration, mental health may well be affected.

77% of cannabis smokers who responded to the survey used tobacco with their cannabis.

One important factor to highlight when discussing cannabis use in the UK is the prevalence of tobacco in joints. The Global Drug Survey 2017 showed that in the UK 77% of cannabis smokers who responded to the survey used tobacco with their cannabis. This is far higher than Canada (17%) and the US (8%), and relatively close to many other European countries (range 58-94%). The introduction of tobacco alongside cannabis adds many additional risk factors to consumption, from an increased risk of dependency to the impact on the consumer’s physical health. The harms of tobacco are exceptionally well researched and the impact it has on a consumer’s physical health is well known.4

Two-Way Street

We must also recognise the positive role cannabis can play in managing someone’s mental health and the complexities that exist when evaluating the intoxication of a substance. Many consumers of cannabis state that it is highly beneficial for their mental health. Cannabis is medically prescribed in more than ten countries and 29 US states. It is used for a range of ailments, both physical and psychological, and there is a comprehensive research base to support its prescribed use. A research review carried out by Mike Barnes found that there was an evidence base for CBD as a treatment for anxiety, but the same could not be said of THC which appears to exacerbate the condition.5

It is important to recognise that the majority of cannabis users consume the drug for pleasure and enjoy using street cannabis. Intoxication from THC can be a euphoric and relaxing experience, enjoyed by millions of people around the world. People who consume high THC, low CBD strains are likely to state that it does improve their mental health as it makes them feel good during consumption and that they experience few problematic effects.

‘The reason I like weed is because it feels great. I love the feeling of being stoned and the stronger the better to be honest. It’s not like I do it all the time but when I do, I want to get pretty high rather than it just be relaxing.’ – Anonymous male, 18, North Yorkshire

What complicates this relationship further is the fact that any drug-induced experience is reliant upon, not only the drug itself, but the environment in which it is used in and on the individual. Norman Zinberg’s ‘drug, set and setting’ model highlights how both the environment and individual play a major role in defining a drug-induced experience.6 For this reason, high levels of THC and low CBD are just one factor in assessing the experience someone might have consuming cannabis. Having a predisposition to a mental health condition, living in deprivation, going through a particularly difficult time in life, or smoking the drug to excess all impact on the likelihood of a problematic relationship. Addiction itself is not ‘black or white’, it is a complex relationship and, just like mental health, exists as a spectrum.

Anecdotal evidence suggests that medical users of cannabis seek strains of cannabis with high levels of THC to help with the management of pain, whereas the recreational consumers seek strains which contain higher levels of CBD to reduce anxiety. The relationship, however, is complex and ultimately down to personal experience and desired effect.

According to the United Patients Alliance (UPA), which represents many medical cannabis consumers in the UK, CBD oil is often used to supplement street cannabis in order to reduce the problematic effects of the latter. Jonathan Liebling, the UPA’s Political Director, told us that many cannabis consumers use CBD oil before taking street cannabis to help mitigate against negative effects from the high levels of THC it contains.

A survey carried out by the UPA found that 36% of medical cannabis consumers in the UK used the drug to help manage a ‘mental or behavioural disorder’, which was the largest stated reason of all available categories. The same survey also indicated that the main method of procurement was to buy from street dealers (52.6%), which suggests many medical users of cannabis may not be obtaining a strain of cannabis that is ideal for their condition. In an unregulated market, the consumer is given no choice of strain and procurement is a lottery in which the acquired drug could do more harm than good.

Beyond Psychosis

There are other factors besides cannabis use that could impact on a consumer’s mental health and wellbeing. The social implications that can come with taking any illegal drug, especially for many young people in the UK, can have a negative and life-changing impact. Research by the charity Release shows that, despite lower rates of drug use, black males are five times more likely to be charged with possession of cannabis than white males.7 The result of this is that many young black males are particularly susceptible to being arrested for possession of cannabis and must deal with the consequences of this both psychologically and socially.8 Many people on the frontline of deprived communities in the UK, who were interviewed for this report, spoke of the many young people lost in a world of procuring cannabis, consuming it daily and committing crime. This lifestyle is distressing, dangerous and can quickly result in life-changing consequences.

The lifestyle that comes with dependant cannabis use consistently puts the consumer at risk of arrest and the stigma attached to offending can have a detrimental effect on a consumer’s mental health. Those using the drug medically must still procure it through the illicit market and regularly offend. Should someone already be struggling with anxiety and using cannabis to manage this, the added stress of committing a criminal act is likely to make them more anxious.

“One of the things from our patient survey was that when we were asking patients about the side effects of cannabis, about 50% of those who said they used cannabis to help with anxiety, also said the main side effect of using the drug was the anxiety and paranoia caused by using the illicit market. As far as we can see, almost all of our patients are experiencing severe and chronic illness, and the fact they have to procure a drug that helps them so much illicitly puts them at greater risk.” – Jonathan Liebling, Political Director, UPA

In an appropriately regulated, legal market, young people would not face the same level of criminalisation for possession and those who use the drug medicinally would not have to risk prosecution and the stress of procurement. By eradicating the illicit market, young people would also not be as easily drawn into patterns of offending and criminality. To obtain cannabis, a young person must currently interact with the illicit market, which brings with it the chance of exploitation and abuse. We need policies that reduce the risk of young people getting lost in lives of crime, not those that present the risk of doing so as a necessary gateway to procurement.

Summary

This chapter has highlighted how mental health, just like physical health, is a spectrum. The discussion around cannabis should reflect this and refrain from focusing purely on the diagnosis of one condition to quantify harm. We should recognise that mental health is fluid and cannabis can play a key role both positively and negatively.

The work of Zinberg shows that the experience of using cannabis is also dependant on factors outside of its chemical components – crucially the environment and the individual. This means that any problematic relationship between a consumer and a drug should look beyond the drug itself. Regardless of this, the chemical components of cannabis could be controlled and consumers could be educated about them. The wide-ranging environments in which people use, and the vast demographic of consumers, are far harder to control.

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