For over half a century, various activist groups in the UK have launched campaigns to legalise cannabis, but with little success. One of the most effective arguments used by those opposed to reform is the absence of any existing regulated legal markets for selling cannabis. This is no longer the case. Over the past five years, eight US states (including California) have voted to legalise cannabis. Next July, Canada will become the first country to legislate with a general election mandate to do so.
So this issue will inevitably become more salient in the years to come. What is already clear is that reform takes place within particular social and cultural contexts. Local conditions dictate its priorities.
Here in the UK, the debate around cannabis cannot ignore the issue of mental health. For years, there has been conjecture in this area as the potency of cannabis, its addictiveness, the impact it has on young people, its links with psychosis, and the best way in which to address its illicit market have all been debated at length.
This report provides a concise and compelling new account of the deleterious consequences of leaving cannabis in the hands of the black market. Drawing on insights from world class academics and original research, it was commissioned to stimulate a better informed and more nuanced public debate.
With inadequate treatment provision, a lack of understanding around the key points, and no effective policy in place, there is an urgency to this issue which can longer be sidestepped. We must be brave in discussing and properly examining the implications of, not only the existing illicit market for cannabis, but the real challenges that exist in implementing a safe and responsible system of regulation in which mental health is a key priority.
Steve Moore, Volteface Director
There is a huge amount of conjecture around the issue of cannabis use and mental health in the UK. The relationship between the drug and how it can impact both positively and negatively on someone’s mental health is a complex one. Debate on this issue is often polarised, with one camp proclaiming cannabis is so safe that it should be legalised and made available to all, and another stating that cannabis is more dangerous than some might think and that we should have harsher sentences for those both growing and consuming it. This report addresses the issue head-on and explores in depth the difficult question of how cannabis impacts a consumer’s mental health. Its findings paint a problematic picture, which can only be addressed through considered reform.
Our study, carried out in partnership with Dr Oliver Sutcliffe, Senior Lecturer in Psychopharmaceutical Chemistry at Manchester Metropolitan University, shows how street cannabis is now exceptionally potent in comparison to previous years. Buying it is a ‘lottery’ in which the consumer has next to no control over the product they are procuring. As this report examines, cannabis of this nature appears to be deeply problematic for many people because it greatly increases the risk of a deterioration in mental health and the chance of forming dependency. Academic research in this area is supported by data and expert testimony from frontline services which suggest that street cannabis is having a direct impact on the number of people accessing mental health services and presenting at drug treatment centres.
Frontline services indicated that young people are experiencing a wide range of mental health problems linked to their consumption of street cannabis.
There are three risk indicators to consider when examining how problematic street cannabis is, the academic research suggests. The first is the level of THC. Higher amounts have stronger correlations with dependency and problematic side effects from paranoia to psychotic episodes. The second factor is how much CBD is present. This appears to be a protective chemical, which mitigates against the negative effects of THC. Finally, the age of the consumer is important when considering longer-term effects on cognition and brain development. Research indicates that, during the period when someone’s brain is developing and growing, cannabis can have a detrimental effect on this process.
In the UK’s illicit cannabis market, all three risk indicators are present. The young people we spoke to and surveyed told us that they can obtain cannabis more easily than alcohol. Frontline services indicated that young people are experiencing a wide range of mental health problems linked to their consumption of street cannabis. These groups of young people, who are often disengaged from frontline services, are rarely explored by academia and more needs to be done to examine the impact street cannabis is having on their mental health. Reports from the frontline and disclosures from young people themselves suggest that the relationship is problematic.
The relationship consumers can form with cannabis can be exceptionally complicated. While the research outlined in this report suggests that cannabis can lead to a deterioration in mental health, many people state that it helps them to cope with their mental health. Cannabis is used by large cohorts of people to deal with anxiety and problematic thoughts, and to these consumers it is medicinal in its nature. While this relationship is complex, and in many respects highly personal, what we have found is that street cannabis is rarely cited as being beneficial for mental health.
It appears that two distinct groups exist: those who are informed about the cannabis they are buying, and those who have no idea and are essentially in the dark. The latter present far more of a concern as they are using forms of cannabis that seem to carry with them higher rates of addiction and dependency, and in the absence of resources, knowledge and understanding, problematic patterns of use remain, and the consumer’s mental health can suffer.
This report acknowledges that a variety of factors impact on the mental health of consumers, and that the relationship someone forms with cannabis cannot only be explained by reference to THC and CBD levels. The reality, however, is that we can regulate and control THC and CBD to reduce the risks, inform consumers and offer choice. Markets are emerging around the world in which this is taking place.
The UK’s illicit cannabis market is out of control and dominated by more problematic forms of cannabis. Systems that bring the market into check, take it out of the hands of criminals and could generate vast tax revenues for government exist. Enforcement of this market has not worked and police forces, failing to see either the benefit or purpose of attempting to enforce it, are surrendering. The tip of the iceberg is becoming clear to see as mental health presentations for cannabis-induced psychosis increase, but the majority of problematic use remains hidden in people’s homes and away from treatment services. We need reform and new drug policies before the crisis deepens.
Key Terminology and Definitions
Due to a lack of education and awareness, the term Skunk is causing confusion and misinformation. New terminology is needed, along with a recognition that cannabis is a highly complex product that people can form a wide range of relationships with – from beneficial ones to those which are problematic. The use of the word Skunk hinders this understanding.
When it comes to cannabis, the term Skunk causes a great deal of debate and disagreement. This is not only a distraction from the real issues at hand, but is creating further misinformation around a subject requiring clarity. Use of the term is damaging the debate and creating confusion with young people in drug education and on their perception and understanding of cannabis.
What is problematic about the term Skunk is that it can mean very different things. Academics and journalists have used the word Skunk to describe a new type of cannabis that is high in THC and low in CBD. To many connoisseurs of cannabis, Skunk is just one strain with similar THC and CBD content to many other available strains. To many young people smoking cannabis, Skunk is just a word used to describe ‘good weed’.
Using the term Skunk to describe high THC, low CBD cannabis also creates a problem in the way wider society understands other forms of cannabis, such as Hash. By using the term Skunk to describe a ‘problem’ strain of cannabis, an impression is created that other forms are safer, when – in reality – they may contain far higher levels of THC and have no CBD. The use of the word is damaging societal health and wellbeing by spreading misinformation. Consumers who encounter Hash may not realise that it can contain extremely high levels of THC, far beyond that of Skunk, whatever their understanding of the term is.
This report will use the term ‘street cannabis’ to describe the strains of cannabis that are bought through the illegal market. We acknowledge that cannabis bought on the street varies in nature with regards to the specific strain, but there is no doubt that, in the UK, street cannabis tends to be high in THC and low in CBD. The impact of this is that, in most cases, people are not given a choice or the opportunity to avoid more potent strains, which present an increased risk to their psychological wellbeing.[footnote]Hardwick, S. King, LA. “Home Office cannabis potency study 2008” St. Albans: Home Office Scientific Development Branch, 2008.[/footnote]
The term potency will be used in this report in reference to the concentration of THC and the ratio of THC to CBD in cannabis. When using the term ‘high potency’, we are referring to strains of cannabis which have a high level of THC and little CBD.
Defining Mental Health
The focus of this report is to examine the way in which cannabis impacts on the mental health of consumers, both positively and negatively. The report will consider addiction as a mental health condition in line with its acknowledgement and definition in the Diagnostic and Statistical Manual for Mental Disorders fifth edition (DSM-5). The report will also look at how cannabis can impact on cognition and the brain development of consumers and classify impairment in this area as an issue of mental health, in line with the DSM-IV-TR.
This report will go on to explore the link between cannabis consumption and psychosis. Before doing so, we need to provide a definition and highlight the broad spectrum of experiences that can occur. The term psychosis covers a variety of symptoms from a relatively minor aberrant experience to a more serious episode of schizophrenia. The definition provided by Gelder et al. is that, when medically diagnosed, psychosis is a descriptive term for hallucinations, delusions and impaired insights that someone may experience for an undefined period.[footnote]Gelder, J. Price, J. “Psychiatry, Fourth Edition” New York: Oxford University Press 2012.[/footnote] A psychotic episode may be drug-induced and last for a short period or several weeks. People’s experience of a psychotic episode can therefore vary greatly and our understanding of it needs to reflect this. Drug-induced psychosis is a term used to describe psychotic symptoms occurring after intoxication of a substance, which can last for any length of time.
The discussion around psychosis must recognise that experiencing it as a condition does not always result in a hospital admission or medical diagnosis. We should view psychosis as a broad set of symptoms which could last for a short period of time, sometimes just due to the intoxication of the substance, and that many consumers of cannabis who experience disorganised thinking, hallucinations or delusions have in effect experienced psychosis.
If we are to effectively discuss and evaluate the role that cannabis has on someone’s mental health, we need to recognise that the debate must take place on a broader level. Even if there is a causal link between cannabis and psychosis, most consumers will not experience a psychotic episode. Far more, however, may be experiencing other issues such as addiction and dependency, which could gradually decline if not addressed, and affect their health and wellbeing on a significant scale.