The Canadian context for cannabis policy and public health approaches to substance use

Transcription

1 The Canadian context for cannabis policy and public health approaches to substance use Cameron Wild, Rebecca Haines-Saah Cannabis Legalization in Canada: Implications for Public Health in Alberta May, 2017

2 We have no conflicts of interest to declare

3 What is a public health approach to cannabis?

4 The longstanding illegal classification of cannabis has promoted a black and white cultural worldview, according to which, any cannabis use = misuse

5 A Public Health Approach This approach to substances recognizes that people use substances for anticipated beneficial effects and is attentive to the potential harms of the substances and the unintended effects of control policies it seeks to ensure that harms associated with control interventions are not out of proportion to the benefit to harm ratios of the substances themselves. Canadian Drug Policy Coalition

6 High costs At the population level A public health approach requires segmentation of populations of interest Problem severity (acuity, chronicity, complexity) Dependence Cannabis users experiencing problems At risk cannabis users Service intensity Service extensity (numbers served) Low costs Healthy population: includes cannabis users and non-users

7 Cannabis Use: The Numbers

8 Use in Canada 34% of Canadians have used cannabis in their lifetimes The prevalence of past-year cannabis use among Canadians aged 15 years and older was 12% (3.6 million) in 2015, an increase from 11% (3.1 million) in Among past-year users, 24% (831,000) reported using for medical purposes The prevalence of past-year cannabis use in 2015 was higher among men (15% or 2.2 million), than women (10% or 1.4 million). Provincial prevalence of past-year cannabis use ranged from 8% in Prince Edward Island to 17% in British Columbia. SOURCE: Canadian Tobacco, Alcohol and Drugs Survey (CTADS); Statistics Canada: 2015

9 Provincial Comparisons Cannabis Use CAN NL PE NS NB QC ON MB SK AB BC Lifetime Past-year SOURCE: Canadian Tobacco, Alcohol and Drugs Survey (CTADS); Statistics Canada: 2015

10 Prevalence of cannabis use Canadians 15+ Percentage of Canadians Ever use Past 12-month use Past 30-day use Daily use Males Females SOURCE: Canadian Tobacco, Alcohol and Drugs Survey (CTADS); Statistics Canada: 2015

11 Prevalence of cannabis use Canadians Percentage of Canadians Ever use Past 12-month use Past 30-day use Daily use SOURCE: Canadian Tobacco, Alcohol and Drugs Survey (CTADS); Statistics Canada: 2015

12 Prevalence of cannabis use Canadian youth Percentage of Canadian Youth Males Females 0 Ever use Past 12- month use Past 30-day use Daily use SOURCE: Canadian Student Tobacco, Alcohol, and Drugs Survey ; Grades 7-12 (N = 36,665)

13 Prevalence of cannabis use Canadian youth Percentage of yourh * Ever use * 1* Past 12-month use Past 30-day use S Daily use 4.9 Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12 SOURCE: Canadian Student Tobacco, Alcohol, and Drugs Survey ; Grades 7-12 (N = 36,665)

14 Prevalence of cannabis use Canadian youth Percentage of youth Canada Alberta 0 Ever use Past 12-month use Past 30-day use Daily use SOURCE: Canadian Student Tobacco, Alcohol, and Drugs Survey ; Grades 7-12 (N = 36,665 [Canada]; n = 6193 [AB])

15 Substance use trends over time Alberta youth Percentage of youth Past-Year Substance Use Alcohol Binge drinking Cannabis Nonmedical use of pharmaceuticals SOURCES: Youth Smoking Surveys ; Canadian Student Tobacco, Alcohol, and Drugs Survey ; Grades 7-12

16 Public Health Challenges (1) Meaningful surveillance linked to prevention and treatment system planning has to be developed Current sample sizes for CTADS and CSTADS preclude sub-provincial estimates, limiting utility for regional planning Prevalence data is not used to inform service provision (e.g., identifying sub-populations that would benefit from universal vs. indicated prevention; triaging populations that would benefit from screening, brief interventions, and specialty treatment) Problem severity among cannabis users is not currently being measured in ongoing epidemiologic work, limiting its value for system-wide and local service planning

17 Regulatory Frameworks: Why Legalization and Not Decriminalization?

18 Comparing Policy Options Regulatory Continuum CCSA (2016): Cannabis Regulatory Approaches

19 Centre for Addiction and Mental Health (2014): CANNABIS POLICY FRAMEWORK

20 Legalization: Rationale High rates of use by youth High rates of Canadians with criminal records Profits go to organized crime Most Canadians support legalization Task Force on Marijuana Legalization and Regulation (2016)

21 Regulatory Frameworks: Federal Task Force Recommendations

22 Scope Protecting children and youth Diverting profit from organized crime Reduce the burdens on police and the justice system Protect public health and safety: serious marijuana offences selling outside of the regulatory framework operating a motor vehicle while under the influence

23 Scope (cont d) Ensure Canadians are well-informed through public health campaigns Establish and enforce a system of strict production, distribution and sales regulation of quality and safety (e.g., child-proof packaging, warning labels) restriction of access, application of taxes programmatic support for treatment, support and education programs Continue to provide access to quality-controlled marijuana for medical purposes Conduct ongoing data collection

24 Recommendations Emphasis on: Minimizing Harms of Use In taking a public health approach to the regulation of cannabis, the Task Force proposes measures that will maintain and improve the health of Canadians by minimizing the harms associated with cannabis use. Highlights Set a national minimum age of purchase of 18 Require plain packaging for cannabis products and mandatory labelling Develop and implement factual public education strategies addressing problematic use and lower-risk use guidance Implement an evidence-informed public education campaign, targeted at the general population but with an emphasis on youth, parents and vulnerable populations

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26 Public Health Challenges (2) Protected funding for implementing recommended regulatory framework for cannabis needs to be secured What is Alberta spending currently? Alberta funding The entire mental health and addiction sector accounts for ~ 5% of the total Provincial health budget Yet worldwide estimates: addictions and mental disorders account for ~25% of total population disease burden! Relative to total GoA spending on health, addiction services proportionally receive much less than mental health services SOURCE: Wild, T.C., Wolfe, J., Wang, J., & Ohinmaa, A. (2014). Gap analysis of public mental health and addiction programs: Final report. [Commissioned research report prepared for Alberta Health; 258 pages]

27 Revenue Alberta (FY ) Item Alcohol Gambling Tobacco Total GoA revenue for 3 legal psychoactive drugs/addictive behaviours Government of AB revenue $856 M $1.2 B $980 M $3.04 B Total GoA revenue for non-renewable energy (all sources) $2.8 B SOURCES: Alberta Gaming and Liquor Commission; Alberta Energy

28 Public Health Challenges (2) Protected funding for implementing recommended regulatory framework for cannabis needs to be secured Canada/Alberta model Washington State, Oregon, Colorado, California $ $ General provincial revenue Legislated priorities Prioritysetting Initiatives Initiatives General state revenue

29 Before allocation to general state revenue Washington State Oregon California (pending) $1.25M/quarterly for administration After covering costs to administer marijuana tax (licensing, etc) Up to 4% for administrative costs 50% to state basic health plan trust Common school fund: 40% $10M/yr (increasing by $10M/yr to $50M/yr) to addiction and mental health services Up to 15% (minimum $25M) to addiction interventions for youth Up to 10% (minimum $9M) for public education, prevention, hotline 1% (minimum $1.2M to Universities for research on cannabis health effects and estimating impairment Addiction and mental health services: 20% $10M/yr to Universities to evaluate policy change Law enforcement: 35% $3M/yr to develop protocols to detect intoxicated driving Of remaining 60% to youth prevention, early intervention, treatment 20% environmental damage (illegal production) 20% driver education

30 Intervention Strategies: System-Wide Planning

31 Public Health Challenges (3) System-wide planning for preventing cannabis-related problems and treating cannabis dependence is urgently needed Even if adequate resources were allocated via legislation, our system of prevention and treatment interventions for cannabis is not well defined

32 Prevention and Treatment Access specialty services Long wait lists; continuing problems treating comorbid mental health problems Current state Diagnosed Seen in health services Poor continuity of care between primary, acute, and specialty care Low rates of case-finding Ineffective universal prevention (e.g., DARE) Users who meet clinical screening criteria for problematic use At risk subpopulations Healthy population: includes cannabis users and non-users Throughout the system : Underutilization of evidence-based interventions

33 Future state Stepped care STEP 4: Access specialty services STEP 4: Diagnosed Greater treatment capacity; better continuity of care; routine treatment of comorbid mental disorders Personality-targeted indicated prevention in schools, workplaces STEP 3: Seen in health services STEP 3: Users who meet clinical screening criteria for problematic use STEP 2: At risk subpopulations Routine screening and brief intervention for cannabis problems, including workplaces Universal prevention: Factual cannabis information; lower risk use education STEP 1: Healthy population: includes cannabis users and nonusers

34 CRISM (Canadian Research Initiative on Substance Misuse)

35 CRISM - Objectives 1. Identify and develop the most appropriate clinical and community-based prevention or treatment interventions for substance misuse 2. Provide evidence to support the enhancement of prevention or treatment services regarding substance misuse to decision makers and service providers 3. Support improvements in the quality of care and quality of life for Canadians living with substance misuse

36 CRISM A National and Regional Resource National network funded by CIHR to scale up evidence-based interventions Provides access to the expertise of over 500 members, including addiction researchers and provincial policy makers, service managers, people/advocates with lived experience OPTIMA patient-centered trial National opioid use disorder treatment guideline National lower-risk cannabis use guidelines

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38 Thank you!