MARIJUANA: EXPLORING THE PUBLIC HEALTH APPROACH CIPHI CONFERENCE OCTOBER 2 ND 2017 FAREEN KARACHIWALLA, MD MPH CCFP FRCPC ASSOCIATE MEDICAL OFFICER OF HEALTH KFL&A PUBLIC HEALTH
DISCLAIMER This presentation will raise more questions than answers The devil is in the details, and a lot of the details have yet to be worked out!
OUTLINE [1] Introduction to marijuana (epidemiology, health effects) [2] The policy context in Canada (timelines, key acts and frameworks) [3] Implications for (local) public health practice
INTRODUCTION TO MARIJUANA What is it? Who uses it in Canada? What are the health effects?
MARIJUANA COMES FROM THE CANNABIS PLANT Cannabis plant Marijuan a <20% THC Hashish (pure resin) 90% THC Hash oil 60% THC
MARIJUANA CONTAINS MANY CHEMICALS >100 of these chemicals are cannabinoids THC (tetrahydrocannabinol) = primary psychoactive compound CBD (cannabidiol) = therapeutic uses
CANADA RANKS #1 IN YOUTH MARIJUANA USE
CANNABIS EPIDEMIOLOGY IN ONTARIO
ADVERSE HEALTH EFFECTS: CHRONIC DISEASE Mental health (Psychosis & Schizophrenia) Addiction ( gateway hypothesis ) Cognitive development Respiratory disease effects mostly seen with early and frequent use
GAPS IN THE LITERATURE Occasional and moderate use? Reversibility of effects? Association vs causation? (confounding in studies!)
TAKE HOME POINT #1 We are working with a lot of uncertainty when it comes to the specifics of the harms
ADVERSE HEALTH EFFECTS: OVERDOSES
ADVERSE HEALTH EFFECTS: INJURIES Marijuana use increases the risk of MVCs This effect is worse when combined with alcohol A dose-response does exist What we don t know: Level at which you re intoxicated How to best test whether you re intoxicated
THE POLICY CONTEXT What s the history? What are others doing?
LEGAL COSTS TO THE SYSTEM Marijuana is the most trafficked drug worldwide 60 000 Canadians are arrested for possession of cannabis each year 500 000 Canadians have a criminal record for this offense = $$$$ to the public system
LEGALIZATION IS NOT THE SAME AS DECRIMINALIZATION Decriminalization: Criminal violations Civil violations Legalization: Aspects are not criminal or civil violations
GOALS OF REGULATION INCLUDE MINIMIZING: Use by youth Impaired driving Dependence and addiction Concurrent use of alcohol + marijuana Public use and normative acceptance Consumption of unwanted contaminants and potencies
TIMELINE OF REGULATION IN CANADA 2015: Liberals commit to regulate non medical use 2016: Task Force Convened & report released (Dec) April 2017: Cannabis Act 1 st reading June 2017: 2 nd reading Sept 2017: ON introduces Cannabis Framework Federal target: legalization by July 2018
TAKE HOME POINT #2 Things are moving fast AND It s hard to backtrack here s to hoping we can get it right the first time!
FEDERAL CANNABIS ACT Production Licensed producers (similar to medical model) Home cultivation (with restrictions)** Distribution Model to be decided upon by P/T Ability to purchase from a retailer that has been authorized by the P/T to sell Mail order access (those P/Ts that haven t yet authorized retailers can purchase from federally licensed producer) Do not co-locate with alcohol
OTHER CHECKS & BALANCES Enforcement Prohibition against providing or selling cannabis to youth (min age 18)** Plain packaging and adequate labeling (like tobacco act) Limit advertising and promotion (like tobacco act) Possession limits** Environment No public smoking (restrictions in workplace & public transit)**
OTHER CHECKS & BALANCES Economics Tax scheme based on potency Education Public education - $9.6 million to public education and awareness Ongoing research in impaired driving ( $161 million for training frontline officers) Invest in baseline data collection and ongoing surveillance and evaluation (injury prevention) Empowerment Fund prevention, education and treatment of problematic use
THE ONTARIO PLAN Min age = 19 Ban the use of recreational cannabis in public places, workplaces, vehicle LCBO to oversee retail, separate from alcohol outlets 150 stand alone stores by 2020 Online order service (July 2018) Promote awareness of harms Pricing - TBA
THE ONTARIO PLAN Driving restrictions (news release) Ontario plans to introduce legislation this fall that would increase the consequences and costs for those who drive under the influence of drugs, including cannabis.
THE ONTARIO PLAN A price point of $10 per gram is "certainly something that we're giving consideration to," Sousa said at the Legislature.
IMPLICATIONS FOR PUBLIC HEALTH PRACTICE How will this impact our work? What will inspectors in particular need to consider?
IMPLICATIONS FOR PUBLIC HEALTH We will likely be called on for: Community education on health effects Surveillance Research Municipal policy development Zoning issues Further restricting smoke free areas and home cultivation? Enforcement?
IMPLICATIONS FOR INSPECTORS IN LOCAL PRACTICE Edible products It is the intention of the Government [of Canada] to allow edibles to be sold (Intro to the Cannabis Act: Q&As) Enforcement to: Ensure retail compliance (e.g. not selling to minors) Ensure compliance with home growth regulations Ensure compliance with not smoking in public places Implications on tobacco enforcement Responding to/advising on complaints
TAKE HOME POINT #3 There are more questions than answers when it comes to what local public health s role will be many partners are at the table thinking through theses issues: Police ON government First Nations communities Municipalities Food industry Others within our local PHUs etc
WE NEED TO CONTINUE TO BE A STRONG VOICE AT THE TABLE Successful Interventions Compelling Issue Mandate
QUESTIONS
REFERENCES Cannabis Trade Alliance of Canada. Inclusivity through Regulation: Weeding Out Organized Crime. Aug 2016: http://cannabiscoalition.ca/files/taskforce/ctac_submission_inclusivity%20through%20%2 0%20Regulation_Aug9-2016_Final.pdf Chief Medical Officers of Health of Canada & Urban Public Health Network. Public Health Perspectives on Cannabis Policy and Regulation. Sept 2016: http://uphn.ca/wpcontent/uploads/2016/10/chief-moh-uphn-cannabis-perspectives-final-sept-26-2016.pdf Canadian Public Health Association. A Public Health Approach to the Legalization, Regulation and Restriction of Access to Cannabis. Aug 2016: http://www.cpha.ca/uploads/policy/cannabis_submission_e.pdf Canadian Medical Association. Legalization, Regulation and Restriction of Access to Marijuana. Aug 2016: http://s3.documentcloud.org/documents/3100676/cma-submission- Legalization-and-Regulation-of.pdf Canadian Pharmacists Association: https://www.pharmacists.ca/cphaca/assets/file/cpha-on-theissues/taskforce_marijuanalegalizationregulation_cpha_final.pdf The Arthritis Society, Canadians for Fair Access to Medical Marijuana, Canadians AIDS Society: http://arthritis.ca/getmedia/9f76e06d-6381-40ab-99fb-e48458317157/submissionto-task-force-on-marijuana-re-medical-cannabis-28-aug-2016
REFERENCES Government of Canada - Task Force on Marijuana Legalization and Regulation. TOWARD THE LEGALIZATION, REGULATION AND RESTRICTION OF ACCESS TO MARIJUANA Discussion paper. 2016: http://healthycanadians.gc.ca/health-system-systemesante/consultations/legalization-marijuana-legalisation/alt/legalization-marijuanalegalisation-eng.pdf Centre for Addiction and Mental Health. CANNABIS POLICY FRAMEWORK. 2014. https://www.camh.ca/en/hospital/about_camh/influencing_public_policy/documents/c AMHCannabisPolicyFramework.pdf Toronto Public Health. Legalization and Regulation of Non-Medical Cannabis. May 2016: http://www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-93042.pdf Pacula RL, Kilmer B, Wagenaar A, Chaloupka FJ, Caulkins JP. Developing Public Health Regulations for Marijuana: Lessons From Alcohol and Tobacco. American Journal of Public Health. 2014. 106(6): 1021-2028. Maccharles, T. Toronto Star. Doctors say pot-smoking should be banned for Canadians under 21. Sept 7 th 2016: https://www.thestar.com/news/canada/2016/09/07/doctors-saypot-smoking-should-be-banned-for-canadians-under-21.html