Sir, – The upcoming Citizens’ Assembly will debate the merits or otherwise of liberalising the current law on cannabis. The letter signed by numerous doctors in your paper highlighting their concerns is to be welcomed (April 12th).
While critical of what they see as the pro-cannabis messaging on social and traditional medicine, they do not call for the status quo ante regarding the legal status of cannabis, but rather call for “renewed priority to the more important issues of prevention and treatment”.
Decoupling the issues of cannabis-related illness and legalisation might provide the “opportunity to move on from the endless conversation about legalisation”.
Cannabis use is increasing globally, with recent estimates of over 200 million users, an almost 25 percent increase over the last decade.
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The international trend is for increasing liberalisation of drug use, most particularly cannabis. The emerging evidence suggests that neither the dire warnings of critics nor the optimistic forecasts of advocates have materialised. Advocates promoted the view that legalisation would reduce crime rates, save on the criminal justice system and improve public health. Critics warned of a frightening increase in use, with consequent increased rates of illness and dependence. However, a systematic review (Melchior, et al, 2019) concluded that “Cannabis policy liberalisation does not appear to result in significant changes in youths’ use, with a small increase in recreational use”. A review in September 2022 found “results for youth are mixed, with the majority of studies showing no pronounced increase” (Rubin-Kahane, et al).
Canada, now in its fifth year of legalisation, is finding an increase in use by older adults, but no significant increase in adolescents. In addition, rates of cannabis-related psychosis have not significantly changed.
The promise of a reduction in crime rates have also not materialised, the illegal trade in cannabis continues, with as many as 50 per cent of users buying the drug illegally. There has been a boon in tax revenues derived from drug sales.
Of the multiple factors that influence the decision to use cannabis, it would appear its legal status is not critical.
The doctors highlight the 1,000 admissions in 2020 with a cannabis-related diagnosis, overwhelmingly psychosis.
Cannabis-related psychosis results in earlier presentations, more frequent and longer admissions.
The association between cannabis and psychosis is well established, though debate continues as to how causal the relationship is in older adults. The association does, however, reach the criteria of causality in younger teenagers, developing brains, high-potency cannabis (high THC levels) and frequent use.
This demographic (under 18) will lie outside any liberalisation in drug policy. There is an urgent need to develop public health initiatives and effective interventions aimed at this cohort of teenagers.
The vast majority of cannabis users will not develop psychosis, and the corollary also holds. Psychotic disorders are among the least understood and challenging to treat illnesses encountered by doctors. There are no cures, and anti-psychotic drugs are often only partially effective and can cause significant adverse effects.
People living with psychosis are among the most marginalised in society. They exercise little power, and rarely draw the compassion and concern afforded sufferers of “medical” disease.
People living with psychosis often live impoverished lives, and for some using cannabis is central to their daily activity, despite repeated warnings of the harm it is causing. Legalising cannabis will alter little in their lives, other than avoiding a criminal conviction.
There continues to be huge under-investment in areas of research, treatment and broader management of this neglected group. Any initiative that draws attention to this neglect is to be welcomed.
Perhaps the Citizens’ Assembly will provide such an opportunity. – Is mise,
TOMAS McBRIDE,
Letterkenny,
Co Donegal.