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There are several different issues arising for the Citizens Assembly on Drug Use doctors should contribute to each one, writes Dr Brendan OShea

Apologies for the melodramatic title, but this is a very exercised topic. Cannabis use is prevalent in most practice populations, particularly so among the young and middle-aged. Evidence suggests that availability of unregulated cannabis is tending towards more potent forms. Across some societies, the commercialisation/commoditisation of cannabis is proceeding energetically.

As registered medical practitioners, we can keep our heads buried in the sand for long periods at a stretch, but inevitably cannabis will intrude, either in the context of our individual patients and their families, in calls for the legalisation of medical uses of cannabis and/or the regulated availability and commoditisation of cannabis, raising the prospect that it somehow may, in time, even flourish on a scale similar to tobacco and alcohol.

Beyond our personal views, and our clinical practice, we are likely to be called on at a societal level to attempt to inform the public debate (er.bunfight..culture war??) as our Postgraduate Training Colleges and other miscellaneous professional organisations are requested formally and informally to comment to the Oireachtas, Ministerial Reviews, RT, Newstalk and whatnot.

Tobacco and alcohol were well established deeply as cultural and social phenomena long before there was reliable evidence of their harms. This is not the case regarding cannabis.

In all of this, what can and should we usefully do as medical practitioners? There is a clinical imperative to be aware and alert to instances where individual patients are consistently using cannabis and the consequences of this, for the care we are providing, and for their own wellbeing.

We will be asked from time to time regarding legalisation of cannabis for medical use, and for a spectrum of guidance on legalising cannabis for recreational use, ranging from decriminalising for possession of small amounts for personal use, up to the full licensing for the commercial sale of cannabis, and indeed the blessing of society for the development of this, as a substantial taxable part of mainstream culture and economy.

In practiceIn practice, it is reasonable to admit that doctors do not see the proportion of people who regularly use cannabis with no apparent medical consequences; we see those with problems. What is the proportion of users who experience problems ? This question was at the heart of a decent systematic review by Janni Leung and colleagues from Queensland in 2020, since which I would guess that cannabis consumption has only increased. They included 21 studies in their review, and concluded that prevalence of Cannabis Use Disorder was almost one in five among regular cannabis users, and that almost one in 10 regular users have evidence of cannabis dependency.

As clinicians, we need to be able to respond to individual cases, and also to keep the epidemiology in perspective. Were a car manufacturer to apply for a licence to manufacture and sell a new model, where they could confidently assert that the risk of harm to drivers of the new model (and nearby pedestrians!) was as high as one in five, no government would licence the sale of such a vehicle.

Closer to home, should a pharmaceutical company wish to licence the sale of a new drug, the use of which was associated with a substantial harm in as many as one in five of those using it long term, it would be highly unlikely that it would be made generally available for broader use.

Elsewhere the evidence strongly indicates that the criminalisation of cannabis use at the level of the individual is not a successful strategy, is expensive, punitive, is a waste of a range of resources, and does not help the individuals affected. Thus, one might support a reform of our own approach through the Irish justice system.

But this is a very different issue from enabling the commercialisation and wilder availability of cannabis in our communities. Resources inappropriately consumed thorough the justice and law enforcement systems would be far better spent on earlier and more consistently available therapeutic services, including greater capacity for earlier brief interventions in primary care, and paying more attention to the factors which drive younger people into all forms of substance misuse, and/or who rely on the pharmacological effect of cannabis, alcohol and nicotine as unsafe psychological supports for their journey through the considerable anxiety of adolescence and early adulthood.

Many of us in general practice (c4,000 GPs) have our own dozen or so of (mainly) young men, whose lives are adrift in anxiety, intermittent depression, purposelessness and social withdrawal. In many such instances, problem drinking and cannabis use are a recurrent feature. The findings of Leung et al absolutely ring true at the practice level. In my view, and informed by years in practice, the impact of cannabis, alcohol and other illicit substances on the life trajectory of many younger patients is real and significant; opening up the supply, and putting a strong profit imperative behind it all sounds very alarming and quite counter-intuitive.

Before leaving the clinical space, there is the issue of availability of cannabis for medicinal use, particularly in pain management, and refractory mental health diagnoses and progressive neurological conditions. I use the BNF to inform and support my prescribing; there is a vast plethora of pharmacological agents there already, and I would greatly value additional time with my patients, more talking therapy time for them, life-coaching, better social supports for them and their beleaguered households, rather than yet another drug. Medicinal use of cannabis is a much smaller issue for society than broadly opening the floodgates and selling cannabis for profit as a mainstream activity.

The public debateOf course, is it even a debate? In this era of burgeoning social media, the ubiquitous, restless and all pervasive always on media cacophony, the braying of populist politicians, and growing expression of verbal aggression, trolling, unabashed subjective personalised commentary, click-bait culture, and incessant sensationalism, are we ever to have a debate on anything ever again?

It is likely that we will, even as societies struggle with the restless emergence of always on social media. In this debate, it will be better perhaps, if we as clinicians have the best current scientific knowledge to hand, and where there are remaining uncertainties, admit to these honestly, and/but always refer back to who are the most vulnerable in all of this, and take the decisions and best judgements with those primarily in mind.

The public debate on this, in my view, is best used to be clear about the toxicology of cannabis, and to advocate for better social capital at the community level, for sane systems of work, decent housing and investment in education, targeting deprived neighbourhoods.

We can look forward in confidence to the outcome of the Citizens Assembly on drugs use, bearing in mind that the Assembly has arguably been a very effective source of reflection, guidance and political direction on issues which are complex, important, emotive, and not well suited for deliberation by the usual rough and tumble of adversarial electoral politics. Due to report to the Oireachtas before the end of the year, we medics would do well to consider our position, individually, and through our own professional organisations, in the year ahead, should any of us find ourselves at the Assembly, in front of a Minister or on Newstalk Radio! Anything could happen.

AuthorDr Brendan OShea is on the Educational Governance Council at the ICGP, and is an ICGP Lead for GP Nursing.

Read more from the original source:
The cannabis culture wars rage on... mildly - Irish Medical Times