New Harm Reduction Guidelines for Cannabis and Public Health

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The forthcoming legalization of cannabis is Canada has prompted the public health community to develop practical strategies to reduce health risks associated with cannabis use.

An important article in the August 2017 edition of the American Journal of Public Health presents “Lower-Risk Cannabis Use Guidelines”(LRCUG) developed by Benedikt Fischer, Cayley Russell and several additional colleagues.

The authors observe that “Prohibition of recreational cannabis use has long been the dominant policy model, yet it has been increasingly recognized as ineffective.” While the public health problems associated with cannabis are “clearly smaller than for alcohol, tobacco and other illicit drugs, it is associated with risks for various adverse health outcomes.”

Readers are cautioned, though, that while there studies associating cannabis use with adverse effects “causality is not established for all of these.”

Nonetheless, the authors are concerned about strong evidence associating cannabis use with a variety of health problems including cognitive impairment, car accidents, brain development, dependence and psychosis, heart and lung problems, as well as poor pregnancy outcomes.

Of great interest, though, is that many of these harms, or their severity, can be influenced by behavior.

The choices cannabis users make—the way they use the drug—can be modified to reduce potential harms associated with cannabis use. Thus, “Lower-Risk Cannabis Use Guidelines (LRCUG) may be a worthwhile public health intervention for cannabis, particularly following legalization of use.”

The authors conducted an extensive and systematic analysis of peer-reviewed research articles to produce the 10 guidelines below, all of which are based on reliable scientific evidence.

They note that in some areas, the evidence is “relatively thin” and that “better studies and data are urgently needed.” Fischer and his colleagues also acknowledge that cannabis users are a diverse population, and that use-related risk factors are influenced by other factors, such as genetic profiles, co-behaviors and social/environmental factors.

However, the driving force behind producing these guidelines and refining them in the future is that “one of the distinct advantages of legalization is that it allows open and direct information of users on risk behaviors, product properties, and more with the aim of reducing harmful outcomes from use.”

This is a giant step forward, a significant departure from prohibition and criminalization. More important, this is not only recognition that harm reduction is a promising public health paradigm to apply to cannabis use but an example of leadership from the public health community with respect to dismantling prohibition.

Here are the 10 recommended guidelines to lower the risk of cannabis use:

(1) The most effective way to avoid cannabis use–related health risks is abstinence,

(2) Avoid early age initiation of cannabis use (i.e., definitively before the age of 16 years),

(3) Choose low-potency tetrahydrocannabinol (THC) or balanced THC-to-cannabidiol (CBD)–ratio cannabis products,

(4) Abstain from using synthetic cannabinoids,

(5) Avoid combusted cannabis inhalation and give preference to nonsmoking use methods,

(6) Avoid deep or other risky inhalation practices,

(7) Avoid high-frequency (e.g., daily or near-daily) cannabis use,

(8) Abstain from cannabis-impaired driving,

(9) Populations at higher risk for cannabis use–related health problems should avoid use altogether, and

(10) Avoid combining previously mentioned risk behaviors (e.g., early initiation and high-frequency use).

The reasoning behind many of these recommendations is clear.

When it comes to the first one, the point the authors emphasize is that “Those who decide to use need to recognize that they incur risks of a variety of—acute and long-term—adverse health and social outcomes.” The risks vary and are not the same for every user or every situation. It has also been long-established that individuals who begin cannabis use are less likely to abuse the drug then those who begin use in their early teenage years.

The potency issue is also easy to understand, especially given the longstanding recognition among many cannabis users that “less is more” (and there are benefits to regulating tolerance to the effects of cannabis through moderate use). It is a new development, though, for the value of CBD:THC ratios to be recognized.

So-called “synthetic cannabinoids” are not cannabinoids at all, and their dangerous effects have received a lot of attention in the cannabis community. Unfortunately, because of the name used to promote them they need to be mentioned in this context.

The benefits of vaporizers have become widely known and popular among cannabis users. The deep inhalation issue deserves more attention in that cannabis users should be educated that this increases their absorption of carbon monoxide.

Frequency of use will always be an issue of contention between public health experts and cannabis users. From the perspective of the public health community, the logic of this recommendation and the evidence to back it up is clear. If something presents risks, the more it is used, the greater the risks involved.

Which leads to the driving issue. Many cannabis users are safe drivers, but from a public health perspective, something that creates impairment is incompatible with safe driving. This is especially important with new cannabis users or those with low tolerance.

Recommendation #9 requires elaboration. “There are some populations at probable higher risk for cannabis-related adverse effects who should refrain from using cannabis. These include individuals with predisposition for, or a first-degree family history of, psychosis and substance use disorders, as well as pregnant women (primarily to avoid adverse effects on the fetus or newborn). These recommendations, in part, are based on precautionary principles.”

Finally, the last recommendation simply recognizes that any combination of these issues magnifies the potential risk associated with them individually. In most if not all cases, heavy consumption of high-potency cannabis is not compatible with safe driving.

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