As the Trump administration signals support for hard line anti-drug policies, Canada is poised to legalize recreational marijuana nationwide – only the second country to do so. Meanwhile, support is growing for more research into using pot as a painkiller to help patients avoid opioid addiction. This month’s Report looks at these developments and the potential impact on perceptions and marijuana use. Our series on statewide initiatives to confront the opioid crisis focuses on Vermont and New Hampshire.
CANADA OPTS FOR POT LEGALIZATION
Canadian Prime Minister Justin Trudeau has introduced legislation that would legalize recreational use of marijuana nationwide by July 2018, a move approved by seven out of ten Canadians and designed to keep marijuana out of the hands of young people. Canada now has the world’s highest rates of youth cannabis use—21 percent of teens 15 to 19 and 30 percent of young adults 20 to 24.
Bill Blair, who will shepherd the legislation through the Canadian Parliament, makes the case that, “Criminal prohibition has failed to protect our kids and our communities.” Ralph Goodale, the nation’s public safety minister concurs, saying, “If your objective is to protect public health and safety and keep cannabis out of the hands of minors, and stop the flow of illegal profits to organized crime, then the law as it stands today has been an abject failure.”
During his campaign, Trudeau promised to expand legalization to recreational marijuana from court mandated medical marijuana. Details of the new measure follow recommendations of a federal taskforce, and include federal control over licensing and production and provincial regulation of how it can be sold.
Pricing and taxation will be jointly decided, and, after the nation’s experience with tobacco—when high prices, rather than reducing consumption, created a black market in cigarettes—should be low enough to limit illicit sales—as should harsh penalties proposed by the legalization measure.
Giving or selling pot to teens or “using youth to commit a cannabis-related offense” could land you in prison for 14 years. Lesser cannabis-related felonies, such as creating, packaging or labeling “products that are appealing to youth” will carry fines and prison terms. Growing, importing, exporting, or selling marijuana without a federal license will remain serious federal offenses.
The federal minimum age to buy marijuana will be 18, but the provinces can set higher minimum ages. Adults can possess as much as 30 grams of pot in public and families are allowed to grow four marijuana plants (to a maximum height of one meter). Aggressive marketing will be discouraged, product information limited largely to brand name, ingredients, strain of marijuana, and the government may insist on plain packaging. Police would be allowed to administer a saliva test to motorists to screen for THC, the psychoactive ingredient in marijuana.
In the workplace, employees would not have the right to freely use marijuana and are still expected to show up sober and ready to work, an assessment in the Globe and Mail newspaper concluded. In the province of Ontario, specifically, restrictions on smoking tobacco in the workplace would apply equally to the smoking of marijuana.
Given Trudeau’s Liberal Party majority, and support from the left-leaning New Democratic Party, recreational pot legalization is expected to pass easily. Conservative Party members voiced opposition, asserting that legalization would only increase adolescent marijuana use, while doctors – who have long had misgivings about medical marijuana – expressed grave concerns about the impact on youth.
The Canadian Pediatric Society warns that legalization does not mean the drug is safe. The doctors hold that one in seven teenagers who start using cannabis develop cannabis-use disorder and, though the adult brain seems able to recover from chronic pot use in just a few weeks, teens who smoke pot frequently can do long-lasting damage to their brains. Concerns about danger to the adolescent brain prompted the Canadian Medical Association to urge the government to ban the sale of marijuana to people under 21 and to restrict the amount and potency of the drug available to those under 25.
Protecting youth, Health Minister Jane Philpott maintains, is “at the center” of the legalization measure, and the government promises, “a robust public education campaign to inform youth of the risks and harms of cannabis use.” Clearly, one is needed, for Canadian Youth Perceptions on Cannabis, a study released at the end of January by the nonprofit Canadian Centre on Substance Abuse found “Young people think marijuana is neither addictive nor harmful.”
Speaking in support of the marijuana measure, Blair maintains that legalization is not aimed at promoting use of the drug or to maximize tax revenues. “In every other jurisdiction that has gone down the road of legalization, they focused primarily on a commercial regulatory framework. In Canada, it’s a public-health framework.”
Canada’s plan for legalization contains much that is attractive to those who believe—as we do—that the paramount issue is limiting adolescent marijuana use. Legalization in the United States has, as opponents point out, led to increased teen use of the drug. Advocates for the Canadian plan contend that what they propose should not raise the nation’s already sky-high rate of youthful use. We doubt that any measure sanctioning adult use can prevent that.
TRADING PLACES: POT OR PAINKILLERS?
Researchers are becoming interested in how certain marijuana components could be used in controlled settings to help curb the opioid crisis. While U.S. Attorney General Jeff Sessions has mocked the idea as “stupid,” recent studies suggest that weed may be a safe substitute for opioid painkillers as well as an aid to curbing opioid abuse. “Epidemics require a paradigm shift in thinking about all possible solutions,” Yasmina Hurd, a neuroscientist at Mount Sinai Hospital in New York, argued in Trends in Neuroscience, explaining the growing interest in pot for these purposes. “We have to be open to marijuana because there are components of the plant that seem to have therapeutic properties.”
At this point, however, studies suggest only correlations between medical marijuana use and reducing chronic pain and opioid addiction. Preclinical animal models have demonstrated that CBD, a non-psychoactive element in marijuana, reduces the rewarding properties of opioid drugs and withdrawal symptoms. A small pilot study by Dr. Hurd mirrored these conclusions, as did research at the University of Michigan and a RAND Corporation paper with researchers at University of California, Irvine that compared states with and without medical marijuana dispensaries.
While intriguing, these initial findings are largely observational and anecdotal. They do not support changing current clinical practice towards cannabis, as the lead author of the Michigan study, Keith Boehnke, has stated. For one thing, these studies were conducted with patients at medical dispensaries who are more inclined to endorse the benefits of medicinal marijuana. Still, it is worthwhile exploring pot as an alternative to dangerous prescription opioid painkillers or to reduce opioid addiction. Research must be pursued in long-term, large-scale clinical studies that focus solely on the CBD component and not THC, a powerful psychoactive element in marijuana.
THE STATES TAKE ACTION: VERMONT AND NEW HAMPSHIRE
These neighboring New England states are struggling to contain the opioid epidemic that has ravaged their communities. Drug overdose mortality rates in 2015 reached 16.7 per 100,000 inhabitants in Vermont, and 34.3 n New Hampshire - one of the nation’s highest, according to the Centers for Disease Control and Prevention.
In 2014 Vermont’s then-governor Peter Shumlin sounded the alarm about his state’s intensifying opioid epidemic, declaring a “full-blown crisis” with a spiraling number of drug overdoses and persons seeking treatment. The state legislature responded with measures to expand the use of overdose reversal drugs; introduce prescription rationing (as of January 2017); promote treatment options in lieu of prosecution and incarceration; and develop the state’s “spoke-and-hub” treatment infrastructure of centralized and local care.
After leveling off for a few years, the number of Vermonters who died from drug overdoses spiked in 2016 to 104, up from 66 the year before, almost evenly split between heroin and fentanyl overdoses. The victims represented a cross section of the state’s population: blue collar and professional class, rural and urban, old and young, and roughly 30 percent were women, the Vermont website Seven Days reported. Vermont’s anti-opioid efforts have had some impact. Indeed, the overdose numbers could have been worse if not for the widespread distribution of the overdose reversal drug Narcan, and the opening of more treatment facilities and a reduction in waiting times.
Despite a relatively small population of 1.4 million, more than double neighboring Vermont, New Hampshire is often called “ground zero” of the rural opioid epidemic. In 2015, the state reported 439 drug overdose deaths - the second highest per capita rate in the nation after West Virginia – and 478 deaths are estimated for 2016.
The state response has focused on expanding access to treatment (New Hampshire ranked second to last nationwide in access to treatment), addressing a shortage of trained staff in recovery programs, and increasing the number of doctors licensed to prescribe Suboxone, a drug that eases withdrawal symptoms. Other measures include a drug crisis hotline; the Safe Station program, where addicts can seek help and referrals at fire stations; and stricter prescription monitoring rules that went into effect at the start of 2017. More than 10,000 persons have received addiction treatment after gaining coverage through the Medicaid expansion under the Affordable Care Act.
Holly Cekala, executive director of Hope for New Hampshire, a recovery community nonprofit, says the state is making strides to confront the epidemic and has come a long way from the “treatment apocalypse” it faced when the crisis first unfolded. But considering the high number of overdoses and waiting times for residential treatment – averaging four to six weeks – “there’s still a lot of work to be done,” she told the Rosenthal Report.
Vermont and New Hampshire are taking the right steps to control the opioid epidemic, putting in place programs that will help save lives and get addicts into effective treatment. In both states, there is a range of options including outpatient and residential treatment lasting up to 90 days, including medication-assisted treatment (MAT) – especially in Vermont. Hard-hit New Hampshire needs to increase the number of residential treatment places and add more recovery housing; raise Medicaid reimbursement payments to allow more lower-income patients to enter treatment; and provide more prison-based drug treatment programs. It’s a resolutely stubborn public health crisis that will take time and determination to overcome.