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WHO Expert Committee on Drug Dependence Pre-Review …………… WHO Expert Committee on Drug Dependence Pre-Review …………….. Cannabis plant and cannabis resin Section 5: Epidemiology This report contains the views of an international group of experts, and does not necessarily represent the decisions or the stated policy of the World Health Organization 1 © World Health Organization 2018 All rights reserved. This is an advance copy distributed to the participants of the 40th Expert Committee on Drug Dependence, before it has been formally published by the World Health Organization. The document may not be reviewed, abstracted, quoted, reproduced, transmitted, distributed, translated or adapted, in part or in whole, in any form or by any means without the permission of the World Health Organization. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. 2 Acknowledgments This report was prepared by the Secretariat of the Expert Committee on Drug Dependence (ECDD) within the Department of Essential Medicines and Health Products (EMP) of the World Health Organization (WHO), Geneva, Switzerland. The WHO staff involved in the production of this document, developed under the overall guidance of Mariângela Simão (Assistant Director General, Access to Medicines, Vaccines, and Pharmaceuticals), Suzanne Hill (Director, Essential Medicines and Health Products), Gilles Forte, (Secretary of the Expert Committee on Drug Dependence) were Dilkushi Poovendran (Technical Officer, WHO Essential Medicines and Health Products) and Wil De Zwart (Technical Officer, WHO Essential Medicines and Health Products). This report was commissioned as a background document for a preliminary review for the 40th Expert Committee on Drug Dependence (ECDD). WHO would like to acknowledge the contributions of the following individuals who authored this report: Chemistry Giuseppe Cannazza (University of Modena and Reggio Emilia), Italy Cinzia Citti (University of Modena and Reggio Emilia), Italy Pharmacology Jenny Wiley (RTI International), USA Epidemiology Vidhi Thakkar (Centre for Addiction and Mental Health), Canada Haya Fernandez (Centre for Addiction and Mental Health), Canada Omer S.M. Hasan (Centre for Addiction and Mental Health), Canada Jakob Manthey (Institute for Clinical Psychology and Psychotherapy), Germany Jurgen Rehm (Centre for Addiction and Mental Health), Canada Astrid Otto (Centre for Addiction and Mental Health), Canada Charlotte Probst (Centre for Addiction and Mental Health), Canada Julian Sauer (Centre for Addiction and Mental Health), Canada Toxicology Jonathon Arnold (University of Sydney), Australia Therapeutic Use Kevin P. Hill (Harvard Medical School), USA Judith Spahr, (Thomas Jefferson University) USA Charles V. Pollack. (Thomas Jefferson University) USA Brock Bakewell (Thomas Jefferson University), USA The Member State questionnaire report was prepared by Jurgen Rehm, Astrid Otto, and Jakob Manthey. Technical editing was provided by Ann Morgan and Susan Kaplan. Administrative support was provided by Afrah Vogel and Christine Berling. 3 Contents 1. Industrial use ................................................................................................................ 5 2. Non-medical use, abuse, and dependence ................................................................... 6 2.1 Non-medical cannabis use ...................................................................................................................... 7 2.1.1 Global and regional prevalence of cannabis use .............................................................................. 7 2.2 Global and regional trends in cannabis use prevalence .......................................................................... 9 2.3 General population studies from the systematic search ......................................................................13 2.3.1 Self-medication ...............................................................................................................................17 2.4 Epidemiological studies on THC content (cannabis potency) ...............................................................22 2.5 Trends in cannabis potency ..................................................................................................................23 2.5.1 Wastewater analyses of cannabis potency .....................................................................................23 2.5.2 Potency measured from cannabis samples (herbal, resin, extract, tinctures) .................................27 2.5.3 THC in other populations ................................................................................................................30 2.6 Cannabis use disorders .........................................................................................................................33 2.6.1 Global and regional prevalence of cannabis use disorders .............................................................33 2.6.2 Global trends in prevalence for cannabis use disorders ..................................................................36 2.6.3 Risk of cannabis use disorder among cannabis users .....................................................................36 2.6.4 Data quality and consistency of epidemiological data ...................................................................37 3. Nature and magnitude of public health problems related to misuse, abuse and dependence 38 3.1 Overview of cannabis-attributable and cannabis-related harm............................................................38 3.2 Quantifying cannabis-attributable harm ...............................................................................................39 3.3 Harm to others ......................................................................................................................................40 3.4 Cannabis exposure among public-health relevant vulnerable and special populations .......................41 3.5 THC concentration while driving under the influence of cannabis .......................................................44 4. Licit production, consumption, international trade .................................................... 48 4.1 Medical cannabis programs ..................................................................................................................48 5. Illicit manufacture and traffic ..................................................................................... 53 6. References ................................................................................................................. 69 4 1. Industrial use In our rapid systematic review, there were no articles that focused on industrial use of cannabis plant and resin. There are two classes of industrial use: pharmaceutical industry and hemp-related industry. These classes which will be discussed in the section on Licit Production, consumptions, and international trade below. 5 2. Non-medical use, abuse, and dependence In this section, the global and regional distribution of a) non-medical cannabis use and b) cannabis use disorders are presented and, if available, time trends are reported. Non-medical cannabis use (i.e., without a valid prescription) implies various cannabis use motives, the majority of which can be distinguished using the following two major categories: Self-medication Recreational/leisure use For both categories, there is a risk of cannabis use disorders, which is a term that has been used differently in different classification systems. In DSM-IV (3), the term “cannabis use disorders” was generally used for the combined categories of “abuse” and “dependence”, and in DSM-5 (1) for the unidimensional concept combining both former categories. However, in ICD-10 (2), the term is not defined, although it is sometimes used to combine dependence and harmful use. We will use the term as used in the Global Burden of Disease Study (GBD; http://www.healthdata.org/gbd), as most of our data on cannabis use disorders were taken from this study (See legend of Table 7 for more details). Thus, non-medical cannabis use as reported in this section involves a heterogeneous group of users with different use motives and also includes those with a cannabis use disorder. On the other hand, cannabis use disorder only involves persons meeting the diagnostic criteria of ICD-10 or DSM-IV or DSM-5 classifications, regardless of their motives. In the latter section, the risk of cannabis use disorder for cannabis users is elaborated on the global as well as on the regional level. Most of the data reported in this section has been obtained from the United Nations Office of Drugs and Crime system (UNODC
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