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Adverse Health Consequences of Cannabis Use a Survey of Scientific Studies Published up to and Including the Autumn of 2003

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Adverse Health Consequences of Cannabis Use a Survey of Scientific Studies Published up to and Including the Autumn of 2003 The mission of the National Institute of Public Health Sweden is to promote health and to prevent illness and harm. Its mandate includes the synthesis and dissemination of research findings. This report is a survey of the harmful effects – mental as well as physical – which can arise as a consequence of cannabis use. The author, Jan Ramström, is a psychiatrist with several years’ experience of specialised drug-abuse services. A long-time Head of Clinic in the field of general psychiatry, he has been affiliated with the Swedish National Board of Health and Welfare for nine years in the capacity of Scientific Adviser on issues of psychiatry Adverse Health and substance abuse. His previous publications include other reports as well as several textbooks in the field of substance abuse, psychiatry and youth development. Consequences of The report is intended for health-care organisations, information officers such as drugs advisers and drug counsellors, and others Cannabis Use in need of knowledge-based information on the consequences of A Survey of Scientific Studies Published up to and cannabis use. including the Autumn of 2003 Jan Ramström national institute of public health – sweden National Institute of Public Health Fax +46 8 449 88 11 Rapport R 2004:46 www.fhi.se Distribution E-mail [email protected] ISSN 1651-8624 SE-120 88 Stockholm Internet www.fhi.se ISBN 91-7257-314-7 Adverse Health Consequences of Cannabis Use A Survey of Scientific Studies Published up to and including the Autumn of 2003 Jan Ramström national institute of public health – sweden www.fhi.se © national institute of public health – sweden r 2004:46 issn: 1651-8624 isbn: 91-7257-314-7 cover photo by: sjöberg, www.sjobergbild.se printing: sandvikens tryckeri, sandviken 2004 Table of Contents Foreword ____________________________________________________________ 5 Introduction __________________________________________________________ 7 Part One – General Remarks ____________________________________________ 11 1. Background and Aims. Facts about the Cannabis Drug ____________________ 11 2. How to Find Information about the Harmful Effects of Cannabis ____________ 20 Part Two – Cannabis and Mental Disorders ________________________________ 25 3. Damage to Mental Health – An Overview ______________________________ 25 4. Development of Dependence in Cannabis Abusers________________________ 27 5. Cannabis and Psychoses – An Overview ________________________________ 31 6. Cannabis-Caused Delirium (Acute Confusional State) ____________________ 35 7. Cannabis Psychosis ________________________________________________ 37 8. Cannabis and Chronic Non-Schizophrenic Psychoses ____________________ 41 9. Cannabis Smoking and Schizophrenia __________________________________ 43 10. Anxiety Conditions and Depersonalisation Syndrome ____________________ 48 11. Depression and Suicide______________________________________________ 51 12. Amotivational Syndrome ____________________________________________ 54 13. Cannabis and Violence ______________________________________________ 57 Part Three – Some Psychological and Psychosocial Harmful Effects ____________ 61 14. Harmful Effects of Cannabis Smoking on Reasoning Ability, Memory and Sense of Coherence (Cognitive Functions____________________ 61 15. Cannabis Smoking in Teenagers ______________________________________ 70 16. Cannabis and Driving ______________________________________________ 82 Part Four – Physical Harm ____________________________________________ 89 17. Cannabis and Pregnancy ____________________________________________ 89 18. The Effects of Cannabis on the Respiratory Organs ______________________ 94 19. Cannabis and the Cardiovascular System ______________________________ 98 4 adverse health consequences of cannabis use 20. Cannabis and Fertility ____________________________________________ 100 21. The Effects of Cannabis on the Immune System ________________________ 101 References__________________________________________________________ 103 Glossary____________________________________________________________ 123 adverse health consequences of cannabis use 5 Foreword During a succession of years, there has been a discussion as to whether – or to what extent – cannabis can cause harm and dependence, and thoughts have also been advanced on the legalisation, in different guises, of cannabis use. The statements made in this context differ in terms of the solidity of their scientific foundations, which is why the National Institute of Public Health Sweden has found it important to present an overview of the range of possible harmful effects caused by cannabis use as presented today in the scientific literature. Jan Ramström has previously compiled a similar knowledge overview. In connection with the United Nations’ General Assembly Special Session (UNGASS) on drugs in 1998, that overview was published in English as well. The report which is presented now has the same starting-points, but it includes the scientific data and findings that have come into existence since the previous survey was made. It is intended for health-care organisations, information officers such as drugs advisers and drug counsellors, and others in need of knowledge-based information on the consequences of cannabis use. The author is responsible for the interpretation of the knowledge survey presented and for the conclusions drawn from this. Gunnar Ågren Director-General adverse health consequences of cannabis use 7 Introduction In 1996 I compiled, as asked by the Swedish National Board of Health and Welfare, a report entitled Skador av hasch och marijuana: En genomgång av vetenskapliga studier av skadepanoramat hos cannabis (subsequently translated into English as Adverse Health Consequences of Cannabis Use: A Survey of Scientific Studies into the Range of Damage to Health Caused by Cannabis). In that report I tried to cover all that had been published up to and including February of 1996. The present version is an update covering the scientific studies published up to and including the autumn of 2003. In principle, then, this re- worked version is intended to have the same structure as the previous one. In other words, the additions are not intended to form a supplement but to be integrated with the earlier material. Trends over the Past Seven-Year Period Notwithstanding this aim, which will inform my work, the approach used and the instructions I have been given enable me to emphasise important trends and shifts that I have observed in this research field over the past seven-year period. In this context, it is important to stress that these reflections, unlike the rest of what is presented in the report, constitute my subjective impressions. Growing Interest in the Harmful Effects of Cannabis In the mid-1990s, there were signs that researchers’ interest in cannabis-related questions was declining. When reviewing scientific reports now, however, my impression has been that, especially over the past few years, interest has increased and studies have multiplied. An attempt to quantify these trends, by means of wide-ranging searches, confirms this impression of greater activity: the number of publications has indeed grown strongly in the past few years. In 1991–1996 there were a total of 1,460 publications, whereas in the next six-year period, 1997–2002, there were 2,500. It may be added that there is no inherent automatic mechanism that will yield a constant increase in the number of studies. In the first half of the 1990s, the number of studies produced each year was more or less constant (ranging from 215 to 264). However, in the later period, the number of articles accepted for publication increases almost every year, reaching 511 in 2002 – i.e. more than twice the annual production in the first half of the 1990s. Part of this increase is presumably attributable to growing interest in medical uses of cannabis, but it is my definite impression that stronger interest in harmful effects has had an impact as well. 8 adverse health consequences of cannabis use Greater Concern over the Increase in Cannabis Abuse As I have been reading scientific works, particularly reviews, during this later period, I have formed the impression that it is now considerably more common for authors to make concerned statements about the current situation. Three circumstances in particular tend to underpin this: first, the increase in the number of smokers, especially among the young (in certain age groups in the United States, cannabis smoking is almost as common as tobacco smoking); second, the increase in studies confirming previously suspected or proven links between cannabis and psychological or social harmful effects; and third, the increase in the THC content of cannabis preparations – an issue which is mentioned ever more frequently. This trend among researchers and clinicians may be illustrated by two 2002 issues of scientific journals. First, one issue of the British Medical Journal devotes its “editorial page” to these problems and also presents four studies shedding light on this theme (Rey & Tennant, 2002). Second, Addiction – which is probably the world’s leading journal in this field – published a 140-page supplement on the treatment of cannabis abuse in December 2002. This supplement begins with a thorough and concerned overview of the increased number of scientific studies demonstrating the harmful effects, particularly the psychological ones, of cannabis. It then devotes thirteen articles to presenting two very large (over 1,000 patients) research projects
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