Cannabis Evidence Series An Evidence Synthesis The Health Technology Assessment Unit, University of Calgary February 2, 2017 Cannabis Evidence Series February 2, 2017 Acknowledgements This report is authored by Laura E. Dowsett, Ally Memedovich, Hannah Holitzki, Laura Sevick, Sarah Ghali, Tamara McCarron, Stephanie Coward, Kelsey Brooks, Kai Lukowiak, Dolly Han, Vishva Danthurebandara, Diane Lorenzetti, Rebecca Haines-Saah, Tom Noseworthy, Eldon Spackman, and Fiona Clement on behalf of the HTA Unit at the University of Calgary. The authors declare no conflict of interests. This report was supported by a financial contribution from Alberta Health through the Alberta Health Technologies Decision Process, the Alberta model for health technology assessment (HTA) and policy analysis. The views expressed herein do not necessarily represent the official policy of Alberta Health. © 2016 Government of Alberta 2 Cannabis Evidence Series February 2, 2017 Issue Cannabis is the most widely used illicit drug in Canada; however, it is illegal to possess, produce or sell it 1. In 2015, the Liberal government of Canada formed a majority government and announced their plan to legalize cannabis. In June of 2016, a nine-member federal task force on cannabis was announced. The task force, chaired by Anne McLellan, includes representation from Quebec, British Columbia, Newfoundland and Labrador, Ontario, and Saskatchewan 2. Guided by this task force, cannabis legislation is expected to be introduced in 2017. Objective To inform Alberta’s response to the federal decision to legalize cannabis, the University of Calgary Health Technology Assessment (HTA) Unit is developing a series of evidence syntheses to support policy development by the Government of Alberta. This evidence series consists of five reports that address: Canadian Context Health effects and harms Medical cannabis Advertisement and communication regulations Experience with legalization among jurisdictions who have legalized including economic, sales and use regulations © 2016 Government of Alberta 3 Cannabis Evidence Series February 2, 2017 Executive Summary and Policy Messages © 2016 Government of Alberta 4 Cannabis Evidence Series February 2, 2017 Background Cannabis is the most widely used illicit drug in Canada; however, it is illegal to possess, produce, or sell cannabis 1. In 2015, the Government of Canada announced plans to legalize cannabis for non-medical use. In June of 2016, a nine-member federal task force on cannabis was established. The task force, chaired by Hon. Anne McLellan, includes representation from Quebec, British Columbia, Newfoundland and Labrador, Ontario, and Saskatchewan 2. The Task Force released its Framework for the Legalization & Regulation of Cannabis in Canada on November 30, 2016. Guided by input from this Task Force, cannabis legislation is expected to be introduced in 2017. To inform Alberta’s preparation for the federal decision to legalize cannabis, the University of Calgary Health Technology Assessment (HTA) Unit has completed a series of evidence syntheses to support policy development by the Government of Alberta. The five evidence syntheses focus on the following topics: 1. Current Canadian context 2. Health harms and effects 3. Medical cannabis 4. Advertising and communication 5. Experience with legalization The purpose of this current report is to highlight the key findings and gaps from these evidence syntheses emerging policy options. Summary of Topic 1: Current Context Cannabis sativa, also known as cannabis, cannabis, weed, pot, or bud, is a multi-use crop that has been cultivated by humans for thousands of years. Today, there are three varieties of cannabis, C. sativa, C. indica, and ‘hybrid strains’, each of which induce different psychological and physiological effects depending on which cannabinoids they contain 3. The two most notable cannabinoids commonly investigated for medicinal use are tetrahydrocannabinol (THC) and cannabidiol (CBD). There are three broad categories of regulation for the non-medical use of cannabis: criminalization, decriminalization and legalization. When cannabis is criminalized, it is regulated as an illegal substance; the purchasing, selling and use of cannabis is prohibited and enforced 4. © 2016 Government of Alberta 5 Cannabis Evidence Series February 2, 2017 Levers for enforcement may include fines, incarceration, and/or mandatory treatment 4. Individuals found possessing, using or selling cannabis will have a criminal record 4. In places where cannabis is decriminalized, it is still considered an illegal substance; however, penalties are non-criminal in nature for some or all offenses 4,5. Some countries that have decriminalized use have regulations on ages of use, what products may be used, how much cannabis may be possessed, and potency 4. Fines may be used as an enforcement lever, but are not related to a criminal record 4. Legalization refers to a regulatory approach where cannabis is identified as a legal substance for non-medical use under the law 4, and all legal prohibitions against it have been removed 5. Where cannabis is legal, it may be regulated by regional jurisdiction, the country, or it may be unregulated (free-market) 4. When regulated by regional jurisdiction or country, elements that may be regulated include: production, distribution, minimal age to purchase, possession limits, cultivation for personal use, and driving while under the influence. 4. International Context Internationally, there is a continuum of cannabis regulatory approaches from criminalization to decriminalization and legalization. The possession of non-medical cannabis is legal in Uruguay, eight American states and one American jurisdiction, including Washington State, Colorado, Oregon, Alaska, Washington D.C., California, Maine, Massachusetts, and Nevada, and has been decriminalized in 31 countries and 18 states. Cannabis continues to be included within the United Nations (UN) drug control regime. When any UN nation chooses to legalize cannabis, it violates international law. Accordingly, that country is required to formally withdraw from these treaties 6. Canadian Context Within Canada, medical use of cannabis became legal with the passing of the Marijuana Medical Access Regulation in 2001. However, non-medical use has remained illegal since it was added to the Opium and Narcotics Drug Act in 1923. The debate on legalizing, decriminalizing or maintaining the status quo of non-medical cannabis largely began in the 1960s. However, no significant steps were taken towards legalizing, until the current Liberal Party of Canada formed a majority Federal Government in 2015 and announced their plan to legalize cannabis. On June © 2016 Government of Alberta 6 Cannabis Evidence Series February 2, 2017 20th, 2016 a Federal Task Force on Cannabis chaired by Hon. Anne McLellan was struck with the purpose of collecting input on how to legalize non-medical cannabis. If the federal government decides to legalize cannabis, Canada would be the second country in the world to consider it a legal substance (Uruguay being the first). Although it is illegal, cannabis is a widely used substance in Canada. Nationally, 10.5% of Canadians self-report using cannabis within the last 12 months and 33.7% report lifetime use. In Alberta, 8.9% used cannabis within the last 12 months. Sixty-five percent of Canadians support legalization of cannabis; support is highest in British Columbia and lowest in Quebec. Individuals are more likely to support legalization if they have used cannabis in the past 12 months, are under 35 years old, are male, have an annual income over $80,000, and have a university degree. Most Canadians who support legalization for non-medical use say they do so because they do not believe alcohol, tobacco and cannabis are different, and because they do not think cannabis possession should be penalized with a criminal record. Those who do not support legalization feel primarily that we need to protect children and youth, are particularly concerned about driving while under the influence, and do not believe the Federal Government should be involved in decisions such as these. Summary of Topic 2: Health Effects and Harms There is a considerable amount of research on physical and mental health harms related to non-medical cannabis use; a review of the literature found 64 systematic reviews on health effects and harms related to cannabis. The evidence suggests that cannabis may be associated with harm to physical and mental health. Specifically, there is an association with an increased risk of: testicular cancer; increased risk of mental health problems (including psychosis, mania, relapse of psychosis or schizophrenia); and, poor outcomes during pregnancy, such as low birth- weight babies, birth complications, pulmonary dysfunction, neurocognitive brain changes and functional brain changes. There is inconclusive evidence on many harms such as brain changes, bladder, prostate, penile, cervical and childhood cancers, bone loss, atrial fibrillation, suicide, depression, anxiety, and all-cause mortality. There is evidence that cannabis does not increase the risk of arteritis, lung, and head and neck cancers. A systematic review on the effects of second-hand cannabis smoke found that inhalation of second- hand smoke can result in detectable cannabinoids and metabolites in blood and urine. © 2016 Government of Alberta 7 Cannabis Evidence Series February 2, 2017 Non-smokers may experience psychoactive effects when exposed