Online survey into developing a model for a legal cannabis market in the United Kingdom

Background Despite rescheduling of cannabis to Schedule 2 and amendments to the law permitting legal availability of cannabis for the treatment of medical conditions, access to cannabis for medical use remains challenging for patients in the United Kingdom (UK). Recreational use is widespread despite laws stating users can be sentenced to prison for up to 5 years for possession. Objective The aim of the study was to develop a model for a legal cannabis market in the UK building upon the results of a preceding study in which a UK population sample determined that pharmacies are the most suitable primary legal vendor of cannabis as opposed to regulated shops or the black market. Methods An online survey was developed using Qualtrics software and advertised via the Multidisciplinary Association for Psychedelic Studies’ Facebook, Twitter and Instagram social media accounts and monthly newsletter. Results Three hundred and ninety seven individuals, a majority having used cannabis at least once, consented to participate in the study. The participants concluded that there is enough evidence for cannabis to be prescribed to treat a range of medical conditions. In addition to pharmacies providing cannabis to patients with a prescription, a majority of participants supported cannabis being sold in pharmacies for harm reduction purposes and allowing access to medicinal cannabis in cases where supporting evidence is insufficient to merit a prescription. Participants supported greater integration between dispensing pharmacies and mental health services. Overall, the participants did not oppose a consultation or screening for potential cannabis users prior to obtaining access from licensed vendors. UK participants were supportive of the concept of a cannabis card, which users can present to licensed vendors such as pharmacies, with specific recommendations (such as strains relevant to a patient’s medical condition) being coded into the card. A majority of participants supported the existence of shisha-type bars for the purchase and onsite consumption of cannabis and determined that such vendors should not be part of a pharmacy chain of stores or regulated by pharmacy regulators. The participants generally preferred that laws regarding public consumption are in line with existing smoking legislation. Participants determined that it should be legally permitted to grow cannabis at home for personal medical and non-medical purposes but not to sell for profit. Conclusion The results are suggestive of a regulatory system that medical and non-medical cannabis users can use which aims to maximise therapeutic applications, minimise harms and respect individual liberty.

Facing drug addiction: Vietnam’s struggle with opioids

Drug addiction is a historical issue in Vietnam. Although Vietnam has a long history as a producer of opium poppies and crossroads for the illicit drug trade, it is now has some of the most stringent drug laws in the world. Vietnam has shown some success in reducing the production, trade, and transportation of narcotics. There has also been a shift in the attitudes of lawmakers and government authorities toward viewing drug abuse as a health problem rather than a social vice. Educating and encouraging citizens to collaboratively reduce drug use has also proven effective. However, despite these changes, the number of people who use drugs has increased in recent years. The US, too, has also experienced an increase in illicit opioid use. The Trump administration declared opioid addiction a public health emergency and has established goals to address the crisis. The results of these efforts have also been uneven. This article reviews Vietnam’s efforts to tackle its opioid epidemic, with the goal of identifying areas where Vietnam’s approach to opioid addiction may be improved. A brief overview of efforts by the U.S. government, an important foreign partner for Vietnam in the control of illicit opioids, serves to demonstrate the difficulty of treating opioid use in different political systems.

Medical cannabis and epilepsy in the UK – A qualitative analysis of the carers’ perspective: “We're asking for quality of life for our children”

Despite the legalisation of cannabis based medicinal products (CBMPs) in the UK in November 2018, today there remains a scarcity of NHS prescriptions, and many patients continue to face unsustainable financial costs to acquire their medicines. Following on from our previous quantitative study highlighting the effectiveness of CBMPs to treat severe intractable childhood-onset epilepsy, for the present study, we used a narrative, open-ended approach to interview parents/carers of these patients. 11 families were interviewed to understand their current situation in more depth, and to contextualise the previous findings. Although these families have found CBMPs to be the most effective treatment for their child’s condition, access to these medicines remains severely restricted, causing serious challenges in their day-to-day life. Participants discussed a broad range of issues associated with medical cannabis. These included the regulation and policy surrounding medical cannabis, the anger and desperation related to these policies, and the benefits and harms of it. Evidently, the benefits of medical cannabis for these patients far outweigh any associated risks. Many of the issues raised in our study go beyond the science of medical cannabis per se. Rather, they are political issues, related to the wider issue of trust and power in society, and associated challenges of the doctor and patient relationship. The findings highlight the importance of including patients in decision-making about their medical plans and the value that should be given to their reported outcomes and wishes. We conclude by offering implications for further research and for policy making so that these families, and others like them, can finally receive the medications they so urgently require without crippling financial costs.

The risk of being culpable for or involved in a road crash after using cannabis: A systematic review and meta-analyses

Background The development of drug driving policies should rest on sound epidemiological evidence as to the crash risks of driving after using psychoactive drugs. The findings from individual studies of the increased risk of crashing from the acute use of cannabis range in size from no increase (and perhaps even a protective effect) to a 10-fold increase. Coherent cannabis-driving policies cannot readily be developed from such an incoherent evidence base. A weighted average measure of risk, as provided by a meta-analysis, might be useful. However, if the range of risks found in the cannabis-crash studies reflects the different ways that a variety of biases are being expressed, then the simple application of a meta-analysis might provide little more than an average measure of bias. In other words, if the biases were predominantly inflationary, the meta-analysis would give an inflated estimate of crash risk; and if the biases were predominantly deflationary, the meta-analysis would give a deflated estimate of risk. Review We undertook a systematic search of electronic databases, and identified 13 culpability studies and 4 case–control studies from which cannabis-crash odds ratios could be extracted. Random-effects meta-analyses gave summary odds ratios of 1.37 (1.10–1.69) for the culpability studies and 1.45 (0.94–2.25) for the case–control studies. A tool was designed to identify and score biases arising from: confounding by uncontrolled covariates; inappropriate selection of cases and controls; and the inappropriate measurement of the exposure and outcome variables. Each study was scrutinised for the presence of those biases, and given a total ‘directional bias score’. Most of the biases were inflationary. A meta-regression against the total directional bias scores was performed for the culpability studies, giving a bias-adjusted summary odds ratio of 0.68 (0.45–1.05). The same analysis could not be performed for the case–control studies because there were only four such studies. Nonetheless, a monotonic relationship was found between the total bias scores and the cannabis-crash odds ratios, with Spearman's rho = 0.95, p = 0.05, indicating that the summary odds ratio of 1.45 is an overestimate. It is evident that the risks from driving after using cannabis are much lower than from other behaviours such as drink-driving, speeding or using mobile phones while driving. With the medical and recreational use of cannabis becoming more prevalent, the removal of cannabis-presence driving offences should be considered (while impairment-based offences would remain).

Nonclinical abuse liability testing of new CNS-active drugs: Role of sex as a critical factor for drug scheduling

All new drugs targeting or influencing the central nervous system (CNS) must be screened for Drug Abuse Liability (DAL) prior to license approval by the FDA. Drug discrimination, self-administration, and drug dependence potential study designs are three core behavioral assays proposed in the 2017 FDA Guidance to Industry on Abuse Liability Testing for submission to the agencies for review at the time of the NDA submission. There are no international or federal drug control agency requirements for which animal species to use and selection of the test parameters for the sex, strain, age, dose range, study duration, systemic drug exposure thresholds or positive comparators to use in the conduct of these studies. In pre-IND and pre-NDA discussions with sponsor representatives, it is the FDA that has placed the financial burden on the industry to conduct these studies in both sexes in, what appears to be, a direct conflict with the intent of the Animal Welfare Act (1996). There is no single drug-of-abuse that is self-administered exclusively by one sex and there are no differential schedule controls placed on any drug substance based on any sex- or gender-based pharmacokinetic parameter. These nonclinical assays used for drug control scheduling actions should be conducted in only one sex unless there is a strong indication that sex is an important factor in the therapeutic use of the new drug or the mechanism of action.

Perspectives of drug treatment and mental health professionals towards treatment provision for substance use disorders with coexisting mental health problems in England

Background Opioid-related deaths are at record levels in the UK and contribute to over half of all drug-related deaths. The prevalence of psychiatric disorders within people who uses substances is known to be considerably higher than the general population, yet only 4% of people accessing treatment are thought to receive integrated care for coexisting conditions. This study aimed to explore perspectives on treatment for people with substance use disorders and coexisting psychiatric problems. Methods Face-to-face semi-structured interviews with community drug workers, specialist nurses, prescribing administration worker and one clinical psychologist were conducted. Deductive analysis of three preconceived themes (i.e. reasons for substance use, treatment provision, the role of medication) was conducted. Results There was agreement between drug treatment professionals and mental health professionals for the complexities for being in treatment for people who use substances. An expectancy of prolonged periods of abstinence from drug and alcohol use before psychological treatment would be initiated leading to relapse was reported. Individual judgements of practitioners, stigmatisation and fear of people who use substances and organisational barriers often meant psychological help was unavailable which contributed to a reliance on medication, against national clinical guidance which was known by only one interviewee. Conclusion The UK drug treatment and mental health services should review the pathways to ensure that national guidelines are followed so that people who use substances are not excluded from accessing psychological therapies. Data from the coronavirus pandemic indicates heightened psychiatric problems, where illicit drug use may escalate as a means of self-medication leading to further increases in drug-related deaths.

Buprenorphine for the management of kratom dependency during covid-19: A case report

We describe a case report where buprenorphine was successfully used for the management of kratom ( Mitragyna speciosa) dependency during the Covid-19 pandemic in a specialist community substance misuse treatment service. The individual had a notable iatrogenic dependency on oral over the counter and prescribed opioid medication. She resorted to using kratom as a ‘tea’ to self-detoxify before getting into difficulty. Upon presentation, she disclosed using kratom up to 70 g/day with hourly dosing, in addition to co-codamol (8 mg codeine/500 mg paracetamol tablets) three times a week. Initiation of oral buprenorphine sublingual tablets was complicated due to Covid-19: dispensing arrangements were liberalised from the outset and the dose was incrementally increased, eventually to 24 mg/day. Comorbidities included mental health conditions and chronic pain which improved with buprenorphine treatment and psychotherapy. Further research is required to determine optimal regimens for the management of kratom dependency. This case study adds to the current paucity of published data regarding how to manage such cases in the community setting, which is important since kratom is thought to be increasingly used in the western world.

The cocaine-e-cigarette – A theoretical concept of a harm reduction device for current users of smokable cocaine forms

Although there are great regional differences, smokable forms of cocaine (crack, free-base, paco, etc.) are a drug complex associated with often harmful and problematic drug use patterns. While strategies based on drug prohibition did not eradicate the consumption of smokable cocaine forms, prohibition itself led to many harmful effects, such as criminalisation, stigmatisation, unpredictable smokable cocaine forms quality and hardly any safer-use education. While there are many positive insights from heroin-assisted treatment programs with regard to heroin users, there are no comparable programs for problematic users of smokable cocaine forms. Smokable cocaine forms are challenging due to their different pharmacology and particularly their short duration leading to often many administrations per day. In this manuscript a device for a heroin-assisted treatment-like program for problematic users of smokable cocaine forms is suggested. This device is a cocaine-e-cigarette which could be prescribed to problematic users of smokable cocaine forms to reduce the risk of lung damage, exclude potentially harmful adulterants, limit intake (by formulation and/or technical settings) and also to bring users of smokable cocaine forms into the medical system to address comorbidities and risk factors, for example cardiovascular conditions, insomnia, depression, etc. This manuscript describes basic functionality and general specifications of a cocaine-e-cigarette as a medical device treating people with respective cocaine use disorder when cessation and substitution are not considered an option.

Illegal drugs in the UK: Is it time for considered legalisation to improve public health?

This paper investigates options available to policy makers responding to the challenges of drug use in modern society, focussing on the UK. It investigates the failings of prohibition policy that has driven historic reactions to drugs, drug use and drug users globally, nationally and locally. This policy paradigm has been largely destructive and counter-productive and has led to a whole host of health and social problems. The authors have approached their investigation from a public health perspective, free from moral biases that have driven many policy initiatives until now. Many countries and regions of the world are rejecting prohibition as they move towards public health models in opposition to criminal justice responses, and this trend is continuing. Four policy models are examined; prohibition as the status quo; extension of prohibition to include alcohol and other drugs; decriminalisation; legalisation and regulation of all drugs. Each of these policy options are contested; none have universal support. However, given careful consideration, this paper proposes that our only way out of the public health and criminal justice crises that have been driven by drug policy globally is to adopt the more contentious option of legalisation and regulation of all drugs commonly used non medically.