End Reefer Madness

The federal government has now produced its policy document on legalizing and regulating marijuana. ((See “A Framework for the Legalization and Regulation of Cannabis in Canada: The Final Report of the Task Force on Cannabis Legalization and Regulation,” published by Health Canada on November 30, 2016, and available at http://www.healthycanadians.gc.ca/task-force-marijuana-groupe-etude/framework-cadre/index-eng.php)) Its recommendations cover the production and distribution of both recreational and medical cannabis products. It is also concerned with restricting access, regulating advertising and promotion, encouraging education about its impacts, and ensuring that under the new regime teenage and adolescent use would be largely prevented.

This is a welcome initiative; legalization has occurred or is under way in many other jurisdictions, and the time has come for Canada to take a more constructive approach to the problems that arise from the use of illegal drugs. The document reflects nearly 30,000 submissions to the task force website by individuals and interested parties, apart from the deliberations of the Task Force on Cannabis Legalization and Regulation that held cross-Canada hearings last fall. Canadians should be pleased that they were consulted, and were given an opportunity to express their views while the legislative process is still evolving.

Public response has been mostly favourable, although many of the comments on the report lament the lack of detail in its more than 80 proposals. To say the least, it is a cautious document, and it reflects the concerns of medical experts who are knowledgeable about the effects of cannabis use on health; this is one of its most positive features.

The report outlines a set of policies that would keep cannabis out of the hands of children and youth, keep the profits out of the hands of organized crime, prevent Canadians from entering the criminal justice system, ensure that Canadians—and youth in particular—are well informed about the risks of cannabis use, and make cannabis available through a strict system of production, distribution and sales. The report also suggests 18 as the minimum legal age for consumption, and recommends that retail distribution be carefully controlled, and separated from existing alcohol and tobacco outlets.

A majority of Canadians want marijuana to be legal. An August 2014 Angus Reid poll showed that 59 percent favoured legalizing it, and more recent polls put the figure closer to 70 percent. However, the reasons for supporting this position vary across different subsections of the population. Regular users want to be able to purchase high-quality marijuana products that are safe and easily accessible, without any risk of involvement with the police. Yet they represent a very small minority. Statistics Canada’s 2012 Canadian Alcohol and Drug Use Monitoring Survey found that only ten percent of the population said they had used marijuana in the last year. While there may be obvious reasons why people might underreport marijuana use, most people who support legalization are not users, so why do they want a change in the way the government handles marijuana?

Many Canadians have young or teenage children or grandchildren and do not want them to become involved in the criminal justice system simply because they are smoking pot. They do not believe that moderate marijuana use poses significant health risks, and many share the views put forward by people ranging from Jimmy Carter to John Stuart Mill that there should be minimal sanctions on individual activity if it does little or no harm to others. Thus many people view marijuana as a problem only because it is illegal. One of the major consequences of its illegality is the involvement of organized criminal groups such as the Mafia and biker gangs in the production and distribution of cannabis products. If it is illegal, marijuana cannot be regulated, and profits from these activities cannot be taxed. The absence of regulation also means an absence of quality control and the sale of products whose properties are not known to the purchaser. This raises important public health concerns, although they are not as serious as those associated with heroin, cocaine and other hard drugs.

However, there are some concerns about cannabis use. The task force noted that in general, people would like marijuana access to be controlled and limited to adults, and this can happen only when marijuana use is legalized and regulated. It recognizes concerns about the health effects of marijuana use, especially on children and young adults. Current use by under-age adolescents is a major issue, even more so when there is no control over the quality or strength of products available illegally.

It can be argued that the report places too much emphasis on the needs of a minority—marijuana consumers and producers—at the expense of the majority of the population, which is more interested in having a system in which product safety and the health of young people are the overriding priorities. Consumer choice is important for those who use marijuana for pleasure, but marijuana policy should be driven by health and product safety considerations. These are what matter to the vast majority of Canadians who do not use ­marijuana.

Although few Canadians use marijuana, its use by adolescent males between the ages of 15 and 21 is much more common. The rate of marijuana use by young males is also higher than their use of tobacco, according to Statistics Canada. Up to the age of 20, a higher proportion of males use marijuana than cigarettes on a daily basis. Regular marijuana use peaks at age 20 for males. For females, the story is a little different, with much lower proportions of users than males, and less marijuana use than cigarette use. But what is most disturbing is the large proportion of users who start at very young ages. By age 16 about 20 percent of both adolescent males and females had used marijuana. The lowest ages reported were seven or eight. For health reasons, as discussed below, adolescent use is a serious problem, and reducing it should be the primary objective of new marijuana legislation. It is also clear from data on self-reported age at first use that very few adults start regular use over the age of 25. Thus although some adults continue adolescent consumption, there are very few adults who become regular users in later life.

Early use is reported to increase the likelihood of long-term habitual use and dependence. ((Educational attainment is negatively correlated with age of first daily cannabis use. Daily users with age of first use lower than 17 years had an average 62.5 percent lower chance of achieving a high school degree. Cannabis use has been described as a key factor in low educational attainment and increased symptoms of problematic mental health. There is a higher risk of failing to complete high school or postsecondary school among cannabis users who start using early. A recent Canadian-U.S. study showed that users who start below the age of 15 will report significantly poorer mental health scores for the rest of their lives.)) But there is an upside to marijuana use as well. Products derived from cannabis have been found to be effective as pain killers and anti-nausea remedies.

The type of distribution system for both recreational use and for medical use that eventually emerges as a consequence of legalization is critically important. The task force wants a high degree of control over the production and sale of cannabis products, but does not provide sufficient discussion or detail on how this is to be done. There are, in fact, many different models from which to choose.

In the United States, Colorado and Washington use the American liquor store model, where production and sales are carried out by small privately owned and registered vendors. However, price and product characteristics are unregulated, and, furthermore, these jurisdictions have not eliminated the black market for cannabis.

Uruguay uses a different type of model that has been legislated but not yet fully implemented. Marijuana use has been legal in Uruguay since 1974, but it was only at the end of 2013 that it became legal to produce and sell it commercially. Uruguayans can now grow up to six plants at home if they register as cannabis growers (the task force is also in favour of home production). They can buy it from pharmacies or participate in its production through “grow clubs,” which are small collectives in which each member has access to 40 grams of marijuana per month. Grow clubs have to register with the Institute for the Regulation and Control of Cannabis and be inspected on a regular basis. Users must also register. Marijuana products are also available from pharmacies, which are supplied by five large licensed firms, also monitored by the IRCCA as the regulatory authority. These commercial firms are not allowed to participate as retail sellers. Edibles and extracts (such as hashish) are legal, but there is a limit of 15 percent on the content of tetrahydrocannabinol, more commonly known as THC.

The task force discusses the Uruguay model as an option, but does not make any firm recommendations about where regulatory authority should be placed, whether at the federal or provincial/territorial level, or in terms of retail outlets.

A strong case can be made that a centralized federal authority for dealing with recreational use would suit Canadian needs well. Such an entity could be called the marijuana control board. The MCB would set the parameters of recreational cannabinoid products (THC content, pesticide use, treatment for mould, plant variety, testing procedures, etc.) as well as the wholesale and retail prices of all products across the country. This would ensure that the major objectives of government policy are achieved. Prices would be under the control of the agency. The only way illegal producers can be kept out of the market is for market conditions to make it unprofitable for them to participate. One of the main failings of the Colorado model is that retail market prices are so high that a significant proportion of all sales are still from black market producers. As a wholesale monopsony (only one buyer) and monopoly (only one seller to retailers), the MCB could appropriate most of the profits from marijuana transactions. It makes sense to license producers, but they would only be able to sell to the MCB, and do so only if they have successfully bid for a contract. Competition among producers is important and would guarantee the lowest possible costs.

The functioning of the MCB would be similar to that of the Liquor Control Board of Ontario or the Société des alcools du Québec, except that it would be a federal institution. It would have one central office staffed with marketing, health professionals and medical experts who can determine the most suitable and safest products to be made available to the market. Such a regulatory institution would oversee and control the activities of all the players involved in producing and distributing cannabis products.

The task force emphasizes the importance of ensuring uniform standards and regulatory controls over production, distribution and sales. It also recommends that the provinces and territories be responsible for overseeing wholesale distribution of marijuana, and of retail sales in close collaboration with municipalities. Given that pharmacies are provincially regulated, this would facilitate achieving the uniform standards established by the federal government.

Uruguay plans to use its network of pharmacies to sell recreational and medical marijuana to the general public. This is a good idea for several reasons, including the fact that pharmacies already exist in all the provinces and territories, so there would be no need to create new specialized distributors. Medical marijuana products should also be sold in pharmacies like other prescriptions or as over-the-counter medicines. There is no need for an additional set of outlets. There is some discussion of pharmacies by the task force, but their recommendations on store-front dispensaries do not distinguish between pharmacies and specialized stores. Internet access is also considered as a component of a distribution system.

The delivery system of marijuana distribution also has implications for the culture of marijuana use itself. There is a big difference between a system of stand-alone dispensaries highlighting their products, and the pharmacy model. A system of independent special purpose cannabis stores creates a higher profile for marijuana products. In Denver, Medicine Man, a family business, is the largest dispensary selling a wide variety of products for both medical and recreational purposes: 33 varieties of indica, sativa and hybrid marijuana for smoking, as well as extracts, edibles, tinctures, drinks and topicals. One of its hybrid products is “Purple Dream,” which has a THC content of 19.5 percent and sells for about US$354 an ounce. Its store on Nome Street in Denver has “bud­tenders” to assist its customers.

In Colorado, marijuana outlets also have their own websites promoting products in a way that is similar to advertising, but not recognized as such. Dispensary websites read like a department store catalogue. While advertising options are limited by law, websites are able to convey the characteristics of the products sold, customer reviews and the seller’s views on the benefits of consuming them. For example, Dixie Elixirs and Edibles, a Denver wholesale producer, sells a product called “Orange Awakening Mints.” According to Dixie, these mints “help enhance your alertness and increase your stamina.” Statements like this often appear as part of the seller’s product description and are an integral part of the industry’s sales strategy. Consumers can order online and have their choices ready for pick-up on the same day. Some stores also accept credit cards and offer loyalty programs.

In Colorado, pot is just another consumer product. It is questionable whether such a high-profile marketing approach, focusing on the desirability of cannabinoid use, is in the public interest. Pharmacies with their much larger product range would not focus exclusively on cannabinoids and would operate with a much smaller footprint.

The task force report notes that medical ­marijuana should be treated differently from recreational use but fails to reach firm recommendations on how.

It could be argued that medical marijuana should be the responsibility of Health Canada rather than a central marijuana control board such as the MCB.

At present, the way medical marijuana is made available to those in need is quite different from the usual procedures that cover the production and distribution of medicines. Pharmaceutical companies are the suppliers of both over-the-counter and prescription drugs. All medicines have to go through clinical trials whose results are then given to Health Canada as part of that approval process. When drugs come to market, they are accompanied by a detailed product description that says what the product is for, the appropriate dosages, possible side effects, and who should not take it and under what circumstances. This information is made available to doctors and pharmacists. Presumably this is the procedure that the task force wants when it says that medical marijuana products should be distributed “consistent with federal policy.” This protocol should be applied to all medical cannabis.

When cannabinoids become legal, the pharmaceutical industry will eventually produce a wide variety of products that will replace what now passes for medical marijuana. Synthetic THC (dronabinol and nabilone), and Savitex, which uses Tetranabinex and Nabidiolex extracts from the sativa plant, are already available as prescription drugs, and many more will follow. The evolution of this new class of products will make the distinction between recreational and medical marijuana less important.

Under the current system, doctors and pharmacists have argued that they are not well informed about the properties of medical marijuana. This makes it difficult for them to give their patients the best advice, and the Canadian Medical Association, as a result, is not in favour of doctors prescribing medical marijuana. This problem needs to be addressed, and making Health Canada approval for all medical cannabis products a requirement would go a long way in solving that problem.

A further concern is the age limit on recreational use; the task force suggests 18. As a policy, it may have little impact on use except that it allows for the prosecution of individuals selling to under-age users. What is needed are educational programs directed toward children and young adolescents. A recent Canadian Alcohol and Drug Use Monitoring Survey found that 62 percent of teenagers thought that regular marijuana use was harmful to present or future health, a reassuring finding that suggests there is some scope for successfully educating young adults about the adverse effects of early use.

The task force has produced a thoughtful and carefully considered document with many useful recommendations. It highlights the social and health costs associated with cannabinoid use. It also recognizes that there are medical benefits to marijuana use and that a policy is required to deal with the conflict that arises between the desire for recreational use and the health requirements of individuals who need marijuana. The sharing of regulatory responsibility between the proposed MCB and Health Canada is one way of dealing with this conflict.

All things considered, marijuana is much less harmful than tobacco. As a society we have come to terms with tobacco in spite of the fact that it has been shown to be dangerous to health and results in a large number of premature deaths every year. Concerns about marijuana use are real, but marijuana is less problematic and we should be optimistic that its legalization and regulation can be achieved relatively painlessly and with a large measure of public support.

The current policies relating to both recreational and medical marijuana use do not work and the general public has little confidence in them. It is time to turn the page on what has been a dismal policy failure and look for better alternatives. Hopefully, there will be a much fuller examination of the benefits of a centralized model of production, regulation and distribution before Canada adopts its new legislation.