Are cannabis use problems comparable across individuals using for recreational and medical purposes? An international cross-sectional study of individuals who use self-grown cannabis.

BACKGROUND: Little is known about cannabis use problems among individuals who use cannabis for medical purposes and whether rates and determinants of cannabis use problems in medical users differ to those observed among individuals using for recreational reasons. This study examines whether Severity of Dependence Scale (SDS) scores differ across individuals who use self-grown cannabis for the following reasons: "recreational only", "medical and recreational" and "medical only". Furthermore, the study tests whether cannabis use frequency, cannabis strain, and type of cannabis influences the strength of the association between purpose of use and cannabis use problems. METHODS: Data (n = 5,347) were collected from a subsample of the Global Cannabis Cultivation Research Consortium project, focusing on small-scale cannabis growers in 18 countries. Robust regressions analyzed differences in SDS scores across the three use motivation groups. RESULTS: Compared with respondents reporting only recreational motivations of cannabis use, those with medical (with and without recreational) motivations were associated with lower SDS scores (B: -0.190 and B: -0.459, p < 0.001 respectively). Daily use was associated with significantly higher SDS scores across all cannabis motivation groups, albeit the magnitude of the association was significantly smaller among individuals with medical motivations of use. CONCLUSION: The extent to which people experience cannabis use problems, and the determinants of these problems may differ depending on whether cannabis use is motivated by recreational or medical purposes. As such, the findings of the current study suggest that public education efforts, harm reduction approaches and policy responses should be tailored depending on whether cannabis is used for recreational or medical purposes.

Perceived harms and protective behavioural strategies among khat chewers: a qualitative study in Jimma, Ethiopia.

BACKGROUND: While there have been many previous studies focusing on the adverse effects of khat chewing, attempts to investigate the protective behavioural strategies (PBS) employed by the khat using population are rare. PBS are strategies that substance users employ to minimize or alleviate the possible negative consequences related to the behaviour. This study focuses on the harms that chewers associate with khat use, and the behavioural strategies they practise to prevent or minimize these harms. METHODS: A community-based qualitative study was conducted using a snowball sampling technique to recruit a diverse sample of khat chewing participants (N = 102) in Jimma city, Ethiopia. Face-to-face in-depth interviews were carried out with the participants. RESULTS: Participants identified a variety of harms likely to result from chewing khat. These include impacts on their finances, work, social life and health. The PBS that participants employed to avoid or minimize the risks were classified into four themes based on their temporal sequence with khat chewing sessions: prior to chewing, during chewing, after chewing and general PBS covering the whole of their khat chewing career. The PBS enable khat chewers to prevent or minimize the adverse health consequences of chewing, socialize and work without or with fewer difficulties and manage their economy successfully. CONCLUSION: The study participants believe that khat-related harms are avoidable if khat users implement appropriate strategies prior to, during and after chewing, and if they apply PBS to khat-related factors (e.g. type, amount and frequency), set factors (e.g. reason for using and health behaviour) and setting factors (e.g. place of use, when used, with whom used and social norms) covering the whole of their khat chewing career.

Is chewing khat associated with mental health disorders? A scoping review of the content and quality of the current evidence base.

BACKGROUND: Khat (Catha edulis) is a plant commonly found in the horn of Africa whose leaves are chewed for their psycho-stimulant effects. Several studies have demonstrated the association between khat use and mental health problems. Nevertheless, evidence is mixed and inconsistent, warranting further review of available studies. This scoping review is aimed at investigating the content and quality of evidence base on the associations between khat use and mental health disorders and suggesting avenues for further research. METHODS: We used a scoping review methodology to map the existing evidence using PubMed, SCOPUS, Embase, and CINAHL databases. Primary studies focusing on the association between any pattern of khat use and any form of mental health disorders are included. The review focused on all age groups, any study design, all geographical locations, and any publication year. The terms used for searching eligible studies include khat, mental disorders, and various alternative terminologies. Narrative review is employed to present findings. RESULTS: 7,121 articles were found, of which 108 were eligible, conducted across 12 different countries. The majority of the studies was done during the last ten years and the studies mostly employed cross-sectional design. About 10 different categories of mental health disorders have been identified as showing associations with khat use. Despite many contradictory findings between the studies, most of the evidence base suggests that khat use is associated with mental health disorders. Non-specific psychological distress is the most frequently mentioned mental health problem (reported in 26.9% of the studies). Khat use as a predictor variable is mostly assessed using a 'yes/no' category, and as a result, dose-dependent effects of khat use on mental health are not given much consideration. CONCLUSION: Although most of the studies associate khat use with mental health disorders, the causal relationships are inconclusive given the cross-sectional design of the studies, and the presence of potential confounders and several forms of biases. Available studies also report contradictory findings. Further studies are recommended using prospective designs, standardized and valid measures of khat use, and focusing on specific types of mental health disorders.

Assessing options for cannabis law reform: A Multi-Criteria Decision Analysis (MCDA) with stakeholders in New Zealand.

BACKGROUND: A number of jurisdictions are considering or implementing different options for cannabis law reform, including New Zealand. Multi-Criteria Decision Analysis (MCDA) helps facilitate the resolution of complex policy decisions by breaking them down into key criteria and drawing on the combined knowledge of experts from various backgrounds. AIMS: To rank cannabis law reform options by facilitating expert stakeholders to express preferences for projected reform outcomes using MCDA. METHODS: A group of cannabis policy experts projected the outcomes of eight cannabis policy options (i.e., prohibition, decriminalization, social clubs, government monopoly, not-for-profit trusts, strict regulation, light regulation, and unrestricted market) based on five criteria (i.e., health and social harm, illegal market size, arrests, tax income, treatment services). A facilitated workshop of 42 key national stakeholders expressed preferences for different reform outcomes and doing so generated relative weights for each criterion and level. The resulting weights were then used to rank the eight policy options. RESULTS: The relative weighting of the criteria were: "reducing health and social harm" (46%), "reducing arrests" (31%), "reducing the illegal market" (13%), "expanding treatment" (8%) and "earning tax" (2%). The top ranked reform options were: "government monopoly" (81%), "not-for-profit" (73%) and "strict market regulation" (65%). These three received higher scores due to their projected lower impact on health and social harm, medium reduction in arrests, and medium reduction in the illegal market. The "lightly regulated market" option scored lower largely due its projected greater increase in health and social harm. "Prohibition" ranked lowest due to its lack of impact on reducing the number of arrests or size of the illegal market. CONCLUSION: Strictly regulated legal market options were ranked higher than both the current prohibition, and alternatively, more lightly regulated legal market options, as they were projected to minimize health and social harms while substantially reducing arrests and the illegal market.

Growing practices and the use of potentially harmful chemical additives among a sample of small-scale cannabis growers in three countries.

BACKGROUND: With the growth of legal cannabis markets there has been recognition of the adverse impacts of certain cannabis growing practices, notably, use of harmful chemicals. A major concern has been the use of Plant Growth Regulators (PGRs) which limit plant size and stimulate bud production. These chemicals, many of which have been banned from food crops, have been found unlisted in cannabis growing nutrients sold online or in hydroponic stores. This study describes the cannabis growing practices used by small-scale recreational cannabis growers and specifically their self-reported use of chemicals. METHODS: Web survey data from 1722 current and recent cannabis growers in Australia, Denmark, and the UK, who were asked about their cannabis growing practices, including the use of fertilizers and supplements. RESULTS: Overall 44% of the sample reported using any chemical fertilizers, supplements or insecticides. Logistic regression indicated that the unique predictor of the use of chemicals was growing hydroponically. CONCLUSION: Problems associated with product labeling and uncertainty regarding product constituents made it difficult for growers and the researchers to determine which products likely contained PGRs or other harmful chemicals. There is a need for further research to analyze constituents of chemical products marketed to cannabis growers.

The burgeoning recognition and accommodation of the social supply of drugs in international criminal justice systems: An eleven-nation comparative overview.

BACKGROUND: It is now commonly accepted that there exists a form of drug supply, that involves the non-commercial supply of drugs to friends and acquaintances for little or no profit, which is qualitatively different from profit motivated 'drug dealing proper'. 'Social supply', as it has become known, has a strong conceptual footprint in the United Kingdom, shaped by empirical research, policy discussion and its accommodation in legal frameworks. Though scholarship has emerged in a number of contexts outside the UK, the extent to which social supply has developed as an internationally recognised concept in criminal justice contexts is still unclear. METHODS: Drawing on an established international social supply research network across eleven nations, this paper provides the first assessment of social supply as an internationally relevant concept. Data derives from individual and team research stemming from Australia, Belgium, Canada, Czech Republic, Finland, Germany, Hong Kong, the Netherlands, England and Wales, and the United States, supported by expert reflection on research evidence and analysis of sentencing and media reporting in each context. In situ social supply experts addressed a common set of questions regarding the nature of social supply for their particular context including: an overview of social supply research activity, reflection on the extent that differentiation is accommodated in drug supply sentencing frameworks; evaluating the extent to which social supply is recognised in legal discourse and in sentencing practices and more broadly by e.g. criminal justice professionals in the public sphere. A thematic analysis of these scripts was undertaken and emergent themes were developed. Whilst having an absence of local research, New Zealand is also included in the analysis as there exists a genuine discursive presence of social supply in the drug control and sentencing policy contexts in that country. RESULTS: Findings suggest that while social supply has been found to exist as a real and distinct behaviour, its acceptance and application in criminal justice systems ranges from explicit through to implicit. In the absence of dedicated guiding frameworks, strong use is made of discretion and mitigating circumstances in attempts to acknowledge supply differentiation. In some jurisdictions, there is no accommodation of social supply, and while aggravating factors can be applied to differentiate more serious offences, social suppliers remain subject to arbitrary deterrent sentencing apparatus. CONCLUSION: Due to the shifting sands of politics, mood, or geographical disparity, reliance on judicial discretion and the use of mitigating circumstances to implement commensurate sentences for social suppliers is no longer sufficient. Further research is required to strengthen the conceptual presence of social supply in policy and practice as a behaviour that extends beyond cannabis and is relevant to users of all drugs. Research informed guidelines and/or specific sentencing provisions for social suppliers would provide fewer possibilities for inconsistency and promote more proportionate outcomes for this fast-growing group.

Regulating Cannabis Social Clubs: A comparative analysis of legal and self-regulatory practices in Spain, Belgium and Uruguay.

BACKGROUND: Cannabis Social Clubs (CSCs) are a model of non-profit production and distribution of cannabis among a closed circuit of adult cannabis users. CSCs are now operating in several countries around the world, albeit under very different legal regimes and in different socio-political contexts. AIM: In this paper we describe and compare the legal framework and the self-regulatory practices of Cannabis Social Clubs in three countries (Spain, Belgium, and Uruguay). The objective of our comparative analysis is to investigate how CSCs operate in each of these countries. To foster discussions about how one might regulate CSCs to promote public health objectives, we conclude this paper with a discussion on the balance between adequate governmental control and self-regulatory competences of CSCs. METHODS: The data used for this analysis stem from independently conducted local studies by the authors in their countries. Although the particular designs of the studies differ, the data in all three countries was collected through similar data collection methods: analysis of (legal and other documents), field visits to the clubs, interviews with staff members, media content analysis. FINDINGS: We identified a number of similarities and differences among the CSCs' practices in the three countries. Formal registration as non-profit association seems to be a common standard among CSCs. We found nevertheless great variation in terms of the size of these organisations. Generally, only adult nationals and/or residents are able to join the CSCs, upon the payment of a membership fee. While production seems to be guided by consumption estimates of the members (Spain and Belgium) or by the legal framework (Uruguay), the thresholds applied by the clubs vary significantly across countries. Quality control practices remain an issue in the three settings studied here. The CSCs have developed different arrangements with regards to the distribution of cannabis to their members. CONCLUSIONS: By uncovering the current practices of CSCs in three key settings, this paper contributes to the understanding of the model, which has to some extent been shaped by the self-regulatory efforts of those involved on the ground. We suggest that some of these self-regulatory practices could be accommodated in future regulation in this area, while other aspects of the functioning of the CSCs may require more formal regulation and monitoring. Decisions on this model should also take into account the local context where the clubs have emerged. Finally, the integration of medical supply within this model warrants further attention.

Lessons from conducting trans-national Internet-mediated participatory research with hidden populations of cannabis cultivators.

BACKGROUND: Internet-mediated research methods are increasingly used to access hidden populations. The International Cannabis Cultivation Questionnaire (ICCQ) is an online survey designed to facilitate international comparisons into the relatively under-researched but increasingly significant phenomenon of domestic cannabis cultivation. The Global Cannabis Cultivation Research Consortium has used the ICCQ to survey over 6000 cannabis cultivators across 11 countries. In this paper, we describe and reflect upon our methodological approach, focusing on the digital and traditional recruitment methods used to access this hidden population and the challenges of working across multiple countries, cultures and languages. METHODS: Descriptive statistics showing eligibility and completion rates and recruitment source by country of residence. RESULTS: Over three quarters of eligible respondents who were presented with the survey were included in the final sample of n=6528. English-speaking countries expended more effort to recruit participants than non-English-speaking countries. The most effective recruitment modes were cannabis websites/groups (33%), Facebook (14%) and news articles (11%). While respondents recruited through news articles were older, growing practice variables were strikingly similar between these main recruitment modes. CONCLUSION: Through this process, we learnt that there are trade-offs between hosting multiple surveys in each country vs. using one integrated database. We also found that although perceived anonymity is routinely assumed to be a benefit of using digital research methodologies, there are significant limits to research participant anonymity in the current era of mass digital surveillance, especially when the target group is particularly concerned about evading law enforcement. Finally, we list a number of specific recommendations for future researchers utilising Internet-mediated approaches to researching hidden populations.

Global patterns of domestic cannabis cultivation: sample characteristics and patterns of growing across eleven countries.

BACKGROUND: This article aims to provide an overview of: demographic characteristics; experiences with growing cannabis; methods and scale of growing operations; reasons for growing; personal use of cannabis and other drugs; participation in cannabis and other drug markets; contacts with the criminal justice system for respondents to an online survey about cannabis cultivation drawn from eleven countries (N=6530). Important similarities and differences between the national samples recruited will be discussed. METHODS: This paper utilizes data from the online web survey of predominantly 'small-scale' cannabis cultivators in eleven countries conducted by the Global Cannabis Cultivation Research Consortium (GCCRC). Here we focus primarily on descriptive statistics to highlight key similarities and differences across the different national samples. RESULTS: Overall there was a great deal of similarity across countries in terms of: demographic characteristics; experiences with growing cannabis; methods and scale of growing operations; reasons for growing; use of cannabis and other drugs; participation in cannabis and other drug markets, and; contacts with the criminal justice system. In particular, we can recognise that a clear majority of those small-scale cannabis cultivators who responded to our survey are primarily motivated for reasons other than making money from cannabis supply and have minimal involvement in drug dealing or other criminal activities. CONCLUSIONS: These growers generally come from 'normal' rather than 'deviant' backgrounds. Some differences do exist between the samples drawn from different countries suggesting that local factors (political, geographical, cultural, etc.) may have some influence on how small-scale cultivators operate, although differences in recruitment strategies in different countries may also account for some differences observed.

Assessing the harms of cannabis cultivation in Belgium.

BACKGROUND: Since the 1990s, a shift from the importation of foreign cannabis to domestic cultivation has taken place in Belgium, as it has in many other countries. This shift has prompted Belgian policy-making bodies to prioritize the repression of cannabis cultivation. Against this background, the article aims to systematically map and assess for the first time ever the harms associated with cannabis cultivation, covering the whole spectrum of growers. METHODS: This study is based on a web survey primarily targeting small-scale growers (N=1293) and on three interconnected sets of qualitative data on large-scale growers and traffickers (34 closed criminal proceedings, interviews with 32 criminal justice experts, and with 17 large-scale cannabis growers and three traffickers). The study relied on Greenfield and Paoli's (2013) harm assessment framework to identify the harms associated with cannabis cultivation and to assess the incidence, severity and causes of such harms. RESULTS: Cannabis cultivation has become endemic in Belgium. Despite that, it generates, for Belgium, limited harms of medium-low or medium priority. Large-scale growers tend to produce more harms than the small-scale ones. Virtually all the harms associated with cannabis cultivation are the result of the current criminalizing policies. CONCLUSIONS: Given the spread of cannabis cultivation and Belgium's position in Europe, reducing the supply of cannabis does not appear to be a realistic policy objective. Given the limited harms generated, there is scarce scientific justification to prioritize cannabis cultivation in Belgian law enforcement strategies. As most harms are generated by large-scale growers, it is this category of cultivator, if any, which should be the focus of law enforcement repression. Given the policy origin of most harms, policy-makers should seek to develop policies likely to reduce such harms. At the same time, further research is needed to comparatively assess the harms associated with cannabis cultivation (and trafficking) with those arising from use.

Cannabis social clubs in Belgium: organizational strengths and weaknesses, and threats to the model.

BACKGROUND: Cannabis Social Clubs (CSCs) are private organizations or clubs of users that produce cannabis for non-profit distribution to adult members to meet their personal needs without having to turn to the black market. CSCs can be found in many countries, but the term often covers very different empirical realities. Inspired by the Spanish CSCs and similarly taking advantage of a grey area in the Belgian cannabis legislation, Belgian cannabis activists set up the first Belgian CSC in 2006, and there are now at least 5 Belgian CSCs. The paper's main objective is to analyse the (internal) strengths and weaknesses and the (external) opportunities and threats of the model, as it exists today. METHODS: The paper draws on a review of international literature and qualitative data on the Belgian cannabis social clubs. Field visits and interviews were conducted with each club. We analysed membership application forms, cultivation protocols and contracts with growers, cannabis ownership certificates of members, information leaflets, the clubs' websites, and all media articles and documentaries on the clubs in the Belgian media. RESULTS: The paper describes the membership criteria and house rules, the members' profile, the organization and protocols for cannabis production, the distribution of cannabis through 'exchange fairs', the administrative features of the clubs and their contacts with other CSCs and with local authorities, the drug sector and the media. Belgian CSCs seem not profit-driven, and operate as a system in which cannabis is not too easily available. The clubs have fairly direct control over the quality and the potency of the cannabis they distribute. The model offers important potential opportunities, in terms of economic advantages and monitoring consumption patterns. The main threats to Belgian CSCs consist of attempts to criminalize the model, the emergence of profit-driven clubs and systemic violence from criminal entrepreneurs. Weaknesses of the model relate to the unstable or transient nature of the clubs, the transparency of their operational procedures, the superficiality of their quality control strategies, and the risk of morphing into marketing enterprises. CONCLUSIONS: The CSC model could be a safe and feasible option for policymakers to move a meaningful distance along the spectrum towards legally regulated cannabis markets without crossing over to full commercial availability. Governmental regulation could convert weaknesses and threats to the model into strengths and opportunities to ensure best practice. If authorities refrain from action, the model might dilute and evolve in a similar way as the Spanish CSCs did recently, with the establishment of large, commercial clubs.

Growing medicine: small-scale cannabis cultivation for medical purposes in six different countries.

BACKGROUND: The production and consumption of cannabis for the treatment of medical conditions is of increasing importance internationally; however, research on different aspects of the phenomenon is still scarce. In this article, we report findings from a cross-cultural study of small-scale cannabis cultivation for medical purposes. This kind of comparative study has not been done previously. METHODS: The data were gathered with a help of web surveys conducted by the Global Cannabis Cultivation Research Consortium (GCCRC) in Australia, Belgium, Denmark, Finland, Germany and the UK (N=5313). In the analysis we compare reports of medical motives, for what conditions cannabis is used, whether users have diagnoses for these conditions and whether the use of cannabis been recommended as a treatment of those conditions by a medical doctor. Descriptive statistics are used to show the main commonalities and noteworthy disparities across different countries. RESULTS: Findings from countries were quite similar, even though several national differences in details were found. Growing cannabis for medical purposes was widespread. The majority of medical growers reported cultivating cannabis for serious conditions. Most of them did have a formal diagnosis. One fifth had got a recommendation from their doctor, but in most cases cannabis use was self-medication which was not discussed with their doctors. CONCLUSION: There is a wider demand for licit access for medical cannabis than currently available in these countries. Ideologically, medical growers can be seen distancing themselves from both the legal and illicit drug markets. From a harm reduction perspective, it is worrying that, in the context of present health and control policies in these countries, many medical growers are using cannabis to treat serious medical conditions without proper medical advice and doctor's guidance.

The case for small-scale domestic cannabis cultivation.

The shift to (inter)regional production, trade and domestic cultivation has become an irreversible international trend. Until now, the focus of most empirical work has been on large-scale, commercially oriented and professionally organized segments of the cannabis industry, often based on police data and on the perspective of law enforcement agencies. This paper offers a review of recent Dutch-language research that focuses on cannabis cultivation. Empirical studies were identified through literature searches using relevant search terms and Web of Science, Elin, Social Science Research Network and Elsevier ScienceDirect. The paper presents the main findings of Dutch and Belgian empirical work on the factors that stimulated the import substitution process on the cannabis market, aspects related to quality and potency issues, typologies of cannabis growers, and (unintended) effects of pursued policies. In the light of this (selective) review the author offers some commentary and analysis concerning the claims made by different stakeholders, and concludes with some reflections on future research and on policy implications. The author outlines the importance of small-scale, independent or ideologically oriented cannabis cultivation as an under-researched market segment. The author also makes a case for greater toleration of small-scale cannabis cultivation, to secure the least worst of cannabis markets.

Antwerp Drugs and Alcohol Monitor: a Belgian local drug scene in the picture.

INTRODUCTION AND AIMS: Qualitative data on local drug scenes in Belgium are scarce. As information on them remains limited to the official registration systems, the needs of a number of drug users are not taken into account. From a social scientific and policy point of view, there is a need for information on the experiences and the patterns of drug use. In this study, we have developed and tested a drugs and alcohol monitor for the city of Antwerp. DESIGN AND METHODS: The Antwerp Drugs and Alcohol Monitor (ADAM) combines three qualitative methods: (i) in-depth interviews with 39 key informants; (ii) ethnographic fieldwork by four community fieldworkers; and (iii) ethnographic fieldwork by the researcher. This methodology is based on an analysis of national and international literature on drug-monitoring systems. RESULTS: This paper presents an overview of the results of a pilot study in the city of Antwerp. The ADAM produces a detailed picture of the local drug issues (nature and extent of use, drug markets, quality of life, etc.) and thus offers the understanding that is required for a well-founded local drug policy. DISCUSSION AND CONCLUSIONS: Provided that repeated measurements are made, a local drug monitor can inform policymakers, treatment experts, etc. on developments and phenomena concerning drug use. However, the ADAM is a qualitative drug-monitoring system, and it must be emphasised that a combined monitor is more efficient. Indeed, a combination of qualitative and quantitative methods enhances the reliability of the results.