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Official websites use. Share sensitive information only on official, secure websites. Landevej 61 - Herning - Denmark E-mail: p. Pedro Cabral Barata has received non-financial support from Janssen and Lundbeck. No other conflicts of interest declared concerning the publication of this article. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Cannabis is probably the most commonly used illicit drug. It is often regarded as a relatively nonharmful experience, even though evidence indicates otherwise. Legalization of non-medical cannabis, which has already taken place in several countries, is currently a controversial issue. To provide an up-to-date overview of current models and policies and their outcomes that can inform future political decisions regarding non-medical cannabis use. The reference lists of these articles were similarly used as bibliography sources. Gray literature was also included. While non-medical cannabis has been decriminalized in many countries, it has only been legalized in Uruguay, Canada, and some U. Several benefits of legalization were identified: decreases in cannabis-related crimes, law-enforcement and judicial costs; reduction in synthetic cannabis supply; decline in black economies and possible diminution of other illegal drug buying; and tax revenue increases. Reported legalization problems included: increases in cannabis use; cannabis-related disorders; and cannabis-related accidents and hospitalizations. Harm-reduction strategies are available in the scientific literature. Growing, although incomplete, evidence exists to guide policy makers, minimize cannabis-related harm, and positively contribute to public health, if the legalization path is to be followed. Dialogue between legislators and science should be encouraged. There are more than a few legalization pathways, with diverse economic, social and health wellbeing effects. Public health-driven, instead of profit-driven models, seem to offer the most benefits regarding non-medical cannabis legalization. Most of the true public health effects of cannabis legalization are still unknown, for we are still in the early stages of these policies and their implications. Future studies should address the medium-to-long-term social, economic, and health consequences of legalization policies. Keywords: Cannabis legalization, non-medical cannabis, Portugal, cannabis decriminalization. Cannabis is possibly the most widely-used illicit drug in the world. Recently, several countries have been discussing the possibility of legalizing largescale commercial cannabis production and sale of cannabis for non-medical use, sometimes called recreational use, after others had already established decriminalization and depenalization policies. Non-medical cannabis legalization is a controversial issue due to various moral, ethical, public health, legislative, and logistic issues associated with the matter. This review aims to provide an overview of current models and their outcomes that may help to inform future non-medical cannabis use policies. Taking the status quo of Portuguese cannabis usage and legislation as a point of departure, we comprehensively reviewed the existing literature regarding the experiences of countries where this drug has been decriminalized and, chiefly, legalized for non-medical use. We performed an up-to-date and comprehensive review based on scientific article searches and use of gray literature. We included peer-reviewed articles written in English, Spanish, and Portuguese, published between and December We included articles related to cannabis legalization policies across the globe and to the Portuguese drug decriminalization laws. The gray literature consisted of governmental and national legal documents, governmental and non-governmental organizations research reports, addiction textbooks, newspaper articles related to the legalization of cannabis, and Portuguese drug laws. We included gray literature written in English, Spanish and Portuguese. This literature was included because of the fact that such documents can hold essential and up-to-date information unavailable solely through article databases searches. While being aware of the risk of incorporating low-quality research, as well as possible bias due to political and social agendas, we aimed to include up-to-date gray literature of high quality and from reliable sources, attempting to cross-check the information whenever possible. In Portugal, cannabis is considered an illicit drug. For cannabis this is 25 grams and for hashish it is 5 grams. While the data on the outcomes of the Portuguese drug reform of is complex, it appears to have been positive in the 10 years that followed it, as consistently found across the literature:. Reduction of drug-related judicial costs. Even though drug use is not legal in Portugal — but a social offence 20 , 24 , 25 — the legalization of cannabis cultivation, sale and use has, in the last years, become a recurrent issue in Portuguese society, largely due to the unsatisfying results obtained under the prohibitionist pathway. This matter has already been reflected in Portuguese research, as a recent paper by Baptista-Leite et al. The estimated prevalence of cannabis use at any period of life in the Portuguese population is 9. A recent retrospective observational study that analyzed all hospitalizations that occurred in Portuguese public hospitals from to , reported a total of 3, hospitalizations with a primary diagnosis of psychotic disorder or schizophrenia and with a secondary diagnosis of cannabis abuse or dependence. Cannabis legalization is not a binary option opposing commercial legalization to continuing prohibition, as it includes a variety of possible programs. Several countries and states have abandoned the prohibitionist approach to drug use, and different regulation models have been adopted: Belgium, 20 , 38 the Netherlands, 20 , 22 - 24 , 37 , 39 , 40 Spain, 23 , 24 , 37 - 39 Uruguay, 22 - 24 , 38 , 41 Canada, 24 , 42 and, in the United States, 11 states and the District of Columbia. However, cannabis use for non-medical purposes has not yet been legalized in any European Union country. Some considerations must be made about the Dutch experience, both positive and negative. In Spain, possession and use in a public place is subject to administrative sanctions or fines. The first cannabis social club opened in Barcelona in Cannabis has been legalized and regulated for non-medical use in Uruguay, 22 - 24 , 38 , 41 , 45 Canada, 24 , 42 , 45 and some U. Uruguay became, in December , the first country in the world to legalize cannabis production, supply and non-medical use by adults. But legalization has not been a bed of roses in the United States. A large, nationally representative survey with , respondents comparing marijuana use before and after the legalization of non-medical marijuana in the United States identified increases not only in marijuana use but also in cannabis use disorder. On 17 October , Canada legalized and regulated non-medical use and supply of cannabis, 42 making it the second nation to do so, after Uruguay. The dual goals of this legalization were to reduce youth use and eliminate the illicit cannabis market. The economic impact of this policy has recently been studied. Legalization of non-medical cannabis use has had more than a few generalizable benefits: significant decreases in cannabis-related crimes, law-enforcement and judicial costs; reduction in synthetic cannabis supply; decline in black economies; and tax revenue increases. Cannabis use is common among young adults and less deleterious than other substances already available, like alcohol or tobacco; the criminalization of cannabis use is more injurious than the substance itself, since users can be subject to criminal charges for consuming it and they often disproportionately affect ethnic minorities; legalization can enable regulation of the content of cannabis products, therefore protecting consumers. Unsurprisingly, legalization of cannabis use has been associated with several drawbacks. Mixed outcomes were not restricted to Uruguay e. Moreover, both nations reported rises in cannabis experimentation. Box 1 presents a summary of the greatest benefits and drawbacks of the different types of legalization policies. These elements outline the careful and thoughtful considerations that ought to be undertaken before legislating. Hall et al. Governments can:. Target vulnerable cannabis users for intervention and treat them e. Along the same lines, and in the aftermath of legalization in the United States, Pardo 65 proposed that non-medical cannabis legalization policies should promote a public health perspective, avoiding early commercialization and focusing on non-commercial models, maintaining price, rigorously regulating potentially harmful formulations of the substance, and controlling production and supply, while ensuring public security. Naturally, and given the inexistence of comprehensive data, such innovative and broad policies have to be conceived in a flexible way, since they will require continuous and frequent data collection, allowing for future adaptations when necessary, because their initial forms will surely — and understandably — lack perfection. Many ideas can be proposed and conclusions drawn from the data available at the present time, which may help to pave the way for the future. However, most of the true public health effects of cannabis legalization are still unknown, for we are still in the early stages of these policies and their implications. Analysis of international strategies and their outcomes ought to be taken into consideration in the debate on non-medical cannabis legalization and in development of policies, whether in Portugal or elsewhere around the globe. In accordance with our review, we propose general guidelines for national policies on legalization of non-medical cannabis use in Portugal. However, they are not exclusive, since they follow ideas that have the potential to be tailored to fit the context of each country. A non-medical cannabis use legalization policy in Portugal would probably be most useful and beneficial if developed from a public health perspective, as a non-commercial centralized model in order to avoid the dangers of profit-driven models. We believe the following points constitute the baseline for the development of such a strategy:. Our study helps summarize the theoretical background for development of more structured and prospective research on cannabis legalization, showing that we are still in the initial stages of such policies, as the predominant consequences and a comprehensive framework are only expected to be available in the years to come, when a greater number of countries are anticipated to follow the legalization path, and long-term data on these policies start to become available. Our paper provides a generic, theoretical, and science-driven proposal of cannabis legalization that can be of assistance to implementation of such a policy in Portugal but also possibly in other nations , if legalization is to be pursued. Future studies should focus on systematic evaluation of the pros and cons of the legalization of cannabis worldwide. One must be aware that attempts to estimate the outcomes of a drug policy change are complicated by the numerous exogenous factors e. This is why future research ought to be undertaken not purely from economic or social perspectives, but including public health angles and, particularly, the short, medium, and long-term impact of these policies on the mental health of populations whether healthy or with a history of psychiatric disorders. Such research can provide flexibility, enabling the necessary rapid adaptation of policies and development of prophylactic and therapeutic evidence-based interventions. We undertook an up-to-date and comprehensive review of cannabis legalization policies and their short-to-medium-term outcomes, attempting to impartially and equitably report and compare them. Working from this overview, we developed a scientifically-driven perspective on how to adequately apply these learnings to the Portuguese context and, possibly, in other nations. While identifying and summarizing theory about the aforementioned topic, our study helps reinforce the foundations for development of more structured and prospective research on cannabis legalization, while at the same time identifying the research path to be followed. Being a narrative review, our study may not include all the appropriate literature. The existence of bias due to political and social agendas behind the gray literature included cannot be ruled out. Some differences found between the outcomes of policies may be due to the study methodology or a lack of studies or reports, and not to advantages of one strategy over the other e. The legalization of non-medical cannabis issue is a hot political subject with as-yet uncertain public health outcomes and balancing its advantages and disadvantages is no easy task. Although consumed globally, cannabis has the potential to cause detrimental physical and mental effects, with short and long-term consequences. Cannabis legalization has brought benefits where applied. Nonetheless, it has also brought downsides. Countries should carefully evaluate whether and how to decriminalize or legalize non-medical cannabis use, adapting such change to their own circumstances. If legalizing, cautious and thoughtful planning is of extreme importance, as is evaluating the lessons learned in the parts of the world where such changes have occurred. Public health-driven, and not profit-driven models, seem to be yielding the most benefits regarding non-medical cannabis legalization. Existing harm-reduction strategies can guide policy makers and positively contribute to public health, if the path of legalization is to be followed. Healthy dialogues between legislators and science should be encouraged, always keeping in mind that there are more than a few legalization pathways and that each choice influences, in a particular way, social and health wellbeing, government revenue, and job creation. The true public health effects of cannabis legalization are yet to be revealed, for we are still in the early stages of these policies and their implications. Future studies should systematically address the social, economic, and health consequences of legalization policies, paving the way for future policy adjustments and development of harm mitigation and treatment strategies. As a library, NLM provides access to scientific literature. Trends Psychiatry Psychother. Non-medical cannabis use: international policies and outcomes overview. Find articles by Pedro Cabral Barata. Fernando Fonseca, Amadora, Portugal. Find articles by Filipa Ferreira. Find articles by Catarina Oliveira. Received Feb 22; Accepted Jul 20; Collection date PMC Copyright notice. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Uruguay Non-profit, centralized regime. United States Profit-driven commercial regime.
GDS: the world’s largest drug survey
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Official websites use. Share sensitive information only on official, secure websites. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. We investigate the extent of and factors associated with denial of previously reported cannabis and other illicit drug use, and assess the potential of hair testing for measuring substance use in general population samples. Denial of ever use of cannabis and other illicit drugs at age 18 following previously reported use. Positive hair drug tests for cannabis and other illicit drugs, and expected numbers of false positives and false negatives based on expected sensitivity and specificity. Cannabis and other illicit drug use was reported by and individuals, respectively, before age 18 years. Of these Denial of cannabis use decreased with the reporting of other substances and antisocial behaviour. Cannabis and other illicit drug use at age 18 was reported by Of these, Hair analysis provides an unreliable marker of substance use in general population samples. People who report more frequent substance use before age 18 are less likely to later deny previous substance use at age 18 than people who report occasional use. However, it is prone to misclassification and could introduce bias in either direction, challenging the credibility of substance use research 1. It has been suggested the errors encountered are less likely to be the result of intentional distortions but rather the result of poor comprehension, forgetting or even carelessness, as well as age of onset of reporting 4 , 5 , 6. Recanting, if not handled carefully, is likely to have a considerable impact upon our understanding of drug use and our efforts to prevent it 2. Finding an alternative measure of drug use that is less prone to bias would be advantageous to epidemiological studies. Hair analysis holds potential for application to such studies as a biological measure of drug use. While urine and blood samples can be used to provide a measure of recent drug use 2—3 days for a single use of cannabis and up to 24 days for chronic use 9 , 10 , 11 , hair analysis has a potential detection window of several months. Furthermore, hair testing is less invasive, accepted more readily in community settings 12 and can be stored at room temperature without the need for immediate processing Several studies have assessed the plausibility of using hair samples as a replacement for urine in drug testing 15 , 16 , 17 , 18 , 19 , sampling individuals with higher levels of consumption e. These results are unlikely to be applicable to many epidemiological studies examining a general population sample. A total of hair samples were collected from this clinic. Twelve samples did not generate usable results when testing for other illicit drugs and their metabolites, resulting in individuals with available hair drug test data. All illicit drugs other than cannabis were combined. In addition to the drug use measures reported above, individuals were asked about ever use of substances at age 18 years. Individuals who had not reported use at earlier ages were excluded from analysis. Illicit drugs other than cannabis were grouped together. Details of the extraction methods for blood cotinine levels are provided in the Supporting information. Individuals recanting previously reported cannabis and other illicit drug use were compared to individuals who did not recant use on a variety of predictors using logistic regression. This allowed for examination of the reliability of hair drug testing to this sample, as one would expect to find that potential false positives and negatives fall within the expected boundaries. The sensitivity and specificity values used for other illicit drugs calculated by Ledgerwood and colleagues were 0. All analyses were carried out using Stata version 13 Ever use of cannabis was reported by individuals at ages 14, 15 or 17 years. None of the other predictors of recanting showed evidence of an association Table 1. Ever use of other illicit drugs was reported by individuals at ages 14, 15 and 17 years. Of these, 99 There was evidence that individuals whose mother had a higher education were less likely to recant use of other illicit drugs. None of the other predictors of recanting showed evidence of an association Supporting information, Table S1. Only confirmation testing of each drug is shown, as there were no individuals who were detected in the screening phase without being detected in the confirmation stage see hair testing methods in Supporting information. Information on cannabis use in the past 3 months was provided by individuals. Use of cannabis was reported by Four 0. Of those reporting cannabis use in the past 3 months There was minimal change to these proportions when excluding individuals with missing information on predictors used later in this analysis complete case sample Supporting information, Table S2. Expected rates highlighted in bold type relate to the expected numbers of false positives and false negatives in the ALSPAC sample. Heavy cannabis use defined as weekly cannabis use i. They were also less likely to report antisocial behaviour at age 18 years. None of the other factors showed evidence of an association Supporting information, Table S3. Illicit drug use in the past 3 months was reported by 8. A total of 32 of these individuals tested positive for illicit drugs and their metabolites in their hair. Of those reporting use in the past 3 months, 13 6. The expected levels of false positives and false negatives were and 63, respectively. These individuals were also more likely to be female and less likely to report antisocial behaviour at 18 years. None of the other factors showed evidence of an association Supporting information, Table S5. Individuals were less likely to recant use if they reported other drug use and antisocial behaviours. This could be influenced by both reporting and recall biases. However, there were far fewer false positives observed than expected 19 potential versus expected for the detection of other illicit drugs. The number of potential false positives and negatives observed differ from what is expected, considering the performance of hair testing for drug use. However, we have also demonstrated that hair drug testing is unable to provide a reliable measure of past drug use. This analysis has the advantage of a large sample size to examine the applicability of hair drug testing to general population samples. None the less, several limitations should be considered. First, despite the large initial sample, the small numbers of individuals with cannabis and other illicit drugs detected in hair leaves low power for assessment of potential reasons behind any inconsistencies. This is particularly true when examining other illicit drugs, as an initial general population sample in the thousands can result in very few individuals with drugs detected in their hair. Secondly, different types and presentation forms of illicit drugs besides combined use show variations in time and usage pattern 28 , 29 , However, due to the small number of individuals both reporting the use of illicit drugs and with illicit drugs detected in their hair, it would not have been possible to examine these separately. When examining a forensic or court sample, the opposite might apply. There are other metabolites of cannabis that can be detected in hair. This analysis could have been enhanced by testing for additional cannabis metabolites. Percy and colleagues 3 have reported several characteristics associated with recanting. The results presented here are not consistent with those reported by Percy and colleagues on gender Percy suggested that women are less likely to recant use. However, our results are consistent when assessing other substances and antisocial behaviour. This has wider implications for epidemiological studies on correlates of drug use, in particular studies assessing cannabis use as this is often the only illicit drug whose use is common enough in the general population for sample effects to be estimated. Furthermore, this analysis has shown that individuals who report heavier cannabis use in the past are less likely to recant their use, therefore a measure of ever use is more likely to be misclassified and biased than frequency of use. This theory is supported by our results showing that the use of several drugs and recanting of cannabis and other illicit drugs are associated negatively. Our results are in agreement with this, with a higher percentage of ever illicit drug users recanting use. Two studies have assessed previously the use of hair analysis as a biological measure of drug use in a general population sample. These previous studies had small samples sizes in their analysis and , respectively in comparison to the individuals used in this study. We have demonstrated the problem of recanting substance use in adolescents in the general population and shown that individuals recanting reporting are less likely to report the use of other substances, antisocial behaviour and depressive symptoms. It is therefore not a viable tool in many epidemiological studies such as cohorts. Table S1 Predictors of recanting use of other illicit drugs at age 18 years using logistic regression. We are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. This publication is the work of the authors and M. Taylor, M. Addiction, — This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Find articles by Michelle Taylor. Find articles by John Sullivan. Find articles by Susan M Ring. Find articles by John Macleod. Find articles by Matthew Hickman. Open in a new tab. Click here for additional data file. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Fewer than 5 times ref. 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Non-medical cannabis use: international policies and outcomes overview. An outline for Portugal
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Non-medical cannabis use: international policies and outcomes overview. An outline for Portugal
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