Cannabis is the primary driver of demand for addiction treatment among teenagers and young adults across UK, Ireland and Europe. Dr Bobby Smyth writes about why cannabis and its harms should be a top priority for all working in the field of addiction, why terminology matters and why the term “medical cannabis” is a misnomer.
As a child and adolescent psychiatrist, I work full time in adolescent addiction treatment, in a consultant role in Dublin since 2003. When I started out, my main focus was treatment of adolescent heroin addiction. Fortunately, the heroin problem has largely vanished from my age range, so we have been able to develop more general drug and alcohol treatment services for teenagers. To my great surprise, cannabis gradually became the dominant substance driving demand for those services in the past decade.
“The industry is very keen to see the adjectives “medical” or “medicinal” placed before its product. Doing so has the effect of softening up public attitudes and dispelling policy maker concerns.”
These are not the worried well or the consequences of an overzealous criminal justice system, the latter accounting for only 5-10% of referrals. Cannabis addiction is consuming young lives in a manner I wouldn’t have imagined possible when starting out in 2003.
Ireland is not alone in seeing extensive cannabis addiction, the latest EMCDDA report indicates that no drug generated more demand for addiction treatment among new entrants, than cannabis. The latest UK data from NDTMS indicates that cannabis is the substance involved in the largest number of addiction treatment episodes for people under 25 years, being a focus of treatment in over 50% of episodes, surpassing even alcohol.
As psychiatrists, we know the mental health issues related to cannabis use, its contribution to psychosis and the evidence pointing to impacts on cognition in adolescent users [refs 1 – 3].
When looking at NHS data on drug-related admissions to medical hospitals, it is surprising to see that the ICD-10 drug category contributing to the largest number of admissions was cannabinoids in 2019-20, surpassing even opioids and cocaine by 10% and 30% respectively. It is similar in Ireland. Some of these admissions will be due to synthetic cannabinoid products, not cannabis itself. However, an EMCDDA survey of hospitals across Europe found that cannabis was the drug causing the largest number of drug related attendances at emergency departments, again surpassing heroin and cocaine, and that data specifically excluded synthetic cannabinoid products.
Against this backdrop of evidence that cannabis is a major cause of both addiction and wider health problems, we have a growing chorus of voices telling the general public and policy makers that cannabis is in fact a medicine. The burgeoning cannabis industry, which now attracts major investment from both alcohol and tobacco corporations, is funding this conversation. The industry is very keen to see the adjectives “medical” or “medicinal” placed before its product. Doing so has the effect of softening up public attitudes and dispelling policy maker concerns. As doctors, we understand that it is only bodies such as the European Medicines Agency (EMA) in Europe or the Food and Drug Administration (FDA) in the US that can declare what is a medicine. Cannabis itself is nowhere near reaching the required threshold of evidence of effectiveness and safety [ref 4].
“Scientific journals and addiction conferences would not tolerate this activity being described as use of “medical alcohol”. Unfortunately, they do accept the term “medical cannabis” when referring to use of cannabis with these motivations.”
However, some cannabis-based products, such as cannabidiol for Dravets Syndrome, have reached that threshold. This should not mean that the parent plant is referred to as medicine.
We know that alcohol has analgesic, anxiolytic and anaesthetic properties. It is a naturally occurring substance and has been used in tinctures and remedies by shaman, apothecaries and doctors for millennia. Some people still report using alcohol to alleviate stress or for some pain relief. While this is sometimes referred to as ‘self-medicating’, it is never taken as evidence that alcohol is a medicine. Scientific journals and addiction conferences would not tolerate this activity being described as use of “medical alcohol”. Unfortunately, they do accept the term “medical cannabis” when referring to use of cannabis with these motivations.
In the area of addiction, we agonise over language a great deal. We recognise that language is important. I am strongly of the view that the terms “medical cannabis” and “medicinal cannabis” are misnomers. While now used colloquially and out of convenience, they are unhelpful and fundamentally misleading [refs 4,5 & 6 ]. Better terms are “cannabinoid-based medicines” for substances such as Epidiolex (i.e. products that have been formally recognised by regulatory bodies as deserving of the term “medicine”), and “cannabinoid-based products” to describe the other potions and concoctions sold for purported health benefit.
Those of us who are involved in treatment, research and public policy in the domain of addiction tend to maintain a deep scepticism of alcohol and tobacco industries. They have generally been seen as enemies of public health. While pharmaceutical companies fall into a different category, they are viewed with a degree of caution by doctors of all specialities, but especially by those of us working in addiction. Too many of their products have potential to cause addiction, the current opioid epidemic in the US starkly reminding us of this fact. We must now make a decision about how we view the new cannabis industry and those who receive funding from it. An editorial in Addiction by Humphreys and Hall discussed some of these issues and challenges in 2019 [ref 7].
Given the product it sells, and its ever-growing linkages with tobacco and alcohol industries, my personal view is that ‘big cannabis’ falls into the same category as ‘big alcohol’ and ‘big tobacco’ at the very best. Others are entitled to hold different perspectives on this industry. In fairness to alcohol and tobacco corporations, they are at least subject to some regulations while it seems to be the ‘wild west’ for the cannabis industry. Sadly, there is absolutely no line dividing the “medical” cannabis industry from the “recreational” cannabis industry, the same companies catering to both markets with similar products and with the same financial backers [ref 8].
For individuals and organizations involved in addiction treatment, research and policy, it is now timely to actively consider (1) our use of language in discussions about potential therapeutic benefits of cannabis products and (2) our views regarding the nascent cannabis industry, and those who receive funding from it directly or indirectly.
Dr Bobby Smyth MRCPsych PhD is a consultant child & adolescent psychiatrist at Tallaght, Dublin and a clinical senior lecturer with the Department of Public Health & Primary Care in Trinity College Dublin. http://people.tcd.ie/smythbo
1/ Hall, W., Leung, J., & Lynskey, M. (2020). The effects of cannabis use on the development of adolescents and young adults. Annual Review of Developmental Psychology, 2, 461-483. https://www.annualreviews.org/doi/abs/10.1146/annurev-devpsych-040320-084904#
2/ Murray, R. M., Quigley, H., Quattrone, D., Englund, A., & Di Forti, M. (2016). Traditional marijuana, high‐potency cannabis and synthetic cannabinoids: increasing risk for psychosis. World Psychiatry, 15(3), 195-204. https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20341
3/ Gobbi, G., Atkin, T., Zytynski, T., Wang, S., Askari, S., Boruff, J., … & Mayo, N. (2019). Association of cannabis use in adolescence and risk of depression, anxiety, and suicidality in young adulthood: a systematic review and meta-analysis. JAMA psychiatry, 76(4), 426-434. https://jamanetwork.com/journals/jama/articlepdf/2723657/jamapsychiatry_gobbi_2019_oi_180114.pdf
4/ US Food & Drug Administration (2021). FDA Regulation of Cannabis and Cannabis-Derived Products, Including Cannabidiol (CBD).
5/ Budney, A. J. (2021). Teen Reports of Cannabis for Medical Reasons—What Does That Mean?. Journal of Adolescent Health, 68(1), 9-10. https://pubmed.ncbi.nlm.nih.gov/33349361/
6/ Chadi, N., & Hadland, S. E. (2018). Adolescents and perceived riskiness of marijuana: Why care?. The Journal of adolescent health: official publication of the Society for Adolescent Medicine, 63(4), 377. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092750/
7/ Humphreys, K., & Hall, W. D. (2019). Reducing the risks of distortion in cannabis research. Addiction,115(5), 799-801. https://onlinelibrary.wiley.com/doi/full/10.1111/add.14801
8/ Gornall, J. (2020). Big cannabis in the UK: is industry support for wider patient access motivated by promises of recreational market worth billions?. BMJ 2020;368:m1002. https://www.bmj.com/content/368/bmj.m1002.full
The opinions expressed in this post reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the SSA.
The SSA does not endorse or guarantee the accuracy of the information in external sources or links and accepts no responsibility or liability for any consequences arising from the use of such information.
