Policy Tag: Dependency

Adopted by the 68th General Assembly, Chicago, October 2017

 

PREAMBLE

1.      Cannabis is the generic term used to denote psychoactive preparations of the plant Cannabis sativa, which grows wild in many parts of the world and is known by numerous other names, such as: “marijuana”, “dagga”, “weed”, “pot”, “hashish”, or “hemp”.

2.      Cannabis for medical use refers to the use of cannabis and its constituents, natural or synthetic, to treat disease or alleviate symptoms under professional supervision; however, there is no single agreed upon definition.

3.      Recreational cannabis refers to the use of cannabis to alter one’s mental state in a way that modifies emotions, perceptions, and feelings regardless of medical need.

4.      This WMA statement is intended to provide a position on legalisation of cannabis for medical use and highlight the adverse effects associated with recreational use.

5.          Recreational cannabis use is an important health and social issue across the world. Cannabis is the most commonly used illicit drug in the world. The World Health Organisation estimates that about 147 million people, 2.5% of the world population, use cannabis compared with 0.2% using cocaine and 0.2% using opiates.

6.      The WMA opposes recreational cannabis use due to serious adverse health effects such as increased risk of psychosis, fatal motor vehicle accidents, dependency, as well as deficits in verbal learning, memory and attention.  Use of cannabis before the age of 18 doubles the risk of psychotic disorder. The ominously growing availability of cannabis or its forms in  foodstuffs such as sweets and “concentrates”, which have enormous appeal to children and adolescent, requires intensive vigilance and policing.

7.          National Medical Associations should support strategies to prevent and reduce recreational cannabis use.

8.          Evidence for use of cannabis for medical use

8.1       Cannabinoids are chemical constituents of Cannabis sativa that contain similar structural features; some of the chemical constituents act on human cannabinoid receptor cells. Conceptually, cannabinoids that activate these receptors (1) occur naturally in the human body like other endogenous neurotransmitters (endocannabinoids); (2) occur naturally in the cannabis plant (phytocannabinoids); or (3) are pharmaceutical preparations containing either  synthetic cannabinoids, (e.g. delta9-tetrahydrocannabinol [dronabinol, Marinol™], or a related compound, nabilone [Cesamet™], or extracts of phytocannabinoids (nabiximols [Sativex™]).

8.2       Amongst phytocannabinoids is naturally occurring Cannabis sativa, delta-9-tetrahydrocannabinol (THC), the main bioactive cannabinoid and the principal psychoactive constituent, while cannabidiol (CBD) is the second most abundant. CBD lacks significant psychoactive properties but may possess analgesic and antiseizure properties.

8.3    The human endocannabinoid system is believed to mediate the psychoactive effects of cannabis and is involved in a variety of physiologic processes including appetite, pain-sensation, mood, and memory. The significant medical and pharmacological therapeutic potential of influencing the endocannabinoid system has been widely recognized.

8.4    The medical benefits of cannabis reported in scientific literature are widely debated globally. Cannabis has been used for the treatment of severe spasticity in multiple sclerosis, chronic pain, nausea and vomiting due to cytotoxics, and loss of appetite and cachexia associated with AIDS. Evidence suggest that certain cannabinoids are effective in the treatment of chronic pain, particularly as an alternative or adjunct to the use of opiates when the development of opiate tolerance and withdrawal can be avoided. Evidence supporting use of cannabis for medicinal purposes is of low to moderate quality, and inconsistent. The inconsistency can be partially attributable to the prohibition of cannabis. Its classification as an illegal substance in some countries has constrained safe and high-quality clinical research.

8.5    The short-term adverse effects of cannabis use are well documented. However, the long-term adverse effects are less well understood, particularly the risk of dependence and cardiovascular disease. There are also significant public health concerns for vulnerable populations such as adolescents, and pregnant or breastfeeding women.

8.6    Despite weak evidence of its medical benefits, cannabis for medical use has been legalised in some countries. In other countries medical cannabis is forbidden or under debate.

9.      Medical professionals may find themselves in a medico-legal dilemma as they try to balance their ethical responsibility to patients for whom cannabis may be an effective therapy and compliance with applicable legislation. This dilemma can manifest itself both with patients who may medically benefit from the use of cannabis, and those who are not likely to do so, but pressure the medical professionals to prescribe it.

 

RECOMMENDATIONS

10.    Cannabis Research

10.1  In the light of the low-quality scientific evidence on the health effects and therapeutic effectiveness of cannabis, more rigorous research involving larger samples is necessary before governments decide whether or not to legalise medical cannabis for medical purposes. Comparators must include the existing standards of treatment. Expansion of such research should be supported. Research should also examine the public health, social and economic consequences of cannabis use.

10.2  Governments may consider reviewing laws governing access to and possession of research-grade cannabis for the purpose of allowing well-designed scientific research studies to broaden the evidence base on the health effects and therapeutic benefits of cannabis.

11.    In countries where cannabis is legalised for medicinal purposes, the following requirements should apply:

11.1  Requirements for producers and products:

11.1.1    Provision of cannabis plant products for treatment must be in accordance with the UN Single Convention on Narcotic Drugs from 30 March 1961, including the Convention’s rules on production, trade, and distribution. Thus, it is essential that the cannabis included in the products delivered for medical treatment must be provided and handled in accordance with the requirements of the Convention.

11.1.2    Requirements must include that the cannabis plants meet appropriate quality demands for growing and standardization. The produced cannabis plant products must have a specific indication (interval) of ingredients, including the content of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) and strength indication of these.

11.2  Requirements for prescription and dispensing of cannabis for medical purposes:

11.2.1    Cannabis must be prescribed by an authorised physician/prescriber in accordance with the best level of evidence and the country’s regulatory frameworks.

11.2.2    It is recommended that treatment with approved conventional drugs is undertaken before cannabis products are used for treatment.

11.2.3    Each individual physician must take responsibility for and make a decision regarding treatment with cannabis products, in accordance with the best available evidence and country specific registered indications.

11.2.4    Cannabis for medical purposes must only be dispensed at pharmacies or by authorised dispensers in accordance with the country´s regulatory frameworks.

11.2.5    Effective control measures must be put in place to impede illicit use of medical cannabis.

11.2.6    Public health surveillance systems to monitor prevalence of cannabis use and trends in utilisation patterns are necessary.

12.    In considering policy and legislation on cannabis, governments, NMAs, policymakers, and other health stakeholders, should emphasize and examine the health effects and therapeutic benefits based on the available evidence, while also recognizing various contextual factors such as regulatory capacity, cost-effectiveness, societal values, social circumstances of the country, and the public health and safety impact on the wider population.

Adopted by the 56th WMA General Assembly, Santiago, Chile, October 2005
And rescinded at the 68th WMA General Assembly, Chicago, USA, October 2017

PREAMBLE

  1. Alcohol use is deeply embedded in many societies. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco or hypertension. Overall, there are causal relationships between alcohol consumption and more than 60 types of disease and injury including traffic fatalities. Alcohol consumption is the leading risk factor for disease burden in low mortality developing countries and the third largest risk factor in developed countries. Beyond the numerous chronic and acute health effects, alcohol use is associated with widespread social, mental and emotional consequences. The global burden related to alcohol consumption, both in terms of morbidity and mortality, is considerable.
  2. Alcohol-related problems are the result of a complex interplay between individual use of alcoholic beverages and the surrounding cultural, economic, physical environment, political and social contexts.
  3. Alcohol cannot be considered an ordinary beverage or consumer commodity since it is a drug that causes substantial medical, psychological and social harm by means of physical toxicity, intoxication and dependence. There is increasing evidence that genetic vulnerability to alcohol dependence is a risk factor for some individuals. Fetal alcohol syndrome and fetal alcohol effects, preventable causes of mental retardation, may result from alcohol consumption during pregnancy. Growing scientific evidence has demonstrated the harmful effects of consumption prior to adulthood on the brains, mental, cognitive and social functioning of youth and increased likelihood of adult alcohol dependence and alcohol related problems among those who drink before full physiological maturity. Regular alcohol consumption and binge drinking in adolescents can negatively affect school performance, increase participation in crime and adversely affect sexual performance and behaviour.
  4. Alcohol advertising and promotion is rapidly expanding throughout the world and is increasingly sophisticated and carefully targeted, including to youth. It is aimed to attract, influence, and recruit new generations of potential drinkers despite industry codes of self-regulation that are widely ignored and often not enforced.
  5. Effective alcohol social policy can put into place measures that control the supply of alcohol and/or affect population-wide demand for alcohol beverages. Comprehensive policies address legal measures to: control supply and demand, control access to alcohol (by age, location and time), provide public education and treatment for those who need assistance, levy taxation to affect prices and to pay for problems generated by consumption, and harm-reduction strategies to limit alcohol-related problems such as impaired driving and domestic violence.
  6. Alcohol problems are highly correlated with per capita consumption so that reductions of use can lead to decreases in alcohol problems. Because alcohol is an economic commodity, alcohol beverage sales are sensitive to prices, i.e., as prices increase, demand declines, and visa versa. Price can be influenced through taxation and effective penalties for inappropriate sales and promotion activities. Such policy measures affect even heavy drinkers, and they are particularly effective among young people.
  7. Heavy drinkers and those with alcohol-related problems or alcohol dependence cause a significant share of the problems resulting from consumption. However, in most countries, the majority of alcohol-related problems in a population are associated with harmful or hazardous drinking by non-dependent ‘social’ drinkers, particularly when intoxicated. This is particularly a problem of young people in many regions of the world who drink with the intent of becoming intoxicated.
  8. Although research has found some limited positive health effects of low levels of alcohol consumption in some populations, this must be weighed against potential harms from consumption in those same populations as well as in population as a whole.
  9. Thus, population-based approaches that affect the social drinking environment and the availability of alcoholic beverages are more effective than individual approaches (such as education) for preventing alcohol related problems and illness. Alcohol policies that affect drinking patterns by limiting access and by discouraging drinking by young people through setting a minimum legal purchasing age are especially likely to reduce harms. Laws to reduce permitted blood alcohol levels for drivers and to control the number of sales outlets have been effective in lowering alcohol problems.
  10. In recent years some constraints on the production, mass marketing and patterns of consumption of alcohol have been weakened and have resulted in increased availability and accessibility of alcoholic beverages and changes in drinking patterns across the world. This has created a global health problem that urgently requires governmental, citizen, medical and health care intervention.

RECOMMENDATIONS

The WMA urges National Medical Associations and all physicians to take the following actions to help reduce the impact of alcohol on health and society:

  1. Advocate for comprehensive national policies that
    1. incorporate measures to educate the public about the dangers of hazardous and unhealthy use of alcohol (from risky amounts through dependence), including, but not limited to, education programs targeted specifically at youth;
    2. create legal interventions that focus primarily on treating or provide evidence-based legal sanctions that deter those who place themselves or others at risk, and
    3. put in place regulatory and other environmental supports that promote the health of the population as a whole.
  2. Promote national and sub-national policies that follow ‘best practices’ from the developed countries that with appropriate modification may also be effective in developing nations. These may include setting of a minimum legal purchase age, restricted sales policies, restricting hours or days of sale and the number of sales outlets, increasing alcohol taxes, and implementing effective countermeasures for alcohol impaired driving (such as lowered blood alcohol concentration limits for driving, active enforcement of traffic safety measures, random breath testing, and legal and medical interventions for repeat intoxicated drivers).
  3. Be aware of and counter non-evidence-based alcohol control strategies promoted by the alcohol industry or their social aspect organizations.
  4. Restrict the promotion, advertising and provision of alcohol to youth so that youth can grow up with fewer social pressures to consume alcohol. Support the creation of an independent monitoring capability that assures that alcohol advertising conforms to the content and exposure guidelines described in alcohol industry self-regulation codes.
  5. Work collaboratively with national and local medical societies, specialty medical organizations, concerned social, religious and economic groups (including governmental, scientific, professional, nongovernmental and voluntary bodies, the private sector, and civil society) to:
    1. reduce harmful use of alcohol, especially among young people and pregnant women, in the workplace, and when driving;
    2. increase the likelihood that everyone will be free of pressures to consume alcohol and free from the harmful and unhealthy effects of drinking by others; and
    3. promote evidence-based prevention strategies in schools.
  6. Undertake to
    1. screen patients for alcohol use disorders and at-risk drinking, or arrange to have screening conducted systematically by qualified personnel using evidence-based screening tools that can be used in clinical practice;
    2. promote self-screening/mass screening with questionnaires that could then select those needing to be seen by a provider for assessment;
    3. provide brief interventions to motivate high-risk drinkers to moderate their consumption; and
    4. provide specialized treatment, including use of evidence-based pharmaceuticals, and rehabilitation for alcohol-dependent individuals and assistance to their families.
  7. Encourage physicians to facilitate epidemiologic and health service data collection on the impact of alcohol.
  8. Promote consideration of a Framework Convention on Alcohol Control similar to that of the WHO Framework Convention on Tobacco Control that took effect on February 27, 2005.
  9. Furthermore, in order to protect current and future alcohol control measures, advocate for consideration of alcohol as an extra-ordinary commodity and that measures affecting the supply, distribution, sale, advertising, promotion or investment in alcoholic beverages be excluded from international trade agreements.