Thinking Beyond Legalization: The Case for Expanding Evidence-Based Options for Cannabis Use Disorder Treatment in Canada

Abstract

With the impending legalization and regulation of nonmedical cannabis use and supply for the benefits of public health and safety in Canada, intensive discussions are ongoing on many important fronts: age and use restrictions, retail distribution, cannabis-impaired driving, and so on. One issue has received surprisingly little attention: the phenomenon of cannabis use disorders (CUD). We are writing to highlight that, despite a substantial burden of CUD in the population, there is limited availability and access to evidence-based, effective treatment options. As Canada undergoes a fundamental policy change towards cannabis legalization, it is important not to lose sight of the opportunity and need to create better evidence and scale-up of effective interventions for CUD. It is well-recognised that CUD (i.e., the new diagnostic term that covers both the previous concepts of cannabis abuse and dependence) can develop as a consequence of cannabis use and occurs in sub-sets of users; select symptoms of CUD include difficulties in use control, disruptions in functioning, and increased tolerance and withdrawal. Well-documented predictors of CUD include: initiation of cannabis use early in life, intensive or frequent use, and the use of high-potency (e.g., high tetrahydrocannabinol [THC] content) cannabis products. Given cannabis’ status as the most commonly used illicit drug, there were an estimated 13 million or more individuals (0.2% of the population) with CUD (dependence) globally in 2010, with peak prevalence among young adults. Previous epidemiological estimates suggest that about 10% of users develop dependence; yet, more recent data indicate that larger proportions of users, and mainly those with intensive use, may develop CUD. Recent preeminent US-based surveys (e.g., National Survey on Drug Use and Health [NSDUH], National Epidemiologic Survey on Alcohol and Related Conditions [NESARC]) found that the (past-year) prevalence of CUD among general-population adults ranged from 1.5% to 2.9% (depending on the survey), whereas estimates for CUD rates among active (i.e., past-year) cannabis users in the US ranged from 12% to 31% in adults, and 20% to 25% in youths. In the US and elsewhere, CUD has been found to be more common among males and ethnic subgroups, and is associated with other substance use and/or mental health comorbidities. Recent analyses suggest that both the rates of cannabis use and CUD have increased more among adults in US states (1991/92 – 2012/13) with “liberalised” (e.g., medical/legalisation) cannabis control regimes, as compared with less-