Canada has been at the forefront of cannabis research, education and regulation for the past 2 decades, yet uncertainty remains about how the drug should be used in medicine. Physicians lack evidence-based information and formalized training about cannabis, which stems, in part, from the drug's previously illegal status that hindered research. Among the public, however, many perceive cannabis as a natural and safe medical treatment. Patients increasingly seek advice about cannabis from physicians, request prescriptions or experiment with cannabis for medical problems on their own. However, physicians must adhere to good medical practice regardless of public pressure and provide counselling to patients based on up-to-date knowledge and evidence. Now that cannabis is legal in Canada more research should be forthcoming, but the evidence base remains weak. [continues 887 words]
Vancouver has entered unchartered territory as the first Canadian city to regulate marijuana dispensaries, with proponents arguing that regulation protects people's health and restricts access. The chief medical health officer for Vancouver Coastal Health, Dr. Patricia Daly, who helped inform the decision to regulate, says that "city council may be seen as the Wild West, but they're stepping in to reduce potential harms associated with the complaints they had from the community." Over the past few years, 100 marijuana dispensaries have opened in Vancouver. Only 25 licensed producers, which deliver their product by mail, have been approved by Health Canada to sell medicinal marijuana from federally sanctioned growers. The remainder presumably obtain their cannabis from black market sources. These businesses were run without any city bylaws restricting how the illegal drug was sold. [continues 739 words]
What role should doctors play in the control of marijuana? Health Canada in a news release late last year announced proposals for "new Marihuana for Medical Purposes Regulations," suggesting that "changes improve public safety [and] maintain patient access."1 The document goes on to suggest that "the proposed new Marihuana for Medical Purposes Regulations aim to treat marihuana as much as possible like any other narcotic used for medical purposes."1 Under the existing regulations it is the federal minister of health who issues a patient with authorization to possess marijuana. Under the proposed new regulations it is doctors, or possibly other health practitioners, who will issue "a medical document, similar to a prescription" allowing their patient to obtain marijuana. The language is soothing and suggests that marijuana is a medicine, albeit one that needs special oversight like morphine and for which users may be seen as patients in certain circumstances. It is but a sma! ll step from here to suggest that doctors should prescribe marijuana for medical indications. But is marijuana a medicine? Or, more specifically, is it a prescription medicine? [continues 819 words]
Canada's new mandatory minimum sentences for drug offenders are based on "very bad criminal law policy" and constitute a threat to public health as well as the concept of judicial proportionality, former Supreme Court of Canada Justice Louise Arbour says. The law should, and almost certainly will, face a justifiable constitutional challenge, Arbour adds of the omnibus crime legislation, Bill C-10, which received royal assent in March (www.parl.gc.ca/HousePublications/Publication.aspx?DocidT65759&file=4). Forcing judges to impose minimum sentences for drug offences endangers the legal precept of proportionality, under which judges must tailor the level of punishment to the severity of the crime, adds the former United Nations high commissioner for human rights and former chief prosecutor of the International Criminal Tribunals for Rwanda and the former Yugoslavia. [continues 734 words]
Background: Chronic neuropathic pain affects 1%-2% of the adult population and is often refractory to standard pharmacologic treatment. Patients with chronic pain have reported using smoked cannabis to relieve pain, improve sleep and improve mood. Methods: Adults with post-traumatic or postsurgical neuropathic pain were randomly assigned to receive cannabis at four potencies (0%, 2.5%, 6% and 9.4% tetrahydrocannabinol) over four 14-day periods in a crossover trial. Participants inhaled a single 25-mg dose through a pipe three times daily for the first five days in each cycle, followed by a nine-day washout period. Daily average pain intensity was measured using an 11-point numeric rating scale. We recorded effects on mood, sleep and quality of life, as well as adverse events. [continues 258 words]
Correspondence to: Dr. Donald P. Tashkin, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), 10833 Le Conte Ave., Los Angeles CA 90095-1690, USA; fax 310 206-5088; dtashkin@mednet.ucla.edu Marijuana is the second most commonly smoked substance worldwide after tobacco.1 The constituents of marijuana smoke are qualitatively and, to a large extent, quantitatively similar to those of tobacco smoke, with the exceptions of 9-tetrahydrocannabinol (THC), found only in marijuana, and nicotine, found only in tobacco. Given these similarities, there is concern that the health risks of regular marijuana smoking may be similar to those of habitual tobacco smoking. Chronic obstructive pulmonary disease (COPD), which is associated with high morbidity and mortality, is among those risks. [continues 1585 words]
From the iCapture Centre for Cardiovascular and Pulmonary Research (Tan, Lo, Jong, Xing, Sin), St. Paul's Hospital and the University of British Columbia, and the Vancouver General Hospital (FitzGerald), Vancouver, BC; the Oregon Health and Sciences University (Vollmer) and the Kaiser Permanente Center for Health Research (Buist), Portland, USA Correspondence to: Dr. Wan C. Tan, University of British Columbia, iCapture Centre for Cardiovascular and Pulmonary Research, St. Paul's Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-8351; wtan@mrl.ubc.ca [continues 292 words]
Insite, Vancouver's supervised injection facility for injection drug users, opened in 2003 under an exemption from Canadian federal drug laws. A substantial amount of research has since been conducted on the facility (www.vch.ca/sis/). Although randomized controlled trials have not been possible, the research has indicated substantial public health benefits associated with the facility's operation. In this issue, Bayoumi and Zaric present a model of the cost-effectiveness of Insite.1 The model's basic comparison is between other interventions for the prevention of HIV infection in Vancouver, such as needle-exchange programs and methadone maintenance treatment, and these interventions plus Insite. Although the authors recognize great potential variation of the cost-effectiveness in their sensitivity analyses, some of their model's assumptions are questionable. Most importantly, the model generates an incidence rate of HIV infection of 5-6 per 100 person-years over their 10-year time horizon. This estimated rate forces us to challenge their cost-effectiveness model. [continues 1541 words]
I read with interest the recent Public Health piece on methamphetamine hydrochloride (crystal meth).1 Two subsequent articles on the same topic provided more details, but there were no comments on prevention programs or on limiting production of this drug.2,3 I had a distinct sense of deja vu. Forty-five years ago, I reported in CMAJ the first North American case of addiction to diethylpropion.4 This drug is chemically distinct from amphetamines, but the symptoms resulting from abuse are identical to those described by Buxton and Dove.1 The only difference is one of degree. [continues 169 words]
[One of the authors responds:] Joseph Caplan's suggestion that the chemicals involved in the synthesis of methamphetamine hydrochloride be regulated is highly relevant to the prevention of crystal meth use, but this issue was outside the scope of my review article.1 Canada's Precursor Control Regulations include requirements, as Caplan recommends, to control precursors and other substances used in the production of methamphetamine, including ephedrine, pseudoephedrine and red phosphorus.2 Before 2003 these regulations did not exist and there was much concern, especially in the United States, about the export of precursors from Canada for illicit methamphetamine production.3 It can be argued that the Canadian legislation should be strengthened by requiring more frequent reporting by the chemical industry of the sale of precursors, by requiring licensing of end-users and by other approaches such as requiring that anhydrous ammonia (a nitrogen fertilizer used in methamphetamine synthesis) be stored in government-approved containers.4 [continues 331 words]
In the Realm of Hungry Ghosts: Close Encounters with Addiction Gabor Mate MD; Knopf Canada; 2008; 480 pp $34.95 ISBN 978-0-676-97740-0 If stigma still shapes the ways we understand and respond to addictions in contemporary society - and it does - then this book deserves our attention. Gabor Mate employs both passion and reason in shaping an ambitious, sprawling book that is engaging and provocative. The crucible that shapes Mate's views is Vancouver's Downtown Eastside, where for 8 years he has been staff doctor for the Portland Hotel Society, a remarkable agency offering "safety and caring to marginalized and stigmatized people," by housing and supporting the homeless. It is there that Mate starts and ends the book - with his patients and himself. But the journey he takes us on passes through all kinds of rough terrain to show us what addiction is, how it develops and what can be done about it. [continues 967 words]
Youth Substance Use And Abuse: Challenges And Strategies For Identification And Intervention Jeremy is 17 and has lived on the street for 3 years. He visits the emergency department for the fifth time in the past month reporting chest pain: "My heart's jumping out of my chest. Think I'm having a heart attack or something." He further reports symptoms of anxiety and panic attacks. He admits to using cannabis daily, and cocaine and ecstasy several times a week. The emergency physician takes a few minutes to ask Jeremy about his health concerns. Jeremy says he wants "to know that I'm not crazy." The physician wonders why Jeremy has not visited the substance abuse treatment agency he has been referred to and subsequently allays his fear that he will be "locked up" if he goes for treatment. With Jeremy's permission, the physician leaves a message for a worker at the street youth centre where Jeremy often hangs out. The following week, the worker accompanies Jeremy for an assessment at the treatment agency and to an appointment to see a psychiatrist. With support from the youth centre, Jeremy applies to stay at a group home to stabilize his living situation while he seeks treatment. [continues 2310 words]
Studies have suggested that as many as 1 in 4 cannabis users may be genetically at risk for developing schizophrenia or a related psychotic disorder. Now, a new study reveals all users are at risk.[1] Given recent United Nations' statistics citing Canada as the industrial world's leading consumer of cannabis, this news should set alarm bells ringing. After all, a leading role in cannabis consumption sets the stage for a leading role in psychotic disorders. Instead, Canada's mainstream media responded in chorus from The Happy Hippy Hymn Book, failing to notice that it is 10 years out of date. [continues 667 words]
Studies have suggested that as many as 1 in 4 cannabis users may be genetically at risk for developing schizophrenia or a related psychotic disorder. Now, a new study reveals all users are at risk.1 Given recent United Nations' statistics citing Canada as the industrial world's leading consumer of cannabis, this news should set alarm bells ringing. After all, a leading role in cannabis consumption sets the stage for a leading role in psychotic disorders. Instead, Canada's mainstream media responded in chorus from The Happy Hippy Hymn Book, failing to notice that it is 10 years out of date. [continues 560 words]
Federal Minister of Health Tony Clement promised a bevy of new health-related federal initiatives in an address to the Canadian Medical Association (CMA) annual General Council in Vancouver Aug. 20, including a crackdown on illicit drug use, a renewed tobacco-control strategy aimed at reducing national smoking rates to 12% from 19% by 2011 and more stringent regulations to prevent the import of counterfeit or contaminated food, drugs and consumer products. Clement was most emphatic about the need for a tough new national strategy to prevent illicit drug use, indicating that the government is determined to redress the long-standing absence of a "significant anti-drug campaign," a condition that he asserted has led to Canada having the highest percentage of marijuana users (16.8%) in the industrial world. [continues 205 words]
But Where's The Science? New evidence-based guidelines are urgently needed to help doctors negotiate Canada's hazy medical marijuana landscape, particularly in light of Health Canada's efforts to impose new dose limits, say the nation's leading cannabis researcher and doctors who have been queried about their marijuana authorizations. Canada should also re-establish a formal process for developing responsible dosing strategies, says Mark Ware of McGill's University Health Centre, the sole researcher funded under the now defunct Medical Marijuana Research Program (CMAJ 2006;175:[12]: 1507-8). [continues 948 words]
Evan Wood, MD PhD, Julio S. Montaner, MD, Kathy Li, MSc, Lucy Barney, RN MSN, Mark W. Tyndall, MD ScD and Thomas Kerr, PhD From the British Columbia Centre for Excellence in HIV/AIDS (Wood, Montaner, Li, Tyndall, Kerr), St. Paul's Hospital; the Department of Medicine (Wood, Montaner, Kerr), University of British Columbia; and the British Columbia Centre for Disease Control (Barney), Vancouver, BC Correspondence to: Dr. Evan Wood, British Columbia Centre for Excellence in HIV/AIDS, Rm. 608, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-9044; ewood@cfenet.ubc.ca [continues 295 words]
We read with interest Wendy Muckle and Jeffrey Turnbull's guest editorial on homelessness.1 Although shelters are not perfect, they do protect people from some aspects of homelessness. For example, there is evidence of cognitive impairment in some homeless people,2 and this association is partially dependent on housing quality.3 We compared substance misuse in 31 homeless people staying in supportive shelters with that in 15 people who were literally roofless in Sheffield in the United Kingdom. Thirteen (87%) of the roofless people had injected drugs in the past month compared with only 4 (13%) of the people in shelters. All 15 (100%) of the roofless people had been using heroin or crack cocaine regularly in the past year compared with only 10 (32%) of the people living in shelters. [continues 200 words]
Rejecting the findings of a Public Health Agency of Canada (PHAC) review that indicated needle-exchange programs for injection drug users in prisons reduce the need for health care interventions, the Conservative government says sterile syringes aren't needed to control the spread of AIDS and hepatitis C in cellblocks. Although a Prison Needle Exchange Program (PNEP) has long been advocated as a means of reducing the spiraling incidence and cost of treating infectious diseases within the prison population, Public Safety Minister Stockwell Day has decided a needle-exchange program is fiscally unjustified. [continues 390 words]
The federal government's decision to cancel the Medical Marijuana Research Program (MMRP) sends a strong message that clinical research into the risks and benefits of herbal cannabis -- the kind distributed by Ottawa under Supreme Court order -- is not a priority. The discontinuation also signals Canada is no longer interested in being a leader in cannabinoid research despite its unique position as the only country with a federally controlled marijuana grow-op to supply registered users. The federal government has "suddenly taken away the research, or the possibility to do additional research, to inform not only the physicians but patients about safety and efficacy," says Dr. Mark Ware, the sole researcher to receive MMRP funding. [continues 796 words]
