When recreational marijuana became legal to buy in Colorado on Jan. 1, 2014, public health officials figured they’d see a rise in teenage users.
What they didn’t anticipate was a spike in calls to poison control, an increase in emergency room visits from tourists who had overindulged, and a surge in edibles, some seemingly geared toward children and many with confusing serving sizes.
“[Colorado was] rushed into it and we were also the first, so we didn’t have anyone to look to,” says Tista Ghosh, a physician and epidemiologist at the Colorado State Department of Health. “We’ve been very proactive in talking to other states who are considering legalizing. Learn from our mistakes! Preparing the regulatory infrastructure, the product safety infrastructure, the data infrastructure will make things go much more smoothly.”
It might seem counter intuitive that many in public health welcome the legalization of marijuana. But it opens opportunities to set age restrictions for buyers, establish regulations around use when driving, monitor the quality and safety of cannabis legally for sale and build better support for people who struggle with addiction.
With the Canadian federal government poised to table legislation as early as this spring to legalize the recreational use of marijuana, we’re taking a closer look at some of the public health challenges that will move to the forefront.
Curbing Impaired Driving
Since marijuana has been shown to impair reaction time and other abilities needed for driving, one of the biggest public health concerns is keeping people who have been smoking pot from getting behind the wheel.
“A lot of users believe that cannabis doesn’t affect their driving or increase their collision risk, and that’s a very hazardous perception,” says Robert Mann, a senior scientist at the Centre for Mental Health and Addiction.
Seven police forces across Canada are currently assessing a roadside test that can detect seven classes of drugs in the saliva, including tetrahydrocannabinol or THC, the substance in marijuana that produces the feeling of being high.
The test can’t determine quantity, only that the drug has been used within the past four to six hours. If a driver fails the screening test, a second step may involve a blood or urine test, which could provide more clarity on how much has been ingested. Since the initial roadside test is expensive—costing $20 or more per test—it’s unclear how or where it will be used in each province, or what will happen if a driver fails that preliminary test.
It’s also unclear where provinces will set limits for driving, although evidence suggests that a THC concentration of seven to 10 nanograms per milliliter in serum would produce a similar impairment to 0.05 per cent blood alcohol content. Colorado set its limit at five nanograms per milliliter.
In its recent framework for legalization, the Canadian Task Force on Cannabis Legalization and Regulation made no recommendations on this, except to say more research was needed to support setting limits.
National data published by Mothers Against Drunk Driving Canada in 2012 showed for the first time that the number of motor vehicle fatalities where the driver was found to have drugs in their system was 25 percent greater than alcohol-related fatalities. Nearly one in five drivers involved in motor vehicle fatalities had alcohol in their systems; a quarter had other drugs; 16 percent had a mix of both. While other drugs were present, the most common drug was marijuana.
That suggests urgent action is needed to make drivers aware of the dangers of smoking pot and driving, says Andrew Murie, Chief Executive Officer of MADD Canada.
MADD would like to see a zero tolerance approach for drivers aged 22 and under, just like alcohol, meaning any evidence of marijuana use would result in the suspension of their licence, fines or worse.
“We’re at a really bad stage right now because we’re in this sort of grey freedom stage with no rules and all of us are anxiously waiting for the feds to move forward,” Murie says. “The provinces can’t act until the feds do. The feds need to put their cards on table, get the legislation passed and once we know what that looks like, we can start to plan.”
Marijuana & young people
One of the reasons institutions like the Centre for Mental Health & Addiction supported legalization was the opportunity to use public health approaches to reduce marijuana use in Canadian teens and young adults.
Canadian teens lead the world when it comes to marijuana use, according to a 2013 UN Report published before recreational pot became legal in some US states. Nearly a quarter of Canadian youth and young adults used marijuana, more than 2.5 times the eight percent of adults who reported using marijuana, according to Statistics Canada.
That means the lead up to legalization needs to focus on developing and delivering public health messages that reach and influence Canadian youth, says Ian Culbert, executive director at the Canadian Public Health Association.
Those include education messages encouraging users to understand what they’re buying, where it comes from and how strong or powerful it can be.
After pot became legal in Colorado, state health officials noticed a jump in accidental pediatric poisonings, with the number of children arriving at the emergency department having ingested pot increasing five-fold between 2009 and 2015. In at least one case, a child died.
Ghosh says this was largely due to packaging and unsafe storage of edible products, which, in Colorado, can range from baked goods to colourful candies, and even includes things like butter and ramen noodles.
“We underestimated edibles and the way that market would grow,” she says. Confusing serving sizes not only landed users in hospital, it caused three deaths. In each case, consumers unwittingly ingested far more than the legal serving size and suffered a psychotic break.
In Colorado, a legal single serving is considered to be 10 mg of THC – yet some cannabis-infused cookies and chocolate bars carry 200 mg or more. Because marijuana affects people differently, beginners are cautioned to limit their intake to 5 mg.
Culbert says there’s evidence about the harm regular, heavy use of cannabis can have on a developing adolescent brain, including impacts on attention, decision-making and a decline in IQ of six points or more, on par with lead exposure. Because of marijuana’s current illegal status, there’s little evidence on what happens with the brain development of teens who smoke occasionally.
Culbert says harm reduction messages will likely centre around knowing when enough is enough. Since marijuana can have different effects on different people – and since smoking can have more immediate effects, but ingesting can have longer, sometimes more powerful effects – messaging is needed to help new users better understand what they’re getting into.
“We have to be prepared for the day when it’s legal. We can’t start then – we have to have been out there with messaging months in advance of that,” Culbert says. “We know the manufacturers, they’re spending hundreds of thousands of dollars on branding, packaging, marketing, messaging. We can’t be caught behind the eight ball.”
Surveillance, surveillance, surveillance
“When you’re doing something new like this, you don’t know what the repercussions will be on your society. If you don’t collect data, you won’t be able to pinpoint any problems,” Ghosh says. “You can’t be responsive and tackle your problem areas if you don’t know where they are.”
Colorado had virtually no baseline data on patterns and trends in cannabis use, Ghosh says. Legislation passed in November 2012 went into effect on January 1, 2014, but the public health department had no revenue to put toward campaigns or dedicated staff until sales began. “By the time we got the money, that’s six months into sales and by then you’re playing catch-up,” she says.
It was only because emergency department data and poison control calls were already being monitored that they were able to recognize the increase in accidental poisonings and overdoses and make legislative changes.
Experts agree: no one in Canada is collecting enough data now to understand the impacts of legalization.
Having data on how legalization changes consumption, contributes to addiction or affects public safety “opens the opportunity, especially at the provincial level, to say, ‘whoa, this isn’t working,’” Murie says. MADD is also looking for data to become available more readily and for common testing criteria for drivers in fatal crashes. Figuring out what data are needed, how to collect it and how to use it is part of a conversation that’s happening with public health officials across the country, Culbert says.
“I don’t think anyone’s really tracking cannabis use very closely,” he says. “Five years down the road, we’re going to want to know has usage increased, have emergency room admissions increased because of overdose, have impaired driving charges increased because of cannabis. While we have baseline usage, we aren’t pulling together the data in those other areas.
“We have this window between now and when we flip the switch for retail sales to establish those systems and start collecting baseline data that’s going to be so crucial when there are calls to understand the impact of legalization.”