Cannabis and Tobacco

1
Cannabis and Tobacco Management and
CessationSTCA Presentation29th March
2007 Kevin Flemen
2
Educative Developments
Health Scotland Fags and Hash Leaflet only
leaflet that looks at both substances (initiated
by ASHS with WLDAS and SDF) Know the Score
Cannabis looks at reclassification from
Scottish angle Frank Cannabis Too Much too
Often leaflet looks at management and
cessation doesnt look at tobacco
dependency TV Campaigns 2.75m FRANK ad
featuring Brain Store focus on Mental
Health no mention of smoking/tobacco HIT What
s the Deal on Grass Whats the Deal on
Quitting www.knowcannabis.org.uk UK
self-help site designed by HIT QUIT offer
training course on cannabis for smoking cessation
workers
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Legislative Developments

• Came in to force January 2004
• Cannabis moved from class B to C
• Penalty for possession drops from five to two
  years (max)
• Penalty for supply of Cannabis remains at 14
  years
• Possession will remain an arrestable offence
• Initial ACPO guidance issued in 2004
• Revised guidance issued in 2007
• Guidance and media coverage wholly Anglo-centric
• Reclassification less significant in Scotland due
  to differing legal and policing structures
• Cannabis Warnings are not part of Scottish
  cannabis policing
• Users generally apprehended and decision on
  action taken by Procurator Fiscals office

4
Production Developments

• Shift in UK away from imported cannabis to
  Homegrown
• Estimates that 60-70 of UK cannabis now grown
  locally
• Home-growing moving away from cottage industry,
  and become a bigger gang-led industry
• Police and Media sources suggest Vietnamese
  growers have become key players
• Main crop is high-yield, fast maturing cannabis,
  but with lower potency than stronger skunks e,g
  Blueberry x White Rhino (7-9 weeks) (Drugscope)
• Main import in UK is adulterated cannabis resin
  (soap)
• Production of Moroccan Hashish in decline (62
  reduction) according to INCB/Guardian.
• Increased contamination of herbal cannabis

5
Enforcement Developments
Increased level of police enforcement against
producers/growersCannabis shortages reported
from Summer 06 Operation Keymer announced in
September 2006 involves 20 English
Forces Operation League in Scotland from
October 2006 more than 3m of cannabis reported
seized Cost of cannabis at street level appears
to have increased Availability of herbal
cannabis in many areas is patchy Some sources
report increased use of resins Some sources
suggest increased cannabis imports due to
increased profitability
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Soap Bar
Most of the resin sold in the UK is soap or
soap bar. This is reputedly low grade,
chemically extracted and prone to being
adulterated with bulking agents like henna,
paraffin wax, cloves, paper pulp, plastics or
worse. Allegedly it may sometimes contain other
additives like ketamine to make it feel
stronger. It is lower in THC and likely to be
more toxic than better quality drugs.
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Grit Grass
Increasing reports of contaminated herbal
cannabis Sprayed with some sort of glass spray
possibly glass etching material or
similar Detectable as gritty feel if rubbed
between fingers Subject of DoH bulletin
regarding risks
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Where Next?
Factors promoting no change ACPO guidance
supports and retains current position Evidence
(JRF et al) of savings to police time No
evidence at present for increased cannabis
use Factors for change Prospects of a legal
challenge to the current policing of
cannabis? Increased media support for a move
back from Class B to Class C. Potential for
reclassification to be an issue in run up to next
electionHigh profile criminal cases where
cannabis has been an aggravating factor in
murders/assaults Increase in age for purchasing
of cigarettes from 16-18
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Cannabis v smoking 16-24 1998 2004/05
Based on BCS 1994-2005 Household Survey
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Cannabis v smoking v age
Based on BCS
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Regular Tobacco Use v Cannabis useIn Last Year
Source Drug taking smoking and drinking amongst
young people in 2005
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Regular Tobacco Use v Cannabis useIn Last Year
Source Drug taking smoking and drinking amongst
young people in 2005
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Correlations
Source Drug taking smoking and drinking amongst
young people in 2005
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Methods of Use
Lack of good data on spliff smoking IDMU (1994)
reported 72.5 of use was via spliffs/joints 5
reported neat consumption of Herbal Cannabis
Lack of good data on pipe use, or types of pipe
used IDMU (1994) reported 19 used pipes no
cross correlation of pipe use with tobacco use or
age
Around 1 to 2 of respondents consumed 50 or
more of their cannabis in food or drink, and
around 25 eat or drink their cannabis on
occasions.
15
Pipe Spliff Eaten
1 5 10 15 30 45 60
120 180
Comparative amounts of cannabis consumed by
different routes
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Acknowledging Cannabis Dependency

• People can and do become dependent on cannabis
• Significant lack of research on the mechanisms
  underpinning cannabis dependency
• Historically drugs agencies havent engaged well
  with cannabis use
• Have been over tolerant of it
• Viewed it as a lesser evil
• Did not consider it addictive
• did not engage with cessation strategies
• Cannabis use not tested on arrest
• NDTMS 61 11-18 yr olds presented as cannabis
  main problem drug. Only 6 of those 18 reported
  cannabis as main drug (NDTMS/NTA 05)
• 17 of YP using cannabis came in to treatment via
  YOT

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Markers for Cannabis Dependency

• tolerance increasing dosage or strength to
  achieve same level of effect
• Increasing frequency of episodes of use, and
  duration of episodes
• symptoms of withdrawal physical or psychological
  symptoms when cannabis use is discontinued
• continuation of use despite awareness of negative
  effects
• prioritisation of substance use over other
  essential or important tasks
• Inability to control use in terms of onset,
  duration or cessation
• preoccupation about use
• effort goes in to continuing use
• concealing or lying about use

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Modelling Cannabis Dependency
Physical
5

• Muscular relaxation
• Pain relief
• Increase score if cannabis used for serious
  medical conditions

Group activity Shared with friends Strong
positive associations Likely to be
normalised Viewed as non-problematic
4
3
2
1
Psychological
Social
1 2 3 4 5
5 4 3 2 1
1 2 3 4 5
Calm, - irritability Promotion of
sleep - insomnia Reduced anxiety -
vivid dreaming Reduction in anger -
kicking off Increased relaxation -
inability to relax self medicating -
symptoms overt
Habit of skinning up Ritual of seating and
activities Coping mechanism Times of
day associations
Ritual
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Practice Issues
Little information to guide best practice in
working with cannabis use and tobacco use Lack
of research, evidence based guidance or models of
best practice Scottish practitioners have led in
this area Brian Pringles model of engagement
is the closest that we have to a template for
working with cannabis and tobacco users
http//uknscc.org/2005_UKNSCC/presentations/brian
_pringle.swf
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Initial Questions
Do Smoking Cessation workers routinely ask about
cannabis use? If cannabis use is present, is
smoker assessed for cannabis dependency? Given
outcomes from above, what happens next? Who
should take a lead on cannabis smoking
cessation? At what level should a person be
referred to specialist drug services for support
in cannabis cessation?
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We need to

• Create safe space to discuss cannabis use may
  not be appropriate for group settings better on
  11
• Ensure clarity around confidentiality
• Explore risks of cannabis usage with client
  they may not be aware of the health implications
• Identify client motivation with regards cannabis
• Have access to appropriate, age relevant
  literature regarding cannabis and smoking
• Have effective referral routes to drug and Mental
  Health Services

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Motivational Tools

• goal setting use of inability to meet goals
  as motivational tool
• Cannabis diary review use, assess scale, look at
  cost
• Pros and Cons acknowledge positives of use but
  identify negatives
• Harm reduction allows user to identify
  negatives within use while carrying on use

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Options
Cessation of cigarette use but continues to
smoke spliffs containing cannabis and
tobacco Cessation of cigarette use but
continues to smoke cannabis without tobacco
(pipes, straight herb, bongs etc) Cessation of
cigarette use but continues to use cannabis but
moves to eating it Cessation of cigarette and
cannabis use
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Cessation

• Identification of positive reasons to stop
• Identification of negatives attached to
  continuing
• Use of diary to identify patterns and difficult
  times
• Identification of key benefits attached to use
  and identification of alternative strategies
• Understanding of likely withdrawal symptoms
• Discussion with supportive peers
• Choose day
• Removal of triggers/paraphernalia/drugs
• Change rituals/routines/furniture layout
• Development of self management techniques (as
  for smoking)

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Cannabis and Tobacco Cessation
Option A Cessation of cannabis and tobacco
simultaneously no NRT healthy option -
Uncertain outcomes withdrawing from both
substances likely to be worse than either
alone. May be more likely to lapse back into
smoking Option B cessation of cannabis and
tobacco simultaneously with NRT healthy
option for highly motivated client, may be
better than (A) - 24Hr NRT can disrupt sleep, as
can cannabis withdrawal - Still attempting to
overcome two habits at same time
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Cannabis and Tobacco Cessation

• Option C Cessation of cigarette smoking
  continue cannabis use
• pipes/eating/bongs removes tobacco the
  larger health problem
• eating best option for people who want to
  stop smoking, but continue cannabis, espec for
  self medicating
• - Cannabis use likely to involve tobacco if used
  in spliffs
• Spliff smoking likely to escalate in order to
  meet nicotine craving
• Lapse back on to cigarettes likely
• Use of tobacco-free routes (e.g. pipes/bongs)
  may result in more compulsive use
• use of pipes/bongs still damaging to lungs-
  smoking routes still reinforces smoking
  behaviours and may increase risk of lapse

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Cessation Cannabis and Tobacco

• Option D Stop cannabis first subsequently stop
  cigarettes
• probably more effective for some in long term
  if (A) or (B) not applicable
• Person continues smoking not ideal
• Requires person to be motivated re. Cannabis
• Long process

Stages a complete cessation of cannabis use.
work through withdrawal able to deal with
cravings/risk situation stable without
cannabis b nicotine withdrawal use of
standard smoking cessation approaches
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Decision Tree
Is client highly motivated to stop both nicotine
and cannabis
Consider cessation of cannabis and tobacco with
NRT
Only nicotine
Not viable or successful?
ve outcome
Address ambivalence re cannabis
Consider cessation of cannabis use first, then
tobacco cessation
No increase in motivation re cannabis
Nicotine cessation Use of cannabis without tobacco
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Future Questions

• Are harm reduction interventions something that
  smoking cessation workers can/should endorse for
  cannabis users who are determined to keep using
  but wish to stop smoking cigarettes?
• Is a 6-8 week engagement timeframe viable when
  working with people who are stopping use of both
  cannabis and nicotine
• Is there an evidence base for any of the
  following
• Zyban v NRT in nicotine cannabis cessation
• Risks of zyban for continuing cannabis users
• Relapse rate amongst smokers who continue spliff
  smoking following smoking cessation
• Efficacity of Option (a) against options (b), (c)
  or (d)
• Where will the strategic lead come from?

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Contact
www.ixion.demon.co.uk kevin_at_ixion.demon.co.uk