Hard News by Russell Brown

2

The cannabis referendum: the evidence

If the government has not lined up behind a "Yes" vote in this year's cannabis referendum the way some reformers would have liked, one entirely laudable thing it did do was commission some science around the public's choice.

That science landed today, in the form of the report from an expert panel convened by the Prime Minister's Chief Science Advisor, Professor Juliet Gerrard. The panel was specifically not asked to make a recommendation, but instead to summarise the evidence on legalising and regulating cannabis.

The result is some quite admirable science communication, with evidence available in at-a-glance summaries and FAQs, and in detail. There's even an accompanying 25-minute video by Shirley Horrocks:

It would be redundant to go through all of it here, but it would be fair to say the panel seems to have found more common ground on the social harm caused by the current criminalisation of cannabis than on the public health consequences of legalisation and regulation, as observed in other jurisdictions, although it does indicate that on balance, legalisation will make it easier to get help with use problems and also make research easier to conduct.

Indeed, that's what Professor Gerrard focused on in an interview ahead of today's release

"Instinctively when people hear the word harm, they think about the medical harm. Less well documented is the social harm - people getting kicked out of school for a drug offence, a drug conviction on a record which could affect employment prospects and cascade into a series of social harms.

"The people in that situation are disproportionately young, disproportionately male and disproportionately Māori."

The panel has, however, found a consensus that cannabis is less harmful overall than the two currently legal social drugs, alcohol and tobacco – and on most measures at that. Whether legalising cannabis leads to a substitution of cannabis for alcohol is less clear.

 The at-a-glance page correctly notes a "progressive softening of the law" on cannabis in New Zealand, culminating in last year's Misuse of Drugs Act  amendment directing police discretion away from prosecution and towards a health-based response. It also observes that "enforcement may continue to discriminate against Māori and young men."

Cannabis arrests have already declined sharply over the past decade, and the panel says that the number of convictions "is also likely to decrease over time". Yet within this slow slide into de facto decriminalisation, leaving production and supply as criminal enterprises is "likely to continue to give rise to and boost organised and opportunistic crime."

What the panel doesn't canvas, but which I fret about sometimes, is some evidence that under decriminalisation (and permissive medicinal schemes) in US states, public health outcomes – and rates of youth use especially – were worse than under legalisation.

New Zealand Police are increasingly disinclined to prosecute cannabis possession – and the courts are granting discharges for people caught with as many as 20 plants, especially if there is some evidence of medicinal intent. I do worry about sliding into a messy, unregulated space the way Canada did. Youth use climbed right up to legalisation there, then stabilised and declined. Remember last year when Patrick Gower agonised on TV about the dab bars of Vancouver, where people were inhaling powerful concentrates? They actually predated legalisation by years and the new federal law is being used to close them down.

In Horrocks' video, Dr Irene Braithwaite of the Medical Research Insitute of New Zealand draws a distinction between "recreational" use and the medicinal use permitted and regulated under last year's Misuse of Drugs (Medicinal Cannabis) Regulations. On one level, this is just clearing up the dfference between two laws, but as we know from research conducted in the past year by both MCANZ and Massey SHORE, there is a large group of  New Zealanders using cannabis illegally in ways that are at least as much therapeutic as "recreational". Adult use of cannabis isn't just one thing.

As controversial as it's proving to say, that community isn't necessarily going to switch wholesale to prescribed GMP-standard cannabis products – and certainly not before there are many more products and GPs willing to prescribe them. The referendum is about whether we should continue to criminalise those people too.

My impression overall is that there's more in the expert panel's consensus to please reformers than the people who favour continued prohibition of cannabis, especially in the area of social harms. To be honest, that was to be expected.

Whatever any of us takes from this exercise, I think the government is to be commended for requesting it and the PMCSA for delivering it in the way it has. Bravo.

–––

There's another new presentation on the implications of cannabis legalisation – and in a place where you might not expect it.

Auckland Transport has just published a swathe of cannabis-related papers presented to its board last month and it while most of those are external documents attached for the reference of the board (including health and safety advice from Canada) , the discussion document presented by AT staff is solid, sensible stuff.

What's missing for now is active consideration of a switch from urine to saliva testing within AT itself. Saliva testing offers a much better measure of actual impairment, it will be fairer for employees and there's now a New Zealand Standard for it. AT should be talking about this to its employees and their unions.

But there's time for that. For now, AT deserves plaudits for getting out in front of the issues. Other organisations could follow suit.

4

Paula Bennett and the Scientology leaflets

I wrote earlier in the week about the Scientology front organisations Drug Free World and Drug Free Ambassadors and their quite prominent role in anti-cannabis reform "coalition" assembled by Family First and a new local branch of the American prohibitionist organisation SAM.

It turns out Family First aren't the only ones helping the Church of Scientology market itself to vulnerable people. National's former drug reform spokesperson Paula Bennett did her bit too.

On February 24, Bennett was the guest of honour at a meeting on drug reform – one of a series of such meetings where she spoke – staged by the new National Party candidate for Upper Harbour, Jake Bezzant. It seemed to go well, with Bezzant writing afterwards on Facebook:

Thanks to all who attended and engaged at our drug reform public meeting with Paula Bennett in Westgate tonight - standing room only! 

I appreciate hearing from across our community on the topic. It's vital we're informed as the cannabis referendum nears, along with calls for further drug liberalisation.

Among the audience was Aucklander Emlyn Revell-Nash, who noticed, as he put it to me, "something fishy" about pamphlets that were put out at the meeting. They were from The Foundation for a Drug Free World – which is, as my earlier post this week observed, a front for The Church of Scientology. Says Emlyn:

What was weird was the pamphlets were not only on the table along with the spam signup forms; but Jake announced the last question would be taken from this particular old woman, in her sixties or seventies, who was from Drug Free World. He and Paula then proceeded to hand out these leaflets.

Emlyn accepted a pamphlet, confirmed its provenance, and took a couple of pictures of it.

The source of this material – if not the explicit connection to Scientology – was pretty obvious. I suspect Bennett and Bezzant simply weren't diligent enough to enquire into exactly what they were literally handing out. (Although Bennett possibly should have been, given that she was in government in 2012, when Drug Free Ambassadors got taxpayer money to print 130,000 copies of an "education booklet" that was distributed to New Zealand schools.) Perhaps some shock-horror literature just suited their purpose.

Just in case, Emlyn let them know:

I'd be interested to know if anyone else who attended Bennett's meetings saw this material there – or anywhere else, for that matter. Feel free to get in touch by commenting below or, for more privacy, clicking the envelope icon at the bottom of this post to email me.

To be clear, it is absolutely not the case that anyone who opposes the legalisation and control of cannabis as proposed in the forthcoming referendum is in bed with Scientology. But this is recruitment material for an abusive cult and we need to be able to have our debate on the referendum without it. We also really don't want MPs or candidates handing it out.

27

The Scientology front operation behind the "No" campaign on cannabis

Last night, One News ran a follow-up story to its Colmar Brunton poll results on the cannabis referendum, headed here as Government accuses big American anti-cannabis group of interfering in NZ politics.

In truth it wasn't just the government: Justice minister Andrew Little, National's Shane Reti and the Greens' Chloe Swarbrick all appeared on camera to express unease about the entry to the referendum fray of the American lobby group Smart Approaches to Marijuana.

SAM is controversial in the US too, not least on account of its tireless efforts to avoid revealing who bankrolls its activities. Say Nope to Dope, which was founded by Family First's Bob McCoskrie, yesterday swiftly issued a press release on behalf of SAM-NZ denying that the local "No" lobby was being "bankrolled by or controlled by US organisations".

Further "SAM in the US are not telling our coalition how to run our campaign, and have not contributed one cent to it."

But Say Nope to Dope did, three weeks ago, issue the press release announcing the formation of SAM-NZ, to be fronted by Aaron Ironside, a Christian life coach, former radio DJ and longtime associate of McCroskie, who had also been announced only days before as Say Nope to Dope's new spokesperson.

Yesterday's press release included a list of other individuals and organisations who are part of the "No" coalition. It includes quite a number of well-known conservative voices, such as school principal Pat Walsh and Jess McVicar of Sensible Sentencing Trust. There are individuals with a commercial interest in talking up the drug war, such as Methcon's Dale Kirk and Drug Detection Agency owner Kirk Hardy.

There are various conservative Christian groups, along with a couple of senior members of the New Zealand Muslim Association (but not, it appears, the association itself). It's about what you'd expect: people with vested interests and people and organisations that routinely oppose liberal social change, along with a few who have entered the fray because they're genuinely concerned about cannabis legalisation.

But there are also four names from an organisation that will be less familiar: Drug Free World. That will be Drug Free World Aotearoa New Zealand, which set up a Facebook page earlier this year. It appears to have evolved from Drug Free Aotearoa, which was estabished by Taranaki woman Rose Denness in 2012. Denness's name will be familiar to people who have studied the Church of Scientology.

Yes, she is a Scientologist, and Drug Free World Aotearoa New Zealand is Scientology front, along with Narconon and various others listed by then-Green MP Kevin Hague in Parliament in 2009. Said Hague at the time:

I am not a person with a religious belief myself, but I do not object to churches providing social services, provided that the church connection is transparent and that the service is not a front for recruiting into the church. It seems to me that the Church of Scientology fails on both those fronts.

The "About" page of Drug Free World Aotearoa New Zealand's Facebook links directly to the website of the Foundation for a Drug Free World, a notorious Scientology front with a long history of wangling its way into official drug education programmes to peddle pseudoscience.

It even happened here: Drug Free Ambassadors, another Scientology front managed to get public money for 130,000 copies of a booklet distributed to New Zealand schools.

It's possible, probable even, that many of the people involved here in Drug Free World have no idea what it actually is. The old Drug Free Aotearoa used to wrap itself in tikanga so the links weren't obvious, and Drug Free Ambassadors claimed a "partnership" with Māori wardens. Some may have come to it via the "briefings" that can be booked via its Facebook page (the first one is free, of course).

If some elements of this anti-reform coalition are opaque and questionable, its embrace of a harmful Scientology front is actively alarming. And it says something about the nature of the active opposition to cannabis law reform in New Zealand that it's there.

6

Towards the referendum: this might actually be a trend

Back at the beginning of April, when we had much else on our minds, I wrote this post urging some caution in interpreting the results of the latest Horizon poll, conducted in February, on voting intentions in this year's cannabis referendum, which was paid for by Helius Therapeutics.

I wrote that the structure and style of the questions:

... sets up the proposition in quite an obvious way, with legalisation and regulation implicitly presented as the prudent and responsible course of action: “controls” versus “no controls".

It’s not dishonest: it’s literally the argument most of us make for reform. But it has very probably had a bearing on responses, and was crafted with that in mind.

Well, Horizon and Helius have published another poll, using the same questions and structure, and it really does seem to show a rising trend towards a "Yes" vote in September:

There's a difference in the way the reports are reported though: in Horizon's release on this latest poll, results for the question At this time, do you think you will vote for or against legalising cannabis for personal use in New Zealand? are listed before those on prohibition and its outcomes in New Zealand, not after. I suspect that doesn't actually mean a change in the order of the questions, but I'll check.

The actual overall increase in intending "Yes" voters is modest: from 54% to 56%. But that's up from 39% in August last year. And there are increases over February regardless of who respondents voted for in 2017. Striking increases in support among Act voters (from 45% to 70%) and New Zealand First voters (from 46% to 53%) may reflect a small numbers problem, but even among National voters, 31% would be prepared to overlook partisanship and vote "Yes", up from 27% in February.

In demographic terms, only the over-65s aren't showing majority support for reform.

What's happened between the two polls? A sharp tilt towards Labour in party voting intentions for one thing. But Horizon polled its panel between June 4 and 10 – days after the New Zealand Drug Foundation's 'On Our Terms' campaign launched on June 2.

The message of the campaign is very clearly emphasised on its home page. The page leadline is: It's time to take control of cannabis on our terms. The referendum is characterised as the Cannabis Control Referendum. It lists 8 key control measures of The Bill. And that's all above the fold. The word "control" is further emphasised with the use of colour.

This aligns with the way the Horizon poll questions talk about Controls over growing and selling personal use versus Continuing with no controls.

I don't think Helius and the Drug Foundation are really colluding over this – they're simply discovering what argument resonates with the public in their research.

So we're not only seeing a steady increase in support for reform – albeit in response to a poll structured to cultivate that support – we may also be seeing what the winning argument might be.

The challenge for reformers as September approaches will be to keep that the argument – and, ideally, to separate that argument as much as possible from political partisanship. In the run-up to an election, that might not be easy. But it's becoming clear that's the job.

16

Cannabis research: there's a lot of it about!

I try my best to know what I don't understand, and one of the things I know is that meta analyses and evidence reviews are difficult for lay people to assess. The merging of data from multiple sources is complex and understanding what's going on requires actual knowledge of the character of the studies incorporated in the review.

So when the people from Say Nope to Dope last week trumpeted a new meta analysis of findings about cannabis and violence, I was cautious. In the case of this new paper from the University of Montreal, I didn't have journal access anyway. But one of the headline findings struck me as extraordinary: the headline odds ratio for lifetime use was 1.94; meaning that anyone who has ever tried cannabis was nearly twice as likely to have committed a violent offence as as anyone who hadn't. In a country like New Zealand, where 80% of us use cannabis at some point, this seemed to have some remarkable implications.

So I asked Professor Joe Boden, director of the Christchurch Health and Development Study, whose research interests include both substance use and "the social and psychological determinants of maladaptive behaviour including aggression and violence."

He didn't take long to come back: the Canadian paper had misquoted an odds ratio from a paper by the Dunedin Multidisciplinary Health and Development Study (the companion longitudinal study to the Christchurch one) "as being 6.9, when the adjusted OR is in fact 3.15."

The adjustment of data to account for confounding factors – alcohol use, socioeconomic status, underlying conditions, etc – is crucial in this kind of work, so presenting unadjusted data as adjusted is quite a problem.

It has since turned out that there are sufficient questions about the Canadian paper to warrant a formal approach to the publishing journal, the American Journal of Psychiatry, which might take a long time to work through. But Professor Boden was happy enough to be quoted on what he and his team are seeing.

He says Figure 2, a table and plot of odds ratios from the 30 studies analysed, is "riddled with errors" – including with respect to Arsenault et al, the paper from the Dunedin study.

"Some of the ORs reported are unadjusted, whereas others are adjusted.  It is to some extent unclear which ones were used in the analyses. Given their comments, I believe it is possible that the authors used the wrong odds ratios in their analysis, as the higher ORs were the ORs that appeared in the error-riddled Figure 2."

Further, he says, the authors acknowledge that the dose-response relationship between cannabis and violence  "was observed primarily because of two studies that reported high odds ratios," one of which was the Arsenault paper. The adjusted odds ratio, the one that should have been used, was only moderate.

Professor Boden also noted "a high degree of heterogeneity" in the studies included, meaning "the studies included were sufficiently different in design, scope and analysis that the 'true' effect size is still unknown – effect sizes reported in the paper are indicative)." The effect itself – violent behaviour – is not measured in the same way across the source studies. But the authors observed that odds ratios were lowest (1.66) in the most reliable category of research – the longitudinal studies.

"If the number [in the Arsenault study] included the unadjusted figure rather than the adjusted one," says Professor Boden, "then the already weak OR (1.66) will cross into non-significance and will be no different from 1 (no effect)."

The authors also state that many of the included studies either haven't adjusted for potential confounding, or did not account for things such as other substance (particularly alcohol) use, conduct problems, psychopathic traits, and history of violence.

"Conduct problems is the big one here, as it is highly correlated/co-morbid with substance use and misuse."

One further cause for caution with this kind of work is that it's dealing with an association between two things that are quite rare: heavy and persistent cannabis use (the exposure) and violent behaviour (the outcome).

"What this means is that estimates of the OR will be highly inflated, and it is usually advised to calculate the risk ratio instead in these cases – that is, cumulative incidence in those exposed versus cumulative incidence in those not exposed."

 (There's a reasonably straightforward explanation of the difference between odds and risk ratios here.)

None of this is to reject the idea of an association between (particularly heavy and early) cannabis use and violence, but the association is complex and in some cases causation may run the other way: so conduct disorder involving violence may be a predictor of early cannabis use.

–––

Professor Boden is also the author of a Spinoff article published this week: What 40 years following thousands of NZ people tells us about cannabis harm, which briefly outlines the conclusions of research founded in New Zealand's two longitudinal studies. You're almost certainly familiar with these findings: principally, that early and heavy use of cannabis is associated with an increased risk of psychotic symptoms later in life.

Some of their findings have been challenged, but we can confidently say as a result of these two studies that heavy use of cannabis in adolescence is A Bad Thing.

Professor Boden concludes:

Given our research on the risks associated with cannabis use, why do the directors of both the Christchurch and Dunedin studies maintain that cannabis should be dealt with as a health issue, and not a justice issue? The reason again is related to our findings. 

First, despite being a banned substance, cannabis is commonly used across both cohorts, indicating that prohibition does not stop people using cannabis. Second, we found that those who were arrested or convicted of a cannabis offence did not reduce their use of cannabis (in fact some increased their use), suggesting that being subjected to the force of the law does not deter people from using cannabis. Third, the Christchurch study found that Māori were three times more likely than non-Māori to be arrested or convicted on a cannabis offence, showing that prohibition law is enforced by the police and courts in a racially biased way. 

Collectively, our findings suggest that cannabis prohibition laws are not fit for purpose, and that in the 21st century we must deal with the problems associated with cannabis in a way that promotes health, equity and justice for all New Zealanders. The way forward is through legalisation and strict regulation as provided by the Cannabis Legalisation and Control Bill.

If you find that interesting, you may want to read the long version: Patterns of recreational cannabis use in Aotearoa-New Zealand and their consequences: evidence to inform voters in the 2020 referendum, a new article for The Journal of the Royal Society of New Zealand, with Joe's colleague Richie Poulton as lead author. It concludes with much the same observations as the Spinoff article on the ineffective and counterproductive nature of cannabis prohibition and signs off with this:

Given that the referendum process does not allow for a more graduated, evidence-informed move towards legalisation, we urge the government to establish clear expectations for a careful, deliberative roll out of a new legislative framework if voters select this option. Systematic ongoing evaluation of the impacts of, and concerns about, harmful use will be important. The plan should be flexible in order to consider real-world commercial imperatives and profit-making activities. The parallels are obvious with the alcohol industry, such that identification of new markets (e.g. youth) resulted in the emergence of alco-pop products. In this regard, it is reassuring that the ‘rules of engagement’ published in 2019 (and summarised above) appear thorough and well-considered. One thing is very clear from the research – and thankfully it appears to be a message that has been widely understood and accepted – regulations that restrict access to use by children and adolescents must be prioritised and enforced.

–––

A more recent article from University of Otago researchers, Cannabis, the cannabis referendum and Māori youth: a review from a lifecourse perspective, for the New Zealand Journal of Social Sciences Online, focuses on the particular harms suffered by Māori, both through unhealthy use and the impact of criminalisation. It concludes:

It is clear that the combination of early and regular cannabis use negatively impacts on young people’s health and wellbeing. Rangatahi Māori are more likely to use cannabis in Aotearoa New Zealand compared to their non-Māori peers. Moreover, they are more likely to be criminalised for its use from a young age even when they have similar levels of use to non-Māori. The evidence to date shows deeply entrenched inequities beginning in youth for Māori in relation to cannabis use and convictions. Based on current research findings from Aotearoa New Zealand, we conclude that cannabis use should be treated as a health and not a criminal issue.

–––

The editorial in the May 22 issue of the New Zealand Medical Journal, by Chris Wilkins and Marta Rychert of Massey SHORE, also raises some interesting questions about the Cannabis Legalisation and Control Bill to be voted on at this year's referendum. In truth, most of them – including the detailed regulations for retail premises and the precise role of local authorities – seem like the kind of things on which a Parliament would seek to direct the proposed Cannabis Regulatory Authority, should there be a "Yes" vote, but they're worth discussing now. (I confess, I hadn't picked up that it's still unclear which government agency would direct the new authority.) I do think (the authors disagree) that there is enough explicit provision in the CLCB for non-profit retail outlets without pre-emptively fencing off a specified proportion of the market for them. And I still don't think liquor licensing trusts are a good model.

The authors conclude:

We recommend the inclusion of a formal minimum price for cannabis, the lowering of the cap on the THC potency of cannabis plant products, a set proportion of licenses for social benefit operators, and a framework to allow the emergence of cannabis social clubs.

It's not clear that in New Zealand conditions, particularly with a cap on licences, prices would collapse the way they have in some US jurisdictions, and there are perils, if you want to replace the black market, in setting prices too high. The authors also ask how potency limits for home-grown plants would be monitored – and frankly, they can't. It's not really viable to hold people accountable for the potency of plants they can't test.

Another paper by the same research team, Exploring medicinal use of cannabis in a time of policy change in New Zealand, is not available to non-subscribers, which is a shame, as it's useful and interesting.

It's based on a survey of people professing to use cannabis for medicinal reasons, which is separate to the MCANZ survey I've mentioned here before (that one is still being prepared for publication by its author Geoff Noller), and its results are variously quite similar and quite different to that one. One interesting – and encouraging – difference was the relatively high use of vaporisers (31.5%) compared to the draft MCANZ results. On the other hand, respondents don't seem to have been asked whether they sought higher-CBD ratios in their illicit cannabis, where Noller et al did (and found a relatively high level of awareness).

Also:

• Most people surveyed had used cannabis recreationally, and nearly half were doing so at the time they were surveyed.

• The condition groups for which cannabis was used most often were: pain (80.9% of respondents used cannabis for at least one pain condition), sleep (65.9%) and mental health conditions (64.0%), followed by gastro- intestinal (17.1%) and neurological (12.2%) conditions and cancers (6.7%)

• Participants overwhelmingly believed their symptoms had improved since starting to use cannabis for medicinal reasons. Seizures received the highest scores for perceived improvement (ie, 97.2% who suffered from seizures reported their symptoms had improved)

• Only 14% of patients had asked their doctor for a cannabis prescription, and only a third of those had actually received one. Unsurprisingly, nearly all of those were for CBD-only products, on which there are no official prescribing conditions, and only 18% were for Sativex, which contains THC (and was the only approved THC product at the time of the survey). The NZMA can insist all it likes that people can access cannabis products on prescription, but it still ain't true.

Perhaps the most interesting part is this graph:

It's a bit hard to read here, but the class of prescription medication most often stopped as a result of cannabis use was gabapentinoids. The class in which use was most often reduced was opioids – 95% of those who used opoids reported reducing their use as a consequence of using cannabis. (NB: The reported reduction in anti-psychotic medications might look alarming, but those are frequently used at low doses to treat conditions like anxiety.)

This is exactly what I've heard while talking to patients. There's a quality of life issue here, particularly in the case of the gabapentinoids. About half of the people surveyed reported side-effects from their cannabis use – "increased appetite" was easily the most common (29.5%), but small numbers did report psychological problems such as anxiety (6.4%) and "depressed mood" (3.8%). In general, however, these people seem to have been glad to substitute cannabis for the heavier prescription medications and their side-effects.

I think this is something prescribing doctors need to bear in mind while scorning cannabis as unproven. Patients' sense of wellbeing is not irrelevant.