Ian Hamilton: Healthcare professionals need more guidance to reduce the risk of cannabis related health problems

In 2005 7579 people in England entered drug treatment for problems related to cannabis; by 2014 this had risen to 11 821. It is likely that this rise has continued over the past two years, but a change to the method of reporting in this period (which saw presentations where cannabis wasn’t the primary drug of use also included) means we don’t have the equivalent numbers. Meanwhile, the 2015/16 report on substance misuse among young people concluded: “Since 2005-06, young people have been increasingly likely to seek help for problems with cannabis compared to other substances.”

Public Health England data paint a clear picture that cannabis is increasingly becoming a drug that people are seeking treatment for. Yet this rise in treatment demand has not been accompanied by updated guidance to healthcare workers, which could provide a clear steer on how to effectively respond.

It’s worth noting that similar trends are reflected across Europe, where the number of cannabis users entering treatment for the first time has increased, in contrast to first time treatment admissions for heroin and cocaine, which have declined. But unlike other countries in Europe, the UK does not offer cannabis specific treatment programmes.

Clearly, not all individuals who have problems with cannabis will seek specialist treatment, but it’s likely that in many cases they will still come into contact with primary care and other healthcare workers. So this is not simply a niche issue that those outside of specialist drug treatment can ignore. And it’s not as if there aren’t interventions and advice that the non-specialist can offer to help reduce the risks faced by people using cannabis.

An obvious first step in reducing the harm of cannabis use, for example, would be to try and decouple the British tradition of combining tobacco with cannabis. Over 90% of cannabis users in the UK consume cannabis this way compared with less than 10% of those in America. For many young British people, smoking a cannabis joint will not only be an introduction to cannabis, but also to tobacco and all its attendant health problems, including the risk of tobacco dependency. The National Institute for Health and Care Excellence (NICE) does not include this type of harm reduction advice in its guidance. Yet there is a clear opportunity here for all healthcare workers to offer harm reduction advice by asking individuals to consider using cannabis with less tobacco or to offer nicotine replacement therapy if they are willing to forgo tobacco based cannabis joints completely.

Any updated guidance should also address and clarify mixed messages about the effectiveness of specific interventions for cannabis dependence. For example, NICE does not currently recommend cognitive behavioural therapy (CBT), while in contrast a recent heath technology assessment found that CBT did improve outcomes for this group.

In some ways, these apparently conflicting messages shouldn’t be a surprise as there have historically been systematic problems in the way that cannabis research has been conducted. For example, most of the seminal studies on cannabis examine exposure to low potency cannabis, such as resin, a very different form of cannabis to the one most people consume now. Future research needs to address these oversights and establish robust evidence that can then be translated into practice. Research starting later this year, which will investigate making cannabis use safer, is a step in the right direction, but only one of many that needs to be taken.

It would also be useful to know how healthcare workers view cannabis, their knowledge of the risks and harms associated with the drug, and if they feel equipped to discuss cannabis use with patients. Unfortunately, there is little in the way of contemporary evidence to draw on, but one small pilot study indicated that cannabis can still be viewed as relatively benign—particularly in comparison to “harder” drugs such as opiates. It may be that along with providing healthcare professions with tailored and evidence based guidance on cannabis use, government bodies and policy makers need to start by impressing upon them that cannabis can have serious health implications.

As far back as 2003, the Royal College of General Practitioners was highlighting the growing importance of the profession being able to “offer evidence based information and advice on how to reduce the harms associated with use.” Yet there has been no concerted effort to equip non-specialist healthcare professionals with these skills.

At best, the response to the problems people face as a result of cannabis use appears passive, and at worst disinterested. While there are undoubtedly resource pressures on bodies such as Public Health England and NICE, providing harm reduction advice would not be expensive and in the long term could save money. In the absence of any policy initiative aimed at reducing the continuing harms experienced by some who are exposed to cannabis, we have to be pragmatic in healthcare. This means acknowledging the potential harms that cannabis can cause and doing what we can to mitigate the risks.

Ian Hamilton is an academic at the University of York with an interest in addiction and mental health. He previously worked as a mental health nurse with people who had combined mental health and substance use problems.

Competing interests: I am affiliated with Alcohol Research UK.