Biographical note

In 2014, cannabis became the topic of many discussions in the professional and laic circles in Slovenia. However, many debates and media coverage is still full of unverified information, so that the proponents of prohibition of cannabis and its opponents gain supporters on their side. Probably the greater part of the general public does not support full legalization of cannabis, especially for recreational purposes. But a larger part supports evidence-based policy reforms on cannabis, particularly in regard to so called »industrial« and »medical« cannabis.  Because of existing international conventions or regulations which govern the classification of illicit drugs, prejudices, beliefs and interests, Slovenian legislation and policy towards cannabis is lacking adequate evidence-based  support and has little to do with life, empathy and humanity. The aim of linking research in public health with policy and practice is to improve evidence-based legislation and policies towards cannabis. This contribution reveals some myths about cannabis and summarizes the key scientific findings.

In recent years, the use of Cannabis has become a much debated topic in professional and laic circles, in Slovenia and abroad. However, this phenomenon is due to numerous and complex links with values ​​and views, which only a few authors tackle without prejudice, and is also reflected in the collection of facts. Cannabis is not a standardized commodity. The proportion of THC and other Cannabinoids in Cannabis can vary greatly, so it is difficult to compare individual research results.

We have recorded a mix of statistical correlation and causal relationships, which is evident from the unconvincing ‘entry theory’ (use of Cannabis should lead to use of more dangerous drugs). It is of no wonder that polls suggest that Cannabis is a plant/substance which continues to polarize public opinion. Media coverage is full of unverified and tendentious information, so that the proponents of prohibition of Cannabis and its opponents gain supporters on their side. Reliable information is essential for an adequate response, enabling greater efficiency of measures, if used.

According to a National Institute of Public Health (NIJZ) survey from 2011/12, 15.8% of the population aged 15–64 have used Cannabis recreationally at least once in their life; 4.5% in the past year, and 2.3% (or 32,141 residents) of Slovenia have used Cannabis in the last month. We do not know any cases of overdose leading to death. 64% of the public does not support the full legalization of Cannabis, especially for recreational purposes, although a large part supports evidence-based reform of Cannabis Policy for medical purposes. Due to outdated international conventions and regulations governing the classification of illicit drugs, prejudices, beliefs and (commercial) interests, Slovenian legislation and policy towards Cannabis is lacking adequate evidence-based support and has little to do with life, empathy and humanity.

The aim of linking research in public health with policy and practice is to improve evidence-based legislation and policies towards Cannabis. In this context, the National Institute of Public Health (NIJZ) cooperates with both policy-makers in ministries and NGO’s and civil initiative. The fact is that the international scientific community has not reached a consensus on the understanding of the degree of harmfulness of Cannabis and effectiveness of different measures.

Cannabis is not a harmless substance but its dangers have been overstated, and our existing legal, social and health policies are disproportionate to the effects of individual and social damage. UN Conventions are a major contributor, responsible for the classification of Cannabis among the most dangerous drugs that require strict international and national control. In this context, the problem of solving drug related issues is getting more and more complex; extensive damage caused by its prohibition, however, raises concerns for public health and well-being.

The overall number of violations of the law related to possession and use of Cannabis has been increasing steadily for almost a decade. However, legislation regarding Cannabis in Europe is not homogeneous. Countries introducing decriminalization along with strict legal regulation of Cannabis are both softening and simultaneously reducing the unregulated black market and recording encouraging trends in the field of safety and health. There is a need everywhere for better and stricter regulation of both the Cannabis black market and the legal tobacco and alcohol trade, which will never be achieved by strengthening the repression.

It is also important to highlight opinions/initiative of patients and civil society regarding their role in legalization of medical Cannabis in Slovenia: doctors should respect patients’ wishes, even if they are sometimes contrary to what they consider is best for the patient. Patients expect from medical organizations and competent ministry to advocate for vulnerable groups and health in general and take a more decisive role in reducing harmful effects of Cannabis prohibition.

• organization of multidisciplinary consultation of the competent governmental and non-governmental organizations about regulation of Cannabis for medical, recreational and industrial purposes (government and relevant ministries);
• fix regulatory classification of illicit drugs: instantaneous transfer of Cannabis from Group I to Group III and provide access to “medical cannabis” (Ministry of Health);
• carry out professional supervision of police and judiciary work in the field of drugs, including analysis of data on criminal charges and felonies in the field of Cannabis for the last decade and propose measures to reduce the harms of Cannabis prohibition, including revision of all unjustified sanctions of Cannabis users in the Republic of Slovenia (National Institute for Public Health, Ministry of the Interior, Ministry of Justice and other relevant ministries).

Over the past years the scientific, political and public knowledge have changed quite significantly and recent debates about the classification of certain drugs, especially cannabis, have led to questions about the clarity, reliability and ethics of the current system and whether it remains fit for purpose. The scientific evidence and consensus are growing that the current classification of cannabis in the UN system represents a historical anomaly and should be reviewed at the earliest opportunity. It has been argued that cannabis lacks the high abuse potential required for inclusion among the most dangerous drugs. Also, the discovery of the cannabinoid receptor system in the late 1980s revolutionized scientific understanding of cannabis’ effects and provided further evidence that it has potential beneficial medical effects.

The 2016 UNGASS on drugs provides an opportunity to re-examine these issues. We hope this re-examination will consider the scientific findings regarding cannabis’s safety and efficacy in some medical conditions as well as evidence on the possible health risks associated with cannabis consumption, particularly in its smoked form. The UN should guide national drug control and classification systems to be predominantly science, ethics and human rights informed, including all psychoactive plants and substances (whether licit or illicit), otherwise the credibility of such approaches will be undermined.

The beneficial medical properties of cannabis plant (Cannabis sativa L.) are widely recognized. Yet the plant is still listed in the most tightly restricted category reserved for illict  drugs that have "no currently accepted medical use". This status has prevented the medical use of cannabis and relevant research and triggered the debate between government officials on one side, and active members of civil society, patients and individual doctors  on the other side, whether to legalize the production, possession and use of the plant for medical purposes.

Public health is what we, as a society, do collectively to assure the conditions for people to be healthy, happy and feel-well. It refers to "the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals." In many countries public health is already  providing leadership on matters critical to medical cannabis and  health and engaging in partnerships where joint action is needed. Also, it helps  shaping a  research agenda and stimulating the generation, translating  and dissemination of the  relevant knowledge and  articulating ethical and evidence-based medical cannabis policy options.  Human rights lens also inform the decision making processes and development of optimal medical cannabis policies. Human rights are often divided between those that protect individual, civil and political rights on the one hand,  and economic, social, and cultural rights on the other. Human rights perspective recognizes, among others,  the right of everyone to the highest attainable standard of physical and mental health and well being, including the right to treatment with medical cannabis and necessary  services.

However, in most countries, including Slovenia, medical cannabis policies are still the product of controversy and  remain surrounded by controversy as they are implemented.  Related ethical issues  pose many moral and social  dilemmas rather than  black and white moral questions.  The scientific considerations blend with political and ethical conflicts, questions of public and  individual rights are central and scientific evidence should become imperative to inform appropriate regulation and prescription of the plant.  Public health ethics requires careful balancing between individual interests in personal (e.g., autonomy, privacy, and liberty) and economic (e.g., contracts and property) freedoms on the one hand and collective interests in health safety and security on the other.   

Part of the public (society)  already recognizes that cannabis prohibition clearly causes more harm than good. Many individuals and groups began advocating for effective government regulation of cannabis. Until recently, many medical doctors have been reluctant to publicly voice their opposition to the prohibition of the plant. But through scientific evidence and measuring patients’ experiences many doctors and other health professionals had recognized that prohibition was ineffective and harmful. One of the most egregious outcomes of cannabis prohibition was  that many sick people could not  legally  access the medicine that could work best for them. At the same time, the prohibition  had not  prevented children from accessing the drug and  it had led to the proliferation of  more dangerous synthetic cannabinoids.

This  presentation will not offer clear-cut answers to many of the ethical issues raised. However, it will provide public with many perspectives on the role of public health concerning  medical cannabis . For example: What is the meaning of the most common  concepts in public health, such as:  population,  risk, harm, and benefit in the context of medical cannabis ? How does the population perspective differ from the individual perspective? When it is necessary and appropriate to intervene to protect human rights? And when it is necessary and appropriate to intervene to protect the public’s health? Are factors such as risk, effectiveness, cost, burdens and  fairness  the best ways to evaluate public health interventions ? To what extent should social justice be an advocating value in public health? It is essential to recognize that scientific and ethical arguments about the cannabis prohibition and access to medical cannabis have to be joined to political solutions. This may help us think more clearly and constructively about the medical cannabis challenge that will affect many types of health and social issues common with many people and life in communities.

The  presentation will provide many thoughts by both  authors and some conclusions by first autor with which not everyone will necessarily agree but which can open dialogue with others.