Plotting Change: A Volteface Journal by Volteface

PLOTTING CHANGE A Volteface Journal Issue 01

ISBN: 978-1-5272-1569-6

Contents

Foreword Steve Moore

Introduction Alastair Moore

The Tide Effect How the World is Changing its Mind on Cannabis Legalisation Boris Starling

High Stakes Drugs Crisis in English Prisons George McBride

Black Sheep Existing Support for Problematic Cannabis Use Lizzie McCulloch

Green Screen An Online Cannabis Market Mike Power

127

Street Lottery Cannabis Potency and Mental Health Paul North

161

Foreword In the course of researching my first book , Brain Boxes ( a history of British think tanks ), it struck me that all the institutions I examined had launched without any clearly articulated vision — beyond a shared sense that ‘something needed to change’. So it was with Volteface. When we launched, by publishing a WordPress blog (with a little elegant branding) in late November 2015, I was in Washington D.C. as a delegate at the International Drug Policy Reform Conference, the world’s largest gathering of drug policy reformers. We had no real trajectory beyond a hunch that something new was needed. The drug reform debate in the UK had become stagnant. There was very little innovation in campaigning and activism, alternatives to existing public policies had little traction with the public, and the framing of arguments had barely changed over decades. Consequently, politicians on all sides could choose to ignore the myriad social justice, public health and criminal justice consequences of inaction. Volteface started life as a small platform for change. Slowly, we were able to bring new views and voices into the public sphere. Soon we created a studio space in central London where we could host public events and debates. We started distributing print copies of what had become our online magazine. By the summer of 2016, we finally had to concede that we were a fully-fledged think tank. We have since published four policy reports and engaged widely across the public health, treatment and criminal justice communities, as well as engaging with mainstream broadcasters and print media to generate compelling news stories. This journal marks another key milestone on our journey. It features each of our first three reports, and our latest, Street Lottery, a coming-of-age report for us on the relationship between the potency of cannabis and problematic use, addiction and mental health. The body of work generated to date and the networks of goodwill we have fostered are testimony to the dedication, creativity and intellectual rigour that we pride ourselves on. Our next challenge — and it is a mighty one — is to start to create a public appetite for real change. Our recent fact-finding mission to Canada has given us a real notion of what is possible here in the UK. For now, enjoy our very first Volteface journal, and let us know what you think. Volteface will only be truly successful if we build communities with an aspiration for change, and that is a two-way process. We guarantee that your participation will be welcomed and rewarded.

Steve Moore Volteface Director

Introduction Millions of people in the UK use illicit drugs. Drug scares come and go, but by and large drug policy rarely features in mainstream British political discourse. Since the Misuse of Drugs Act 1971, both policy and the Governmental stance has remained largely unchanged. The gulf between ministerial rhetoric and the reality of what is seen and experienced every day is vast. Out of this, a ‘fudge on drugs’ has evolved and continues to persist. Volteface seeks to rectify this by revivifying the debate and driving policy innovation through clear thinking, relationship building and careful advocacy. We set out to create change - we weren’t sure how to achieve it, but we knew it was sorely needed. We have encountered roadblocks, but we have pivoted and adapted, all the time learning and moving forward. From our start-up roots to our large collaborative projects with think tanks, universities and charities we’ve maintained a sense of pragmatism and creativity as we face new challenges. This Journal, looks to capture some of the innovative spirit of Volteface, its work and the people who give it character. It’s been a journey, a steep learning curve and a unique experience - and it has only just begun. This theme of journeys and routes runs through our reports as we deal with the history, present and future of campaigning and advocacy for drug policy reform in the UK. The foundation of what we aim to achieve and the methods by which we look to do so are contained in this collection of works. Tide Effect is a time-conscious, historic overview of the recent history of cannabis in the UK, written in the context of a sweeping tide of cannabis law reform across North America. Novelist and playwright Boris Staring, the report’s author, took to the topic with great fervour. His Fleet Street background set his research in the direction of Rosie Boycott whose campaign for cannabis legalisation took place during the early months of Tony Blair’s tenure as Prime Minister. He traces the changing legal status of, and stigmas attached to, 6

cannabis alongside prior attempts to challenge these and change the course of the debate. Imminent change looms as the author intertwines history with the present day to give the big picture of cannabis in the UK. This is where we begin. High Stakes takes a fine-tooth comb to the drugs crisis in English prisons and examines the complex circumstances that are fueling the rise in the use of novel psychoactive substances (NPS), in particular synthetic cannabinoid receptor agonists (SCRAs) commonly referred to as ‘Spice’ or ‘Mamba’. With violence, suicide and self-harm at record levels, George McBride investigates how these SCRAs have replaced more well known drugs and why the government has failed to act. McBride argues that something innovative needs to be done to change how we understand and attempt to tackle this radical shift in prison drug markets. The ubiquity of SCRAs in men’s prisons in England owes much to the failure of drug policies both in the UK and internationally to deal with the issue of demand, instead fixating on supply. High Stakes not only maps out how these drugs are entering prisons, but focuses a spotlight on the causes of their popularity while highlighting the increasing mismanagement of our prisons. Black Sheep explores the existing support for people experiencing problematic cannabis use and addresses a topic that is often tricky for drug policy reformers to discuss without hurting their cause: problematic cannabis use. Lizzie McCulloch embarks on an ambitious project, exploring how the current illegal and unregulated market impacts on the visibility of cannabis users, with practitioners reporting that they’re “just fumbling around in the dark trying to find them”. Black Sheep is a first of its kind, and could not have been produced without the input of a wide coalition of experts. Being unafraid to tackle tough problems and engage with new groups can only strengthen a cause. This guiding principle of Volteface is at the core of Black Sheep.

Green Screen by journalist Mike Power, is an exercise in future truthing: developing tangible alternatives. At Volteface we feel that to bring about change you have to give people an idea about what that change could look like. 2017 marks a moment of great importance for drug policy reform. All eyes are on Canada, where, under the leadership of Prime Minister Justin Trudeau, the government has taken action to reduce the ease of access young Canadians have to cannabis, and remove the market from the control of organised crime. Volteface took a delegation of British special advisers and policymakers to Toronto to meet some of the key figures leading Canada’s groundbreaking initiative. The delegation met with MP Bill Blair, former chief of Toronto police, who is attempting to build a regulatory system that works not only for those who support cannabis legalisation but also for those who don’t. This is what we need to achieve in the UK. Green Screen recommends regulating for responsible legal adult use of cannabis, but addresses some of the issues that concern those uncomfortable with the concept - from youth access to high street dispensaries. Borrowing from his unmatched knowledge of the dark web, Mike provides practical, workable suggestions for the legal online supply of cannabis in what we consider to be the inevitable event of cannabis law reform in the UK.

The five reports plot some of the key gaps in UK drug policy and weigh up the effects of international events on the trajectory of local policy development. They deal with intricate issues head on, in the distinctive Volteface style of campaigning - pragmatic and innovative. Keep these two points in mind as you traverse Tide Effect, High Stakes, Black Sheep, Green Screen and Street Lottery. The UK has a unique social and political fabric that must be navigated carefully, but with big thinking, collaboration and determination we can bring about change. It has been a pleasure producing these reports, we hope you can take some inspiration from the people and stories within them.

Alastair Moore Volteface Creative Director

The last of the reports, Street Lottery, is a nuanced look at the highly polarised issue of cannabis potency and mental health. The two are inextricably linked in the minds of the British public. Paul North, Volteface’s Policy Advisor, looks to untangle some of the complexities in the relationship between them. North explores the spectrum of mental health and the cannabis that is available on the streets of the UK. Drawing on new data about the ease of youth access and the potency of street cannabis, Street Lottery aims to move the discussion about cannabis in the UK forward. Tackling tough issues head on is key to creating change, and Street Lottery does just that. 7

THE TIDE EFFEC HOW THE WORL IS CHANGING IT MIND ON CANNA LEGALISATION Boris Starling

CT LD TS ABIS

Executive Summary

“The law against marijuana is immoral in principle and unworkable in practice.” William Rees-Mogg, The Times, July 1967.

For decades, cannabis has been discussed largely in terms of criminality, bracketed with heroin and cocaine simply by virtue of being the wrong side of the law. This is, at last, beginning to change. With the general acceptance that the war on drugs in its current form has failed have come initiatives to legalise cannabis in several countries across the world. So far the UK continues to lag behind, still wedded — officially, at least — to the idea that cannabis remains a matter for criminal prohibition rather than public health. The Tide Effect argues that the legalisation of cannabis in the UK is both overdue and imperative. Attempts to control consumption through prohibition do not work and have not done so for many decades. The health issues around cannabis — for like all drugs, alcohol and tobacco included, it is not harmless, and no serious advocate for legal reform would suggest that it is — are left largely unexplored because the substance’s illegality makes meaningful long-term scientific tests difficult to carry out. The advantages of a properly regulated market providing tax revenues, strict product parameters and health advice far outweigh the disadvantages of such a move. That cannabis is illegal, while alcohol and tobacco are not, is an accident of history. Cannabis policy reform is not a daring step forwards so much as a righting of historical wrongs, a reversion to what the drug’s status should always have been if only it had been treated fairly.

In the Tide Effect we will argue that: Regulation is substantially more desirable than simple decriminalisation or unregulated legalisation, because only regulation addresses all four key issues: ensuring that the product meets acceptable standards of strength and purity, removing criminal gangs from the equation as far as possible, raising revenue for the Treasury through point-of-sale taxation and best protecting public health. The incarceration of more than 1,000 people for cannabis crimes is a blight on not only the lives of those in jail but on the lives of their families too. A proportion of tax revenues from the sale of cannabis should be invested back into public services, particularly for those most vulnerable to the negative impacts of cannabis use. Many shifts in public policy are prompted by an emotional response on the part of the public. Princess Diana shaking the hand of an HIVpositive man in 1987 helped soften attitudes towards AIDS sufferers. Convincing personal stories must play a great part in demonstrating that the cannabis issue also has a human aspect if progress is to be made. The United States provides many useful points of comparison, both in the historical treatment of cannabis and the current movement towards legalisation in certain states.

It is imperative that the entire language around the issue of cannabis changes. Language poses a barrier every bit as formidable as legislation does. The opponents of legalisation have long been able to reinforce their position by using the words of public fear — ‘illegal,’ ‘criminal’, ‘dangerous’, and so on. Only by using the language of public health and harm reduction, the same language used about alcohol and tobacco, can we have a proper debate. This is why the Tide Effect repeatedly emphasises the need for and concept of ‘regulation’.

The Tide Effect is divided into seven chapters: • C hapter One examines the origins and outcome of the last sustained media campaign for cannabis’ legalisation, the Independent on Sunday’s efforts in 1997–8. • C hapter Two covers the rise of ‘skunk’ in both the illegal drugs market and the public consciousness, and asks to what extent it is linked with mental health problems in particular. • I n Chapter Three, we ask how, where, when and why cannabis is consumed, and compare this consumption and its health effects with those of alcohol and tobacco. • C hapter Four covers the muddled, inconsistent vacuum at the heart of British government policy on cannabis. • C hapter Five examines policy innovations in several countries which put the UK to shame in terms of both their enlightened attitude and the consistency of their application. • C hapter Six looks at the size and shape of a newly-legalised cannabis industry, and some of the problems which face it. • F inally, Chapter Seven looks at the implications of all the above for the British political scene over the next few years.

Chapter One: The Independent on Sunday

“Isn’t it time we faced up to the facts and ended this hypocrisy?” Rosie Boycott, Independent on Sunday, September 1997

Victor Hugo said: “there is nothing as powerful as an idea whose time has come.” Both parts of that equation are equally important. An idea can be simple to the point of banality — many good ones are just that — but that ‘time’ to which Hugo refers is a complex thing. All political movements’ success depends on many factors outside of their own merits. Those in power have to be receptive, as do the gatekeepers who control access to those in power. Public opinion is crucial, now more so than ever with social media, rolling 24-hour news cycles and immediate reaction; nothing is as effective at fanning the flames of public opinion as much as outrage and emotion. With that in mind, it’s instructive to look back at the last major campaign to legalise cannabis in this country: the one begun by the Independent on Sunday newspaper in September 1997. The timing is important; it was less than five months since Tony Blair had been elected Prime Minister with perhaps the greatest surge of popular goodwill in modern British political history. Today, Blair is mostly discussed in almost totally unflattering terms, but back then he was a young, fresh, charismatic and dynamic leader. Most of all, he seemed in touch with public sentiment. His ‘People’s Princess’ line about Diana, who had been killed only a few weeks before this campaign began, may now be used as the butt of jokes, but at the time it caught the mood of the time in a way that only a consummate political operator could have managed. ‘Cool Britannia’ was the buzzword for every opinion-former and cultural commentator in town. Where John Major had harked back to a Fifties idyll of cricket on village greens and maiden aunts cycling to church, Blair promised a hip, confident nation for the 21st century.

If ever there was a time and an administration which would put the cannabis issue back on the political agenda, this was surely it: and the Independent on Sunday’s editor Rosie Boycott explicitly played on this regained sense of social tolerance in her rallying cry piece. “I rolled my first joint on a hot June day in Hyde Park. Summer of ‘68. Just 17. Desperate to be grown-up. I’d found a strategic tree overlooking the Serpentine bowl… I had a fingernail-sized lump of hashish, a box of Swan Vestas matches, a broken Benson and Hedges and three small Rizla cigarette papers clumsily melded together. Oh, the glamour of Rizlas. Oh, the illicit thrill of the banal vocabulary — a deal, a joint, a spliff. All deriving, like Mick Jagger’s music, from a remote black American culture I knew little about. Yet it had conquered me, and the entire youth generation. My first smoke, a mildly giggly intoxication, was wholly anti-climactic. The soggy joint fell apart. I didn’t feel changed. But that act turned me — literally — into an outlaw. I was on the other side of the fence from the police — or the fuzz, as we used to call them. So were a great many of my generation.” 1 Although Boycott anchored her own experience in the summer of ’68, her article played on the universal tropes of youthful rebellion and the embracing of a culture as exciting as it was alien, the rueful admission that most teenage ‘first times’ are more notable for what they represent than for the quality of the experience itself. The article went on to quote William ReesMogg’s ‘legendary leader’ in The Times in reaction to the heavy fine given to Mick Jagger for possession of cannabis, where he spoke of breaking “a butterfly on a wheel” and maintained that “the law against marijuana is immoral in principle and unworkable in practice.”

Boycott then pointed out that cannabis’ muchdiscussed ‘gateway’ status, opening the door to harder drugs, was a matter more of dealers’ demographics than of physiological or psychological dependence. She wrote: “If alcohol is a tiger, then cannabis is merely a mouse… The truth is that most people I know have smoked at some time or other in their lives. They hold down jobs, bring up their families, run major companies, govern our country, and yet, 30 years after my day out in Hyde Park, cannabis is still officially regarded as a dangerous drug…. Since my first joint, I’ve smoked a good many more, although I hardly smoke at all nowadays. The habit has given up on me. But I don’t see why people who share my earlier enthusiasm should be branded as criminal.” 2 So began the Independent on Sunday’s campaign, endorsed by an eclectic and almost hilariously typical British mix of bigwigs, boffins, broadcasters and businesspeople. Few would have been surprised to see, say, the Marquess of Bath and Brian Eno among the signatories, but there were also neuroscience professors Steven Rose and Colin Blakemore adding some scientific heft, consultant psychiatrists Judy Greenwood and Philip Robson weighing in for the mental health community, Richard Branson and Anita Roddick flying the flag for business, and Burke’s Peerage publisher Howard BrookesBaker proving that the Establishment was by no means a homogenous or entirely reactionary entity. The generation who had been Sixties rebels with Boycott were now being marshalled by her in support of the cause. They may have been counter-culture once upon a time, but they were emphatically mainstream now: the people who “run major companies [and] govern our country,” as she’d written.

For the next six months, the Independent on Sunday ran a series of pro-legalisation articles and pushed readership over 300,000 as a result. The climax of the campaign was a ‘Decriminalise Cannabis’ protest in central London in March 1998. The newspaper invited people to ‘roll up’ in Hyde Park for a march to Trafalgar Square. Interestingly, given the way in which the US has forged ahead of the UK on the issue since then, the demonstration was seen as groundbreaking by US activists. “I cannot conceive of a demonstration like this in America just now,” said Professor John P. Morgan of the City of New York Medical School. “I wish you success. The eyes of the western democracies are upon you.” Attendance figures were estimated between 15,000 and 25,000 supporters. Before the march, Boycott had emphasised “it is important that everyone remembers that we are out to change the law, not break it. We must not provoke police reaction. We want to change the law on cannabis by legal and democratic means.” Although many of the protesters were openly smoking cannabis, the police let this pass without trouble. Their orders were crowd control and ensuring that the day passed off peacefully, not inflaming the situation by random arrests. Contemporary accounts of the march talk of a friendly atmosphere and the police smiling along with protestors. Boycott, Howard Marks, Paul Flynn MP and Italian activist Marco Pannella all addressed the crowd. The march seemed not just a success in its own right, but a springboard to greater things. As it turned out, however, it was the high water mark of the campaign rather than a stepping stone in the stream of progress towards regulation. Why did this happen? Why did the campaign fizzle out?

There were three main reasons. The first was that Boycott left the Independent on Sunday not long after the march and to take up the editorship of the Daily Express, a paper as unlikely to call for cannabis regulation as you could find. The extent to which the cannabis campaign had been her baby only became clear in her absence. Without her at the helm, no other senior executives at the Independent on Sunday kept the flag flying. Secondly, the size of the march was insignificant when compared to turnout for other issues, notably the 400,000 marchers for the Countryside Alliance in September 2002 and the 2 million for Stop The War in February 2003. And even these high turnouts failed to influence the final decision taken on their respective causes. Finally, the Independent on Sunday’s campaign gained no meaningful traction in the corridors of power. Although grassroots support was strong, the campaign lacked the backing of lobbyists, think tankers, special advisers and all the other players in the Westminster circus. Policy changes may not happen even with their input, but they rarely happen without it. It was still Blair’s first term in office, and despite his administration’s ravenous appetite for reform, Alastair Campbell dismissed Boycott and her fellow Independent campaigners as a “bunch of old hippies still living in the Sixties.”

Chapter Two: Skunk Alert

Nick the Greek: Weed? Tom: Nah, it’s not normal weed. Some fuckedup skunk, can’t-think-let-alone-move shit. Nick the Greek: Doesn’t sound good to me. Tom: Well, neither me, but it depends what flicks your switch, and the light is on and burning brightly for the masses. Lock, Stock and Two Smoking Barrels, 1998.

One of the most common refrains you hear when discussing the cannabis issue is that cannabis nowadays bears little resemblance to the stuff commentators and policymakers smoked back in their own university days. Back then it was ‘grass’, ‘herb’ and ‘weed’ — all natural-sounding stuff which made you giggly and mellow. Now it’s ‘skunk’: something altogether darker, more potent, more dangerous. Something mind-altering rather than just mood-altering. Skunk is an independent strain of cannabis with its origins dating back to the 1970s, although the term is now used more broadly to refer to much of the strong cannabis which accounts for around 80% of the UK market. It’s in that context that we use the word throughout The Tide Effect: not as a substance different from ‘ordinary’ cannabis, but simply a much stronger version of it.

Cannabis contains many different compounds, but two of the major ones (and the most relevant when assessing the drugâ&#x20AC;&#x2122;s strength and effect on its users) are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC helps the user get high: CBD reduces feelings of anxiety.

What’s important is not just the amount of THC and/or CBD but also the balance between them. In the past 20–25 years the general trend amongst cannabis producers, especially those using hydroponic techniques, where plants are grown under strong artificial lights in nutrient-rich liquids rather than soil, 3 has been to increase THC levels while selectively breeding out the more protective cannabinoids. Increased THC levels mean increased potency and increased prices per unit, so there is every incentive for dealers to pursue this path. The higher the ratio of THC to CBD, the greater some scientists believe the risks to the user, particularly dependence, memory impairment and psychosis. 4 The question is this: exactly how much stronger than its predecessor is modern-day skunk? The majority of sound scientific estimates seem to settle around a 15–18% THC concentration, around three times what it was in the mid-1990s. However, this can be exacerbated by the often almost total absence of CBD (Prof Curran recommends a minimum CBD content ‘buffer’ set at 4%.) Skunk’s strength, and the speed of its effects, can catch inexperienced users out, leading to anxiety attacks, projectile vomiting, altered time perception, transient hallucinations and paranoia. More experienced users develop higher tolerance levels, and tend to autotitrate (adjust the amount they smoke to take account of higher strength joints). But the main reason skunk causes such disquiet is purported links with mental health problems, particularly psychosis and schizophrenia. Professor Sir Robin Murray, Professor of Psychiatric Research at King’s College London, is one of the most vocal campaigners for official recognition of a causal link between cannabis use and mental health. According to Murray “If the risk of schizophrenia for the general population is about 1%,” he says, “the evidence is that if you take ordinary cannabis it is 2%; if you smoke regularly you might push it up to

4%; and if you smoke skunk every day you push it up to 8%.” 5 At the launch of a medical paper in 2015, he said “we could prevent almost one quarter of cases of psychosis if no-one smoked high potency cannabis. This could save young patients a lot of suffering and the NHS a lot of money.” 6 The emphasis on ‘young patients’ is one shared by many scientists, who stress that a developing teenage brain is far less well-equipped to deal with the effects of skunk than a mature adult one. A 2012 New Zealand study found that people who smoked significant amounts of cannabis as teenagers showed a significant drop in their IQ levels compared both to non-consumers and to those who only began smoking after the age of 18. 7 And a 2009 report by Professor Stuart Reece of the University of Queensland found that “cannabis has now been implicated in the etiology of many major long-term psychiatric conditions including depression, anxiety, psychosis, bipolar disorder, and an amotivational state.” 8 But this certainty is far from universal across the literature, and Murray’s assertions of causality between cannabis and schizophrenia have been repeatedly challenged. Former government advisor Professor David Nutt has written that “where people have looked, they haven’t found any evidence linking cannabis use in a population and schizophrenia… What we can say is that cannabis use is associated with an increased experience of psychotic disorders. That is quite a complicated thing to disentangle because, of course, the reason people take cannabis is that it produces a change in their mental state. These changes are a bit akin to being psychotic — they include distortions of perception, especially in visual and auditory perception, as well as in the way one thinks. So, it can be quite hard to know whether, when you analyse the incidence of psychotic disorders with cannabis, you are simply looking at the acute effects of cannabis, as opposed to some consequence of cannabis use.

The analysis we came up with was that smokers of cannabis are about 2.6 times more likely to have a psychotic-like experience than nonsmokers. To put that figure in proportion, you are 20 times more likely to get lung cancer if you smoke tobacco than if you don’t. The other paradox is that schizophrenia seems to be disappearing (from the general population), even though cannabis use has increased markedly in the last 30 years. So, even though skunk has been around now for 10 years, there has been no upswing in schizophrenia.” 9 More weightily, the New Zealand data on cannabis and IQ is consistent with confounding by socioeconomic status: those who smoked would have ended up with lower IQs anyway. 10 Social and genetic confounding affects the 2.6 relative risk ratio Nutt’s work returns as well: after accounting for those, standard estimates for England and Wales suggest you’d need to stop 2,800–4,700 heavy cannabis smokers from using the drug to prevent one case of schizophrenia. 11 You’d need to stop 1,360–2,480 to prevent a case of psychosis.

Of course, whatever the links between cannabis and psychosis, the question for us is which policies reduce these harms. Some evidence suggests that tighter control on cannabis, perversely, increases problems with psychosis. A 2014 study found that reclassifying cannabis as class C, in 2009, reduced admissions for psychosis, while returning it to class B increased them. 12 To assume that increased prohibition is the solution to the health risks of cannabis would be a mistake—precisely the opposite is true. Regulation would allow for both the THC and CBD content of cannabis products to be quantified, quality controlled and clearly communicated to consumers, provided alongside extensive and comprehensive health information which could then be built on by wider and deeper medical research. Skunk would still have harmful effects, as it always will do, but those effects would be both controlled and clearly outlined. At the moment, they are neither.

Chapter Three: Cannabis Consumption

“Marijuana is a very dangerous drug. Some people smoke it just once and go directly into politics.” — Barry Crimmins

No report on the issue of cannabis is complete without some idea as to the demographics and motivations of its users. We already know the ‘what’ — 80% of the UK market is classed as skunk, high in THC and low in CBD — but what about the ‘who’, the ‘where’, the ‘why’ and the ‘how’? Who? More than 2m people are estimated to smoke cannabis in the UK, a figure equivalent to the combined total populations of Glasgow and Liverpool. It’s almost three times the number of those who report having taken the next most common illegal drug, cocaine. 13 This means that a minimum of 1 in 15 of the population smokes cannabis—and far more will have tried it at least once in their lifetime. Where? The majority of cannabis users come from middleor low-income backgrounds. Someone earning less than £10,000 a year is almost five times as likely to be a frequent user as someone earning £50,000 or more (6.8% of the total population vs. 1.4%). Cannabis use falls the higher up the income scale you go, whereas cocaine use rises. 14 Similar patterns can be seen in the USA, where those with a household income of less than $20,000 account for 29% of all marijuana use but only 13% of all alcohol use and 19% of the total adult population. 15

These kind of consumers are not, in general, the kind of people who drive political reform. They are not the ones who write letters to newspapers or opinion columns for magazines: still less do they have access to the official and semi-official bodies responsible for inputs into policymaking. A good proportion of them do not vote regularly. They are, in short, the kind of citizens whom governments can and do forget about. Why? People smoke cannabis for any number of reasons (and the overlap between these reasons and those for drinking alcohol in particular is striking). Those who begin in their teenage years are usually driven by curiosity, rebelliousness, peer pressure or a combination of all three. Those who continue into adult life may use cannabis to relax, to escape, to be sociable, to become intoxicated, to improve their mood, to self-medicate, for pain relief, or because they’re addicted and need to satisfy their physical and physiological cravings. It may also be that those with pre-existing mental health conditions such as anxiety, depression, schizophrenia and psychosis are particularly predisposed to using cannabis and other drugs.

How? European cannabis smokers (including the British) tend to mix cannabis with tobacco much more than North American smokers do, which in turn leaves them more vulnerable to the threats to health posed by tobacco. 16 There’s also the perennial question of whether cannabis acts as a ‘gateway’ drug for other, harder, substances. This is a question that cannot be answered without also factoring in alcohol and tobacco use. Studies have found that the socio-economic circumstances of young people consuming alcohol and tobacco has more effect on the chances of their future progression to hard drugs than any other factor. The divisions here — the ‘life chances’ which was one of David Cameron’s projects during his tenure in Downing Street — are much more important than the similarities. A 2010 report by Norwegian researchers suggested the existence of two distinct groups among cannabis smokers: a small group of ‘troubled’ youths with low self-esteem, poor family relationships and possibly antisocial behaviour problems, and a larger group of betteradjusted teenagers. The first group were more than twice as likely to graduate to hard drugs than the second, irrespective of the amount of cannabis smoked. 17 Other reviews have also found that pre-existing factors about those who choose to smoke cannabis mostly explain the surface-level association between cannabis use and use of other illegal drugs. 18 The triangular if largely unspoken relationship between cannabis, tobacco and alcohol is both multi-layered and critical to this issue. Four in five British adults drink alcohol. One in five smoke cigarettes. 19 That’s 10m smokers, of whom around 6m can be classed as ‘dependent’ on one or more of the following counts: they have their first cigarette of the day within an hour of waking, they find it hard to go a day without smoking, or they want to quit. 13

The Royal Society for Public Health has ranked various drugs in order of the harms they cause, considered across a broad range of 16 criteria. With a total score of 72, alcohol was deemed substantially more harmful not just than tobacco (26) and cannabis (20) but also than heroin (55), crack (54), methamphetamine (33) and cocaine (27). Alcohol scored particularly badly in terms of economic cost, injury to others, family problems and crime: tobacco’s worst rankings were indirect fatalities, dependence, economic cost and direct physical health harm. 20 But the real and serious harm caused by alcohol and tobacco is largely accepted as the flipside of the pleasure these drugs give. The billions of pounds per annum spent by the NHS might be seen as a price worth paying even if they weren’t more than covered by the tens of billions of pounds in duties drinkers and smokers pay. 21 When that harm moves from the immediate consumer to those people around them, the state does sometimes act, such as with the banning of smoking in public places under the provisions of the 2006 Health Act. But this works more often in theory than in practice. In many real-world situations, the state either can not or will not act. More than half of all violent crime in the UK in 2015 was alcohol-related. 22 A similar proportion of child protection cases involve alcohol or other drugs. 23 Diagnosed cases of foetal alcohol syndrome have tripled in England since 2000. 24 Barack Obama said “As has been well documented, I smoked pot as a kid, and I view it as a bad habit and a vice, not very different from the cigarettes that I smoked as a young person up through a big chunk of my adult life. I don’t think it is more dangerous than alcohol.” 25 Where hundreds of thousands of balanced studies have been conducted on the health effects of tobacco and alcohol, the literature on cannabis remains skewed towards its most

negative aspects for one simple reason: its illegality. Scientists attempting any serious widespread study are often restricted to observational studies, while funding is often difficult to obtain for anything other than research into harms. We know that a person cannot fatally overdose on pot in the way they can on alcohol. “You can die binge-drinking five minutes after you’ve been exposed to alcohol. That isn’t going to happen with marijuana,” says Ruben Baler, a health scientist at the National Institute on Drug Abuse. 26 “The impact of marijuana use is much subtler.” We also know the long-term effects both of heavy drinking (cirrhosis, liver cancer) and of tobacco smoking (lung cancer, respiratory problems). Until scientists have the same opportunities with marijuana, however, a proper assessment of the effects will remain out of reach. Linking cannabis with various medical problems, as Professor Stewart Reece at the University of Queensland has done, is far from proving causality of same. 27

Therefore, we can see that cannabis is: • widely smoked throughout the UK: so widely, in fact, as to make a mockery of the fact that it’s technically illegal, something which will be explored more fully in the next chapter concerning the current policy vacuum in this country. • i s increasingly a drug of the low and middleincome classes, which also helps explain why it has fallen off the political radar in the past 20 years. • i s no more a gateway drug to harder substances than alcohol and tobacco, which is yet another reason why it should be treated exactly as those substances are — legalised, licenced and regulated.

Already it is clear that keeping cannabis illegal merely because it is harmful does not square with the government’s policies on alcohol and tobacco. Alcohol and tobacco are legal because they have always been, because any attempts at prohibition would be totally unworkable, and because they generate billions of pounds in revenue for the Treasury every year. Were cannabis made legal, it would not be long before similar considerations would apply to it too. The British are very good at grumbling about change when it happens and then accepting it as though it had always been thus. The public smoking ban is a good example of this: it caused outcry at the time but was very quickly assimilated. Now the vast majority of people are in favour of it, and no major political party bar UKIP is campaigning to reverse the ban. 14

Chapter Four: The UK Policy Vacuum

The current policy around cannabis in Britain is a messy patchwork of legislation intermittently enforced. It places political posturing above public health and tabloid values above humane ones. Cannabis is classified as a Class B drug under the Misuse of Drugs Act 1971. Drugs are classified “according to their accepted dangers and harmfulness in the light of current knowledge,” with Class A regarded as the most harmful and Class C the least. 28

Responsibility for developing and enforcing drugs strategy lies primarily with the Home Office, which in itself is a statement of purpose: that this is a matter of public order rather than public health. The current government strategy is based around three main pillars:

Governments of whichever political hue use these classes, in theory at least, to help set out their overall drugs policy. Cannabis has always been Class B except for a five-year period between 2004 and 2009 when it was downgraded to Class C before being reclassified as Class B. This was an episode itself emblematic of politics taking and discarding scientific evidence as it saw fit: in other words, of making the facts fit the theory rather than vice versa. Jacqui Smith, who was Home Secretary during the reclassification process, has since admitted as much. “Knowing what I know now, I would resist the temptation to resort to the law to tackle the harm from cannabis,” she said. “Education, treatment and information, if we can get the message through, are perhaps a lot more effective.” 29

Reducing demand, particularly among vulnerable youths and/or those involved in the criminal justice system.

Restricting supply by tackling the organised crime gangs which supply drugs through importing them from abroad or growing/ manufacturing them on British soil. Building recovery in communities through public health facilities and an attempt to understand and tackle the wider social circumstances which propel people to use drugs in the first place. Even the most cursory knowledge of British politics is enough to assess that all three of those pillars are built on very shaky ground.

Two million cannabis users alone shows that demand is widespread. The rise in hydroponic factories in the UK, plus well-established criminal routes from the continent (used to smuggle not only drugs but also people), means that law enforcement is always fighting an uphill battle in restricting supply. And the social deprivation wrought on thousands of poorer communities across the land is not something which can be fixed with a few headline-grabbing initiatives. Criticism of failure across all three of these areas is both wide and deep: it spans all kinds of stakeholders and goes back a long way. More than half the British public believe that current policies are ineffective 30 — a figure which rises to three-quarters among MPs alone. 31 A Police Foundation report as far back as 2000 concluded that “such evidence as we have assembled about the current situation and the changes that have taken place in the last 30 years all point to the conclusion that the deterrent effect of the law has been very limited” — a point reinforced six years later by the conclusions of the Science and Technology Select Committee: “we have found no solid evidence to support the existence of a deterrent effect, despite the fact that it appears to underpin the Government’s policy on classification.”

When a policy of deterrence is no longer seen as providing that deterrence, those in charge of that policy’s enforcement gradually decide that it’s not worth their time and effort to pursue it, particularly when their own resources are scarce. Durham Constabulary, for example, have stopped pursuing and prosecuting cannabis users and small-scale growers. Ron Hogg, Police and Crime Commissioner there, said: “I believe that vulnerable people should be supported to change their lifestyles and break their habits rather than face criminal prosecution, at great expense to themselves and to society.” 32 Nor is Durham alone in this approach: in Cambridgeshire, for example, charges are pursued in only 14% of incidents. But counties such as Hampshire, where 65% of those caught with cannabis end up with a charge or summons, continue to hold a line of serious enforcement seriously applied. The problems with this system as it stands is twofold. First, it effectively makes the question of cannabis policy a lottery according to which county you happen to find yourself in. This is not the same as the case in the USA, where each state has its own legislature and where drug laws can vary widely from state to state. This is one national law selectively applied, which in itself makes a mockery of that very law. Secondly, even the most laissez-faire constabulary when it comes to individual cannabis users continues to clamp down on the organised crime gangs which supply the drug. “The scant resources of the police and the courts are better used tackling the causes of the greatest harm — like the organised crime gangs that keep drugs on our streets and cause misery to thousands of people — rather than giving priority to arresting low-level users,” said Hogg. 33

One can greatly sympathise with both Hogg’s instincts not to ruin individuals’ lives over something which harms only themselves and with his decision to prioritise finite resources on organised crime — the kind of real-world dilemma which all police commissioners face and which politicians and commentators alike are quick to dismiss. But the endpoint of this approach is illogical to the point of absurdity. Either a substance is illegal or it is not (or, more precisely, it may be legal in certain restricted circumstances such as for carefully assessed medicinal purposes, but that is a side point here). A situation where it is illegal to manufacture and supply something but not illegal to possess it is at best deeply flawed and at worst totally unworkable: the disconnect between the supply side and the demand side is too great. The demand continues to be met by organised crime: both law enforcement and health care remain in limbo. This de facto decriminalisation is the worst of both worlds. The system as it stands, in general, works as follows. The first time you’re caught with a small amount of cannabis, you’re given an informal verbal warning. The second time, assuming it’s within 12 months of the first, you’re given a Penalty Notice for Disorder (PND) and £80 fine which must be paid within 21 days. Neither the warning nor the PND form part of a criminal record. Now the ante is upped. The third time is a caution following arrest, the fourth is a court charge. Both of these do count on your criminal record. The problem is that even a warning, the most lenient and informal option, counts as a ‘recorded crime outcome’ — a crime that has been detected, investigated and resolved. So, cannabis crimes are a good, easy, predictable way for officers to make their statistics look good.

Every year, 10–15% of all indictable offences brought before the courts are for drug possession. According to the latest figures available, there are 1,363 offenders in prison for cannabis-related offences in England and Wales. 34 Those 1,363 people are costing the taxpayer more than £50m a year, are exposed to other criminals while in jail, are more likely to be recidivist offenders once out, and will find it harder to get a job in future because they have a criminal record. The continued concentration of police efforts in poor areas helps perpetuate two forms of inequality. The first is that residents of these areas will continue to regard the police not as impartial upholders of law and order but as agents of an establishment which regards them as at best a nuisance and at worst a threat. The second is that the kids drawn into the criminal justice system this way — and the criminal justice system is like a lobster pot or the Chelmsford one-way system: it’s very easy to get into and very hard to get out of — will continue to have far fewer opportunities for social mobility and life chances. Would there still be cannabis criminals if the industry was legalised and regulated along the lines of tobacco and alcohol: that is, if it was well-regulated with licensed production and distribution? Yes, there would. But there are three main access points to such industries — production, distribution and possession — and only the middle one of these would afford any realistic opportunity for criminals. Possession would be legal, of course, and production (where most harm to the consumer’s health in terms of impurities and toxins can occur) would be economically unviable for the vast majority of criminals.

Take alcohol and tobacco. Yes, there is smuggling in both cases, but in the vast majority of cases the products being smuggled have been legally produced at source and the smugglers are trying to avoid paying tax, which accounts for most of the price (averaging around 80%) of both alcohol and cigarettes in the UK. “Duty on cigarettes and spirits is consistently increased well above inflation, but the production cost of the goods is low. This makes them a prime target for smuggling,” said Roy Maugham, a tax partner at UHY Hacker Young. “A significant number of taxpayers are disinclined to pay the full duty on alcohol and, particularly, cigarettes — which has created a thriving black market. It’s the inevitable result of heaping a heavy tax load onto any product.” 35 In 2014 – 15 HMRC and the Border Force between them seized 5.3m litres of beer, 189,669 litres of spirits and 1.49m litres of wine, almost all of it legally-produced. There is no meaningful large-scale network of illegal alcohol production in the UK for the simple reason that legal, regulated, cheap alcohol is widely available. Why go to the considerable expense and bother of making moonshine when you can just go down to the supermarket and pick up a brand of ownlabel vodka? Cigarettes are a slightly different case. There are three main types of illicit cigarettes smuggled into the UK: contraband (legally manufactured by major Western companies and paid at lower duty rates in their country of origin); illicit whites (legally manufactured in developing economies, such as the UAE’s Jebel Ali free trade zone, to product standards lower than in the West but still acceptable to most Western consumers); and counterfeit (illegally made and passed off as genuine). Of these three, the second category, illicit whites, accounts for the majority of HMRC seizures (more than 6bn cigarettes between 2011 and 2015). 36 “The illicit whites are now the dominant point of threat. They have none of the quality problems of counterfeit cigarettes,” said Euan Stewart, 19

deputy director of criminal investigations at British customs. 37 As with alcohol, there is little mileage for most criminals to go to the bother of full-scale counterfeiting when there are so many easier ways to market. The crucial aspect to this is that the very issue which causes the smuggling — the tax take — is within the government’s purview. It can intervene on price if need be, all the while mindful of the various stakeholders it must keep happy: the Treasury bean-counters, the shareholders of tobacco companies which themselves pay corporation tax and donate to political parties, the NHS which would prefer that fewer people smoked in the first place, and so on. The government has no such luxury in a business like cannabis while it remains illegal. It can still enforce the law on the smugglers, but it can do next to nothing about the conditions which drive them to smuggle in the first place. These black markets for otherwise legal products give us a good idea of what we could expect in a regulated cannabis market post-legalisation. Clearly there would be similar issues with smuggling and customs evasion, but these would in turn represent a great leap forward from the current state of the cannabis market. All the problems of this untrammelled and unregulated market at base come from a single source: the decision to treat cannabis purely as a criminal matter rather than principally a health one. Then Deputy Prime Minister Nick Clegg said in 2014 that “the first step is to recognise that drug use is primarily a health problem. Addicts need treatment, not locking up. It is a nonsense to waste scarce resources on prison cells for cannabis users…. (nobody should) go to prison where their only offence is possession of drugs for their own personal use. Instead these people should receive non-custodial sentences and addicts should get the treatment they need to stop using drugs. These reforms will ensure that drug users get the help they need and that taxpayers don’t foot the bill for a system that doesn’t work.”

Both the Royal Society for Public Health (RSPH) and the Faculty of Public Health (FPH) agree. Their 2016 report, Taking A New Line on Drugs, advocates transferring drugs policy from the Home Office to the Department of Health. “The time has come for a new approach, where we recognise that drug use is a health issue, not a criminal justice issue and that those who misuse drugs are in need of treatment and support, not criminals in need of punishment,” says RSPH chief executive Shirley Cramer. “For too long, UK and global drugs strategies have pursued reductions in drug use as an end in itself, failing to recognise that harsh criminal sanctions have pushed vulnerable people in need of treatment to the margins of society, driving up harm to health and wellbeing.” 38 Transferring principal responsibility from the Home Office to the Department of Health 39 would also take away one of the arguments used by opponents of reform: that those who want cannabis legalised only do so because they erroneously believe it harmless. This is, of course, baloney. It is precisely because cannabis can cause harm that it needs to have appropriate regulations and controls applied. Of course cannabis isn’t completely safe. No drug is safe; no human activity, for that matter, is completely safe. But making it illegal doesn’t make it safer. The Department of Health already provides information on the dangers caused not just by alcohol and tobacco but by sugar too. They are best placed to put cannabis in its context. The time for a root-and-branch reform of UK cannabis policy is long overdue. Current policy emanates from the wrong government department and is aimed at the wrong kind of people. It is misconceived from start to finish. In the next chapter, we explore some of the policy innovations taking place in several other Western countries which we hope will pave the way for the UK to follow suit in one form or another.

Chapter Five: Global Policy Innovations

“Senator, welcome to our microphones. Is there anything of yours that we can keep as a memento of this visit?” “Take California.” Take California, Propellerheads.

November 8th, 2016 saw Donald Trump win arguably the most divisive election in the long and chequered history of presidential campaigns. Yet the focus of many cannabis activists was not so much on 1600 Pennsylvania Avenue as on an address almost 3,000 miles further west: 1526 H St in Sacramento, official residence of the Governor of California. California was one of four states which voted to legalise cannabis that day. With due respect to Maine, Massachusetts and Nevada, 40 the Golden State — the sixth largest economy in the world — was the battleground for campaigners on both sides of the issue. “If there’s one thing we agree on with legalisation advocates, it’s that California is important,” said Kevin Sabet, head of the anticannabis group Smart Approaches to Marijuana (SAM). 41 The repercussions of the vote will be immense. This win for the legalisers “could tip the balance in favour of legalisation on the federal level and usher in a social revolution across America that the Woodstock generation could only dream of.” 42 “Once California legalises marijuana, I think the rest of the country is going to follow,” says Congressman Eric Swalwell. 43 21

Had the legalisation campaign lost, however, any national groundswell towards widespread legalisation would have been stopped in its tracks. Before the vote, Aaron Smith of the National Cannabis Industry Association (NCIA) had said: “If we don’t win California and at least half of the other states in play right now, the public narrative around our industry will dramatically change for the worse and for quite some time, setting us back a decade or more.” 44 California has therefore followed where states such as Colorado have already trodden: 45 marijuana has been legally regulated there since 2013, and the state now has more retail marijuana stores (424) than it does outlets of Starbucks (322) or McDonald’s (202). 46 In general, legalisation in Colorado has been a success. 53% of Colorado residents think legalisation has been a good thing overall, with 39% considering it bad. 47 Marijuana-related crimes account for less than 1% of all crime recorded in the United States. Both teenage consumption of cannabis and cannabis-related crime in the state capital Denver has fallen, with cannabis-related crimes now accounting for less than 1% of all crime recorded in Denver. 48 The burgeoning cannabis industry has created both jobs and tax revenues ($70m of the latter in 2015). The city of Aurora takes $4.5m of that tax revenue, much of which it redistributes to programmes such as the Colfax Community Network which helps low-income families to live in motels, apartments and provides food, clothing, hygiene products and nappies. “Marijuana legalisation in the Rocky Mountain state appears a distinct improvement on the costly morass of prohibition. Britain should pay close attention.” 49

prevent people manufacturing drugs. It has failed to prevent crime, corruption and death on an industrial scale. The old prohibitionist model, enshrined and entrenched in three separate UN treaties (1961, 1971 and 1988) and incorporated into the domestic laws of more than 150 countries, is crumbling. The United Nations Office on Drugs and Crime (UNODC) has acknowledged the “growing recognition that treatment and rehabilitation of illicit drug users are more effective than punishment.” 50 The World Health Organisation (WHO) agrees that prohibition has led to “policies and enforcement practices that entrench discrimination, propagate human rights violations, contribute to violence related to criminal networks and deny people access to the interventions they need to improve their health.” 51 Now more than 90 countries have at least begun to introduce harm reduction policies alongside those aimed at enforcement and punishment. Some of these countries have had such policies in place for many years now: within the EU alone, for example, the Netherlands has effectively decriminalised cannabis since 1976 and Portugal since 2001. But decriminalisation is not enough. Legalisation and regulation are what is needed, so it is three countries — Canada, Germany and Uruguay — which are of particular interest in the context of this report. All three are currently feeling their way towards full or partial legalisation, and their cases will give immediate and relevant pointers as to what kind of future a cannabis-legal UK could anticipate.

What Colorado and California have done are reflections of a wider paradigm shift: a recognition that the ‘war on drugs’ as it has been fought for close to half a century has failed. It has failed to prevent people using drugs. It has failed to

Canada Now that Barack Obama is leaving office, Canadian Prime Minister Justin Trudeau is the poster boy for global liberals. He is committed to changing Canadian laws on cannabis and has pledged to begin legislation by spring 2017, though he’s aware that his country’s large and solid bedrock of conservative citizens — much like the UK’s — (a) prefer a slow and steady approach rather than a zealous headlong rush (b) place great emphasis on personal safety. Hence his focus on strict regulation. “The reason why legalising marijuana is the right step for us,” he told CTV News, “is because of two things. One, it will make it harder for young people to access marijuana, because whatever you say about marijuana compared to alcohol or cigarettes, we know that the impact on the developing brain is something we need to prevent. Right now, young people have easy access. Controlling and regulating it will make it more difficult for them. Two, we need to remove the criminal element — street gangs, the organised crime — from the sale of marijuana. Regulating it and controlling it will do that. Decriminalising does absolutely nothing on either of those two things. If you decriminalise it, you make it easier for kids to access it. Decriminalise it, you continue to have organised crime controlling marijuana. That is counter to why we want to do it. That is why decriminalisation has never been interesting to us.” 52 He has also emphasised that “pot is still illegal in this country and will be until we bring in a strong regulatory framework.” 53 For all his smooth PR and camera-friendly smiles, Trudeau is a smart enough operator to know that talking the talk and walking the walk are two different beasts entirely. The scale of what he faces is enormous. He will have to navigate waters which are not just uncharted but treacherous, teeming with stakeholders — politicians, lawmakers, citizens, consumers, healthcare, businesses — whose competing desires and demands he must somehow fashion 23

it into a working and workable compromise. He has no pre-existing template to work from. This is not taking a country back to a previous legal status, as it was in the US with the repeal of Prohibition (itself famously enshrined in a constitutional amendment which overrode one of its predecessors). It will probably take him two or three years at least, perhaps longer, to move from tabula rasa to completed legislation. If the eyes of British cannabis campaigners and advisers are not on Trudeau during this process, they should be. For all our attachment to the ‘special relationship’ with America and for all our geographical, historical, commercial and social links with Europe, we’ve always had more in common with the Canadians than perhaps we realise. What Trudeau can and cannot manage will give us lots of pointers, if only we are aware enough to see them for what they are. Germany Germany is on the brink of fully legalising cannabis for medical purposes, including the treatment of cancer, glaucoma, HIV-related illnesses, Hepatitis C, neuralgia, Parkinson’s and other serious conditions, having had extremely limited access for a small number of specifically exempted people since 2009. Cannabis used for such purposes will in certain circumstances be covered by public health insurance and available on prescription from pharmacies. The road to even this limited reform has been a long and winding one, and driven far more by activist groups such as Schildower Kreis and Deutscher Hanf Verband than by politicians. Interestingly, given the way in which many public issues are crystallised in a single incident or image, the case of Michael Fischer was a prime mover in the shift towards medical legalisation.

Fischer is a multiple sclerosis sufferer who in April 2016, after a decade of legal battles, finally won the right to cultivate his own cannabis for medicinal purposes. Although his victory was only in narrow legal terms a personal one, it paved the way and provided a precedent for similar court cases, which in turn has helped persuade the government to bow to the inevitable. Since it will take time for Germany to grow enough cannabis of its own to meet the needs of this new market, three Canadian companies — Tilray, Tweed and Canopy Growth — have signed deals to supply cannabis in the interim. This in itself is testament to the growing internationalisation of the cannabis industry, which will be explored more fully in Chapter Seven. However, full legalisation remains some way off. Marlene Mortler, Germany’s federal drug commissioner, maintains that “legalisation for private pleasure is not the aim and purpose of this [legislation]. It is intended for medical use only.” 54 This is consistent with Chancellor Angela Merkel’s long-held position on cannabis. “Through legalisation the threshold for obtaining cannabis would be lowered even further, and we hold — yes — the negative side effects of cannabis are so dangerous that one should not do this. After all, there are two million people who consume cannabis in this country and that is already much too much. Thus in my opinion, we should not legalise cannabis in general.” 55 As we will see in Chapter 7, Chancellor Merkel’s position is very much akin to that of Prime Minister Theresa May. But both women must also know that in politics, the thin end of the wedge is sometimes all that is needed to prise open the door. Take a step, demonstrate that it works, press for the next step, and so on.

Perhaps medicinal legalisation will prove a useful first step on the road to full legalisation in both countries. (Colorado legalised medical marijuana between 2008 and 2013 before expanding the licence across the board). Indeed, in the same week as California voted to regulate adult use of cannabis, the coalition of parties that govern Berlin announced plans to pilot a programme of “controlled distribution of cannabis to adults.” A sign that as the whole of Germany moves towards medical access, further reforms are already underway at a local level. 56 Perhaps a British version of Michael Fischer, someone in unimaginable pain who seeks only an alleviation of their agony and does so with articulacy and stoic humour, may help crystallise the emotional side of the cannabis argument as well as the intellectual one.

However, there is a fourth way, and it’s the same as it’s always been — the black market. That’s because progress to a fully-realised and regulated market has been and continues to be slow, partly deliberately, partly not.

Uruguay Uruguay was the first country to fully legalise the sale and production of cannabis, which they did in December 2013. The move demonstrated the power of a concerted middle-class movement, as it was such consumers who ran a decade-long campaign to persuade the government of the benefits of legalisation.

Former president José Mujica, the architect of the law, repeatedly emphasised the need for caution. “We are not just going to say, ‘hands off and let the market take care of it,’ because if the market is in charge, it is going to seek to sell the greatest possible amount.” 58 The law’s main intention, he adds, was always to seize the market from illegal drug dealers, not encourage people to smoke weed.

Now Uruguayans can, in theory at least, obtain their cannabis one of three ways: • f rom home growing (each person is allowed up to six plants) • t hrough cannabis clubs (effectively private collectives where members can grow and smoke cannabis but may not sell it) • t hrough pharmacies at a set price of around a dollar per gram.

On one hand, Uruguay is aware that everyone is watching to see how what is effectively a great social experiment plays out, and there are at least as many people wanting it to fail as are rooting for it to succeed. “We are doing something completely new for our country and the entire world,” says Milton Romani Gerner, secretary-general of Uruguay’s National Drug Board. “It’s up to our model to overcome prohibitionist attitudes from various agencies and institutions, and general mentalities, that do not accept change.” 57

On the other hand, this sense of caution has inadvertently led to logistical logjams. The process for registering pharmacies has been so laborious that not a single one has yet opened, even though they were always intended to be the chosen route to market for the majority of smokers. So many points have still to be agreed, such as price controls, safety measures, precise legal obligations and so on. Every question seems to beget several more. And the new president, Tabaré Vázquez, is much less of a risk-taker than Mujica was.

For the time being, therefore, Uruguay remains stuck in limbo, halfway between the old failed South American prohibitionist policies and a brave new world of a vibrant, successful cannabis economy. Both its successes and its failures provide lessons for other countries. “We are providing evidence for something that doesn’t yet exist,” Romani said. “But in our favour we have the painful and overwhelming evidence of prohibitionist policies being the total failure of an absurd war.” 59 From these examples, it’s clear that the tide effect is both underway and unstoppable, even if its progress will be anything but linear. The important thing is that it is happening, and the more it happens the more it will continue to happen. As Mike Power, author of Drugs Unlimited, said: “from British Columbia to Berlin, from Oregon to Montevideo, you can sense a distinct whiff of change that is more pungent than protest, and headier than the most abstract theory. We are witnessing a radical, global reboot of cannabis regulation whose potency and novelty is mirrored perfectly by its accompanying industrial and cultural revolution.” 60

Chapter Six: The Shape Of The Industry

“Make the most of the hemp seed, and sow it everywhere.” Note from George Washington to his gardener, 1794.

The majority of new industries begin at a great advantage over the lawmakers in charge of regulating them. The industry’s practitioners understand their businesses’ strengths and flaws better than the regulators, and can therefore minimise any negative effects of regulations. A newly-legalised cannabis industry is a different kettle of fish, however. It is already used not just to government regulation but to government prohibition: laws both too numerous and too prescriptive rather than the opposite. There are three main aspects to any assessment of how this new industry will shape itself: the size of the sector, the scope of the sector, and the stresses which the sector will face. The size of the sector The gold rush is one of the most iconic parts of California’s history. If the state votes to legalise cannabis this November, analysts are expecting a green rush. “We’re looking at the total market for legal cannabis in California to grow to $6.6bn by 2020,” said Troy Dayton, chief executive of research firm Arcview. 61 And that’s just one state, albeit the biggest one. Arcview reckons that by the same 2020 date the entire annual American market could be worth almost $25bn.

Clearly such figures can only at this stage be rough estimates. Ask a dozen analysts and you’d get a dozen different answers, depending not just on the unknowables (how many other states would follow suit towards legalisation, how fast they would do so, how much the price of marijuana would move and in which direction), but also on what those analysts chose to include in and exclude from their calculations (are they counting all the ancillary industries which would spring up around a legal marijuana industry? Are they considering the effects of rising tax revenue and lowered law enforcement costs?) But whatever the figure, it’s safe to say one thing: it’ll be big. The potential UK market is obviously a fraction of the size of the US one, and since we are not as far down the line towards legalisation, estimates are limited. But we can still make some educated guesses. A 2011 study by the Independent Drug Monitoring Unit (IDMU) estimated that the UK cannabis economy would be worth approximately £6.8bn per annum — just under half the size of the British tobacco industry at the time, and more or less exactly the same as Arcview’s projections for California. 62 The Institute for Social and Economic Research (ISER) has modelled three scenarios for a legalised and regulated market in England and Wales alone, depending on both the amount of cannabis sold and the average percentage of THC in that cannabis. It suggests that just the aggregate annual government benefits — that is, not including direct sales revenues, which will form by far the largest part of any assessment — would be between £750m and £1.05bn. 63

Pricing is obviously going to be a key factor in the value of the industry. Both available data and common sense suggest that cannabis prices will fall post-legislation (though in several newlylegalised markets there has been an initial price rise while supply volumes, customer demand and distribution networks sort themselves out and become used to the new paradigm. After that, prices fall.) In Washington state, where cannabis is now legal, prices are falling by as much as 25% per year. 64 “It’s just a plant,” said Professor Jonathan Caulkins of Carnegie Mellon University. “There will always be the marijuana equivalent of organically grown specialty crops sold at premium prices to yuppies, but at the same time, no-frills generic forms could become cheap enough to give away as a loss leader — the way bars give patrons beer nuts and hotels leave chocolates on your pillow.” Falling prices are obviously good news for the consumer but also for the police who will find fewer people seeking out black market dealers. They’re not such good news for the taxman. Whether they’re good news for the business owners depends on the trade-off between price point and units sold. In order to maintain an equilibrium, governments may intervene to keep the price around a certain level, either directly (through price controls) or indirectly (sales tax increases). But if they push these prices too high, then they risk letting the black market dealers back in the game again. They have to perform the regulatory equivalent of keeping the bath level with the taps running but the plug out.

The scale of the sector When people think of a regulated cannabis industry, they tend to think of the people who grow it, the people who distribute it and the people who sell it. Farms, vans, shops. And this triad will indeed form the backbone of the industry, providing many thousands of jobs in the process.

Other investors have been less sure: venture capitalist Zach Bogue, for example, has likened it to “investing in the porn industry. I’m sure there’s a lot of money to be made, but it’s just not something we want to invest in.” 68 But Microsoft is so iconic that their vote of confidence may prove a self-fulfilling prophecy, not just in terms of attracting investors but also influencing legislation.

But there are scores of other job opportunities available too. Who manufactures the high-intensity grow lights for hydroponic farms? Who makes “Microsoft has a leviathan [lobbying] effort up the pipes and vaporisers through which many here in Washington [D.C.],” says Allen St. Pierre, people will consume their cannabis? Who does executive director of the National Organization the growers’ advertising and marketing? Who for the Reform of Marijuana Laws (NORML). organises the cannabis equivalent of wine tasting “Focusing in on these commerce reforms, for tours for all those thousands of people who come example to allow banks to handle this trade — from out of state? Who designs the cellphone they lobby hard for that stuff on the Hill right now, cases, T-shirts, notepads and paperweights which and to have a Microsoft weigh in saying ‘we want can now be emblazoned with company logos? to be part of that commerce’ can only buoy those Who writes books or makes programmes about efforts…. Ten years ago, 20 years ago, if you were the perils of this new industry? 65 Who writes the saying, I have a software and I’m hoping to track business plans and assesses commercial loans? marijuana sale, you and I would be in a RICO Who puts up the venture capital? Who writes conspiracy. So that speaks to how much has and operates the software programmes which changed.” 69 optimise growing methods, track deliveries and maintain real-time stock inventories? Even if the likes of Microsoft might not touch the mechanics of the actual frontline industry for now, In the last instance at least, we already have the the way those mechanics play out will obviously answer. In June 2016, Microsoft announced its be crucial in helping structure the industry. There partnership with the software company Kind are several different possible models, and the Financial, which “provides ‘seed to sale’ services extent to which each is applied (and mix-matched for cannabis growers, allowing them to track with others) will vary depending on location and inventory, navigate laws and handle transactions jurisdiction. all through Kind’s software systems. The partnership marks the first major tech company to attach its name to the burgeoning industry of legal marijuana.”66 Most things which Microsoft does are news one way or another, and this is no exception. For a software giant of such size and reach to invest in the industry — albeit in a company providing services at one remove to the frontline manufacturers and vendors themselves — represents an enormous vote of confidence in the long-term viability of the legalised marijuana sector. 67

In terms of production, there are three main possibilities (and, as Uruguay shows, these can exist in parallel): Large-scale licensed production for retail sales. A newly-created government authority oversees regulation. Producers have to satisfy stringent regulatory conditions before being granted a licence. Producers may or may not be: restricted to operating within their country of origin; limited in the volume they could produce; banned from vertically integrating with retailers. Possible application of the ‘seed to sale’ model (where individual cannabis plants are tracked through every stage from growth to sale) to minimise unlicensed sales and tax avoidance. Small-scale licensed production for membersonly ‘cannabis clubs’. Unlicensed home growing for personal use, but with a limit on the number of plants per individual (existing limits in various jurisdictions vary from four to nine) and with enforceable penalties for breaching. The better (and more affordably) the large-scale licenced market works, the smaller the home growing sector: most users default to the convenience of retail.

As for vendors, they “have a crucial role in any cannabis regulation model. Firstly, they act as gatekeepers of the market, entrusted with exercising regulatory access controls, enforcing restrictions on sales relating to age, intoxication or other criteria. Secondly, the vendor-customer interaction provides a vital opportunity for targeted public health interventions, educating cannabis users about the risks of different products, harm minimisation, responsible use and where to get help or further information.” 70 In terms of sales, there are again three main possibilities, and again they can work concurrently with each other: Physical premises with consumption on site. This may be along the lines of the Dutch ‘coffeeshop’ model, or closer to the concept of the ‘cannabis club’ outlined above. Staff need to be welltrained: not merely in retail and health knowledge, but also in their ability to care for those customers who need it and to refuse service to those underage and/or obviously intoxicated already. Physical premises with consumption off site, such as a pharmacy. Staff requirements are broadly similar to those for establishments offering on-site consumption.

Online and other postal/courier-based delivery networks. There’s a certain symmetry in this — the very first item ever bought online was a bag of cannabis back in 1971 when students at MIT agreed the deal with their counterparts in Stanford over the Arpanet network. And much of the trade in illegal cannabis has so far been conducted via darknet sites such as the Silk Roadl 71. Online retail sites such as amazon and eBay are some of the internet’s marquee brands. In many ways cannabis is a perfect product for online distribution. It’s small, light and hard to damage in transit. 72 Online user reviews are vital tools for undecided or adventurous consumers. The delivery network means the recipient doesn’t even need to leave home and is therefore less likely to, for example, drive under the influence. The stresses which the sector will face On a micro level, each individual company will be different: and as in any industry, particularly any new industry, there will be many more failures than successes. Start-up costs are high: licensing fees, equipment costs, rent and tax liabilities can run into seven figures all told. Bank loans may be charged at high interest rates due to the uncertainty of the sector’s prospects, and as things stand in the US cannabis businesses are also ineligible for federal bankruptcy protection. “The sheer amount of knowledge you have to have to make legitimate investments is huge,” says Rob Hunt of private equity firm Tuatara Capital 73 — and without that knowledge, your money may well go up in smoke. On a macro level, it would be otiose to suggest that any legalised cannabis industry modelled even vaguely along the lines of the alcohol and tobacco industries will not be prone to taking on their kind of troubles too.

Any commercial entity has at base only two obligations: to maximise profits, and to remain within the law. Maximising profits means increasing sales, cutting costs, or raising prices. Increasing sales means increasing consumption. Increasing consumption means persuading new users into the marketplace and/or persuading existing users to consume more. This is at odds with public health exigencies, especially since both the alcohol and tobacco industries (neither of them strangers to making the science fit their agenda) make as much of their profits from a minority of heavy or problematic consumers as they do from the much larger group of casual punters. “We’re going to see a lot of people struggling with marijuana dependency and wonder why we thought it was smart to create another industry that’s going to shape public policy around a dependence-inducing intoxicant,” says Caulkins. “And 25 years later, people are going to look back and say, ‘What idiots you were; what were you thinking?’” Perhaps alcohol, tobacco and pharma will object to the new kid on the block and try to muscle cannabis into the margins. Or perhaps they will not only welcome the newcomer but co-opt it in order to improve their own businesses. “It may not be literally true that big tobacco companies will be the companies that end up selling marijuana,” says Caulkins. “But you should expect the companies to have that kind of approach. It’s entirely possible that even if it’s a homegrown, new company that emerges in the marijuana industry, they may hire the VP of marketing from a tobacco company.” 74 The majority of cannabis campaigners are probably instinctively wary of big business. This is a matter of great personal import to people, and few of them want to see the soul of it sucked out by venture capitalists. But even corporate greed would be a quantum improvement on what we have right now in the UK.

Chapter Seven: Policy Implications

“Drugs policy has been a no-go area for most politicians, with a few notable — and brave — exceptions. Taking a tough line, calling for a war on drugs and stiffer penalties has been the stock in trade of politicians of both major parties. Proposals to liberalise the law lead to accusations of being ‘soft on drugs’ and cost votes.” David Cameron, May 2002.

If this last chapter had been written on 22nd June 2016 rather than in early October, it would have read very differently. David Cameron, as socially liberal a modern-day Tory leader as one could imagine, was still Prime Minister. Both the opinion polls and the bookies had Remain to win the EU referendum, which would put the issue of Europe to bed for at least the foreseeable future. Cameron would have had plenty of time to concentrate on his much-vaunted ‘life chances’ agenda before stepping down in good time for the 2020 election. Perhaps cannabis reform would even have ended up alongside gay marriage in his legacy.

All that is now history. If, as Cameron stood outside No 10 the morning after a sleepless night and announced his resignation, you’d gone through a list of likely runners and riders for his job and figured which of them would prove most inimical to cannabis reform, Theresa May would have been very nearly or very actually at the top of that list. Yes, her tenure as Home Secretary proved her a formidable tackler of injustice when the issues move her, as they did with modern slavery and FGM. But cannabis has never been remotely on her agenda, except in terms of maintaining the status quo. Nick Clegg called her on the issue and accused her of trying to alter a 2014 Whitehall report which concluded there was no link between tough laws and the levels of illegal drug use, “arguing that there would be no change whatsoever as long as she led the Home Office.” 75 It seems extremely unlikely that anything will change now Mrs May has moved from Marsham Street to Downing Street. This is not just down to her intransigence on the issue, but also because the referendum which turfed her predecessor from office has also ensured that the issue of Brexit will dominate the next few years of British politics to an extent rarely seen on a single issue (at least outside wartime.)

Three separate departments fighting within themselves, let alone with each other, as to who does what. Endlessly complicated negotiations requiring both steely overall control and nitpicking of the finest details. Both a media and a population bitterly divided on the outcomes and not shy of offering their opinions. At times it will feel as though thereâ&#x20AC;&#x2122;s no room for any other aspect of public discourse to get a lookin. The only parties really pressing for cannabis reform are the Liberal Democrats and the Greens, but in parliamentary terms they have very little representation. More generally, Britain (and particularly England) is a rather conservative nation. There is little or no mileage for most MPs to press the cause of cannabis reform, since it will win them no support and may indeed cost them some. Therefore the campaign for cannabis must be fought on other fronts â&#x20AC;&#x201D; in particular, through the tide effect of what is happening in other countries. Change can come from without as well as from within. A groundswell of reform across North America will be increasingly hard to ignore, especially if the benefits to public health, law enforcement and taxation revenue are demonstrably positive.

This will not happen overnight, of course. Even the most optimistic reform advocate doubts that Trudeau can push legislation through in Canada before 2019 at the earliest. It will also take at least two or three years for the full effects of Californian legalisation to filter through in terms of other states following suit in any large numbers. Both timescales are consistent with the proposed final date for Brexit and a possible subsequent realignment of political priorities. When the question of cannabis law reform does again cross the desks of UK parliamentarians, it must be made clear to them that the status quo is failing, and what solutions the examples of Canada and US states have to offer to remedy this failure â&#x20AC;&#x201D; those laid out here in the Tide Effect. Rather than inching towards reform by a muddle of police-led decriminalisation efforts, legal regulation of cannabis must be sought outright. The illegal market can be left no space in which to operate, and a UK-based cannabis industry must be allowed to establish itself under a new regulatory framework to replace the illegal trade. Revenue from taxation of the legal market will benefit the Treasury, although this benefit must be secondary to ensuring the legal market is placed at a competitive advantage to the illicit alternative.

Principle responsibility for cannabis should move from the Home Office to the Department of Health, where the terms of the regulated market can be set to an agenda that protects children and public health, targets crime and safeguards consumer rights. The role of the Home Office itself in cannabis policy must pivot from enforcer of prohibition, to that of a regulatory and licencing body, as it is in the case of alcohol. This change in role necessitates a change in the language and thinking used to refer to cannabis. That of public fear — ‘illegal’, ‘criminal’, ‘dangerous’ — must be replaced by the measured language of regulation and harm reduction. Any moves towards the legalisation of cannabis will be slow and painstaking in the making. But what looks impossible today seems inevitable in retrospect. Imagine some years from now, when you can walk into a cannabis store the same way you do into an off-licence today, and you take one as much for granted as the other. You peruse shelves of cannabis products arranged by potency, taste, geographical origin, manufacturer and so on. Those products are labelled with comprehensive health information, most obviously the respective THC and CBD percentages — no product can be sold without those clearly on view. The staff answer any questions you have and give you recommendations — staff picks, perhaps, in the way Waterstone’s assistants flag the books they love. Your fellow shoppers are — well, they are as diverse and different as humanity itself. The woman over there is a teacher whose PSHE classes cover cannabis, tobacco and alcohol. The man a few paces along from her is a taxi driver, though he’d no more take cannabis before starting a shift than he would have a drink, as either would imperil his licence and neither is worth the risk. On the other side of the shop, the young man in a tracksuit is an undercover government inspector,

come to check that the shop is obeying all the laws which make up the conditions of its licence. He watches the way the staff deal with a customer who’s already badly stoned — they gently but firmly remove him, and give him the number of a health centre two streets down who will look after him — and makes a mental note of approval. You choose your purchases, take them in a basket to the till, pay and leave the shop. There used to be some small-time dealers on the streets round here, especially at the entrance to the Tube station, but no longer. The legitimate market has put them all out of business (though a couple of them have retrained and now work at the cannabis store you’ve just left: no point letting all that market knowledge go to waste, after all). When you get home, you smoke a medium-strength joint while your partner vapes. Just like having a glass of wine in front of the latest box set. And the most extraordinary thing about all this is the fact that it’s not extraordinary in the least. It’s what millions of people do every day. It’s a quotidian and unremarkable part of the social fabric. The language around the cannabis business — ‘store’, ‘staff’, ‘recommendations’, ‘licence’ — is the language of business and regulations. Not controversial or subversive. Rather boring, in fact. That is our destination. It is not a place we will reach easily or any time soon. Before we get there, we need to pass through several checkpoints: public opinion, parliamentary debate, executive action. We must make sure the regulatory framework is both sufficiently solid to sustain the industry built upon it and sufficiently pliable to adapt to the inevitable changes along the way. Like all long journeys, it starts with a single step. We just need to take that step.

HIGH STAKES DRUGS CRISIS I ENGLISH PRISO George McBride

IN ONS

Executive Summary Prisons are in crisis with record levels of suicides, violence and self-harm. Traditional drugs have been replaced by a family of drugs called synthetic cannabinoid receptor agonists (SCRAs), generically referred to as “Black Mamba” or “Spice”. The Government has failed to recognise the important policy implications of these new drugs, and the lack of intelligent drug policy in the new white paper risks undermining the entirety of the prison reforms it proposes. This report is the first of its kind, bringing together experts in drug and prison policy to examine the implications of the radical shift in prison drug markets and propose pragmatic solutions to reduce drug-related harms and improve prison safety and security. The report reviews the rise to near ubiquity of Spice in men’s prisons in England. These diverse and multitudinous substances have risen to prominence globally in response to international prohibition of popular illicit substances, in particular cannabis. These new substances have relatively unknown risk profiles and many induce paranoia, behavioural disturbances, violence, seizures and convulsions. They are particularly popular in prisons due to their low cost, difficulty to detect, and “bird [or prison sentence] killing” effects. Too little is being done to fight drug demand within prisons. Prisoners are often left unoccupied in their cells for 23 hours a day. Many prisoners are developing drug problems during their incarceration. Overall, 8% of men in prison in England and Wales report developing a drug problem since they have been in prison. In prisons with the worst regimes, this is as high as 14 – 16%. This is increasing drug use and the frequency of dangerous incidents, which 39

are a substantial drain on prison staff resources. This feeds a vicious cycle, further draining resources while leaving prisoners increasingly unoccupied and under supervised. As staff capacity is reduced this further decreases the ability of prisons to perform essential functions in disrupting the supply of drugs into prisons, leaving criminal organisations able to push drugs with impunity. The supply reduction methods proposed in the white paper are expensive distractions from the real work needed to disrupt criminal supply chains. Proposed extensions to the mandatory drug testing regime will be impracticable with the available resources, only identify a limited range of the drugs in circulation, and fail to assist in identifying those supplying drugs. New sniffer dogs will quickly become obsolete due to the rate of chemical innovation of new substances. We are currently monitoring drug use in prisons through mandatory drug testing and records of seizures. These methods give very little assistance in terms of understanding who is supplying drugs, who is using drugs, what drugs are in circulation, how drugs are getting into prisons, or the level and nature of harm associated with drug use in a given prison.

Recommendations

Risk management, not zero tolerance A chasm exists between the prevailing rhetoric and policy reality. In order to manage prisons effectively, efforts need to focus on disrupting supply chains, reducing demand for drugs, and improving intelligence-gathering. Reducing drug-related harms makes prisons safer places in which rehabilitation is more effective. Helping addicted drug-users who are willing to change to turn their lives around is proven to reduce re-offending rates.

Reduce demand through purposeful activity There needs to be an acceptance that supply reduction measures are there to disrupt supply, not to eradicate it. A shift of emphasis towards demand reduction is required to make prisons more effective at tackling problem drug habits and rehabilitating offenders. There is a clear link between a lack of purposeful activity and the uptake of drug use. Busy prison regimes and treatment are more effective than security measures in managing the drug problem in our prisons. The longheld emphasis on supply reduction over demand reduction creates an increased burden on staff, logistical and management difficulties, and associated difficulties in implementing new policies, supporting work, training, education and treatment schemes. These costs too often go uncounted.

Overhaul monitoring of drug use An essential part of effective management is using appropriate, reliable metrics for measuring success and failure. The Ministry of Justiceâ&#x20AC;&#x2122;s recommendations to monitor prisonsâ&#x20AC;&#x2122; drug policy outcomes by drug testing prisoners on arrival and exit from prison will not provide reliable or useful data. Instead, a system should be implemented to monitor the nature and scale of the drug market and drug-related harms. Regular anonymous audits of drug use and the drug market could provide valuable information from treatment staff, prison officers, current and ex-prisoners.

Overhaul monitoring of drug supply and security Current supply-reduction and security measures are not grounded in evidence. New proposed measures focus on drones and visitors when there is no evidence that these are the primary sources of supply. There is evidence suggesting corrupt staff may be a major source of supply. Evidence gathering is needed on drug seizures to assist in determining their providence, as well as a new regional task force within the Prison Service to oversee periodic spot checks and searches of staff.

Improve staff to prisoner ratio Overseeing busy prison routines and effective treatment is a labour-intensive endeavour with no quick-fix technological solutions. In order to bring about this reform we need a better staff to prisoner ratio. To do so means that we need to either substantially reduce the prison population, or substantially increase prison funding. Reducing the prison population likely has both fiscal and outcome benefits, by reducing the use of a costly and ineffective intervention.

Chapter One: Prisons in Crisis

“I was patrolling the cells and a prisoner ra cell, completely naked. He climbed onto th thinking it was his bed. He soiled himself. to restrain him he had almost super-huma it took three prison officers and a nurse to And shockingly — when he came to the nex did not remember a thing. They never do.”1 In the changing landscape of prison life, traditional drugs have been usurped by poorly-understood synthetic cannabinoid receptor antagonists (known by brand names such as “Spice” and “Black Mamba”). Meanwhile, prisons are suffering from record levels of overcrowding, violence, suicide, and persistently high rates of reoffending. According to Peter Clarke, HM Chief Inspector of Prisons, prisons “have become unacceptably violent and dangerous places.” 2 Total assaults in prisons have risen 64% since 2012, assaults on staff have risen 99%, and the number of selfinflicted deaths in custody has risen by 75%. 3 In the 12 months prior to September 2016, there were 23,775 assaults, 5,954 assaults on staff, and 107 suicides. Prisons now average one suicide every 3 days.4 Over the last 20 years, the prison population has doubled. “Sentences have got longer, there is less flexibility in sentencing, mandatory sentencing has risen. More people are going to prison and they are going to prison for longer.” 5 41

As the prison population grows, so too does overcrowding within an increasingly underfunded prison service. Prisons have lost £900,000,000 in funding over the last parliament,6 while the number of operational staff fell from 29,660 on 31 March 2012 to 23,080 on 31 March 2016.7 A reduction in staff has led to a reduction in purposeful activity for prisoners. With too few staff available to let prisoners out of their cells for education, training, or work, prisoners are often locked down in cells for very long periods,8 resulting in an increase of mental health problems and demand for drugs while the ability to disrupt the supply of drugs has declined. As the Lord Chancellor notes in the foreword to the much-anticipated Ministry of Justice white paper ‘Prison Safety and Reform’, “prisons are not working.” Our prisons are not only failing inside; almost half of all prisoners are reconvicted within a year of release. The cost of re-offending is estimated to be up to £15 billion a year.9

an out of his he snooker table When we tried an strength, and o restrain him. xt morning he

If we are to tackle prison security, reoffending rates, costs, and protect wider society from crime, we need to think seriously and practically when discussing drug policy in prisons. As the MoJ white paper points out: â&#x20AC;&#x153;No one can be expected to change their behaviour and turn their life around while they are dependent on drugs, in fear of being assaulted, or considering harming themselves.â&#x20AC;?10

Chapter Two: The Rise of NPS

“Spice is the perfect prison drug; you take a puff and eight hours later you wake up.”1 Since 2012, we have seen a meteoric rise in the supply and use of a group of novel psychoactive substances (NPS) called synthetic cannabinoid receptor agonists (SCRAs), more commonly referred to as “Spice”. NPS are, in many ways, just new drugs within a long history of drug use in prison, but they also pose unique challenges in the context of our currently understaffed and unsafe prisons. NPS have been labelled a cause of violence by some, and a symptom of cuts and overcrowding by others. The HM Inspectorate of Prisons called NPS “the most serious threat to the safety and security of the prison system.”12 What are NPS? “Conventional supply-reduction strategies used by governments around the world to stem the production, use and trade of illicit drugs, have led drug users to seek alternative, legal supplies of psychoactive substances. Governments are facing progressively more complex challenges in responding to these new drug-markets.” 13 Over the last ten years, organic chemists have greatly accelerated the rate at which psychoactive substances are discovered. Business people have exploited the highdemand for popular illicit psychoactive substances by bringing these novel drugs into new markets, to meet demand with a legal supply of drugs with similar effects. The most popular illicit drug in the world is cannabis. Therefore, a great deal of the innovation has focused on drugs which react with the same systems in the brain. We now know of over 200 different SCRAs available on the international market, making them the largest group of NPS.14 SCRAs are a large and chemically diverse group of molecules with some functional similarity to natural cannabis. They are frequently sprayed onto dried plant material and smoked to imitate herbal cannabis. These drugs have risen to become by far the most popular drugs in English prisons. SCRAs are often vaguely referred to as NPS or by a trade name such as Spice, but what particular brands contain varies widely, and brand names are not reliable indicators of content. Constituents and dosages vary greatly, both between products and between different batches of the same brand. Much of this is driven by reactive prohibition of individual substances, leading producers to new, less well understood substances. Wide ranging differences in strands include metabolism, potency, toxicity and duration of effects.15

Why the shift to NPS? “It is an ideal prison drug because it can’t be detected, doesn’t smell and passes the time. Downside — it makes you very lazy. I couldn’t smoke it outside coz I would get nothing done.”16 In prison, where efforts to reduce the supply of traditional drugs are most keenly felt, and where demand for drugs is extremely high, NPS were always likely to establish themselves in the market. NPS have in general been most popular with vulnerable groups such as young people, the homeless and prisoners, due to cost, availability and intensity of effect. Nicknamed “the bird killer”, SCRAs are a very good product to meet the particular type of demand in custodial institutions: the demand to make long, boring and often painful prison sentences pass quicker. “NPS have radically changed the prison environment since 2012. I was in prison at the time they started coming in. I saw the very first consignments arriving on the wing. It has now reached epidemic proportions.”17 According to a recent survey by User Voice, 33% of prisoners self-identified as having used Spice within the last month.18 In many prisons the figure is likely to be much higher than this. Obtaining accurate data on the issue is difficult, due to the clandestine nature of prohibited drug use in prisons. It is now so commonplace that many prison staff report having become desensitised to shocking incidents, including violent convulsions and seizures.

Rather than guiding drug users to less harmful drugs, drug policies within prisons are instead driving drug use in the opposite direction. Where once the smell of cannabis was part and parcel of men’s local prisons, that smell has now been replaced by a far subtler beast; odourless, synthetic chemicals. When these drugs arrived on the market, there were no tests to detect whether people had used them, whereas natural cannabis stays in people’s systems for up to a month and could lead to extra days in prison or other punishments if caught. NPS are also easier to get past prison security apparatus due to their small size, and difficulties in detecting many of their substances. Legally-produced, high-potency SCRAs can be produced in bulk (predominantly in China and India) for very low cost, and the mark-up is significant. It is these high margins, coupled with a low risk of capture for suppliers, that has fuelled the growth of the market. US states have experienced a similar rise in the use of SCRAs among their prison populations, whereas other countries have largely avoided the trend. In Norway, NPS are used to a certain extent among wider society, but there is no evidence of any widespread use in prisons. There are two main proposed explanations for this: The markedly different nature of drug demand due to busier prison routines, and the lack of a commercial drug market, owing to their drug-demand strategy and dynamic security approach.

Harms of NPS “The key concerns for NPS are the unknown risk-profiles of these products, the availability of these substances without controls, the lack of guidance on how to use them more safely, and the difficulties faced by medical practitioners in being unable to identify the substance taken and the best options for treatment in emergencies.”19 SCRAs are often inaccurately described as synthetic cannabis. Whilst some of the effects of these drugs are similar to cannabis, others are not, including the high levels of toxicity of many of these substances. In general, as compared to cannabis, “SCRAs are characterised by quicker onset of effects, significantly shorter duration of action, worse hangover effects and more intense visual hallucinations, paranoid feelings and behavioural disturbances.” 20 Products containing SCRAs can range from those with a similar potency to cannabis, to those with potency up to 100 – 800 times stronger than typical cannabis.21 “As compared to their natural counterpart, synthetic cannabinoids have at least three major drawbacks: they tend to be more potent than the THC that they mimic; they are more addictive; and, they do not contain any cannabidiol (CBD), which is a naturally-occurring cannabinoid with potentially anti-psychotic and anxiolytic effects.” 22

In the wider community, SCRAs are the most likely drugs to end in hospitalisation, three times more so than traditional drugs,23 presenting acute problems for emergency services, first aiders, and the prisoners themselves. This high rate of hospitalisation is unlikely due simply to these drugs being innately more dangerous. Other factors increasing the potential for harm may include socioeconomic factors of the users, a lack of understanding about how to take new drugs and a lack of harm reduction techniques. “Treatment-providers lack the necessary evidence on which to base their treatment. Paramedics work blind, so they have to make a choice between treating or not treating — both of which could result in potentially worsening the patient’s condition. Paramedics are forced to resort to ‘supportive’ care — i.e. addressing symptoms to improve patient comfort (e.g. administering tranquilisers or antipsychotics), rather than addressing the actual cause of the problem. This approach, although pragmatic, is suboptimal and often insufficient, and in severe cases can prove fatal.” 24 Very little evidence is available to help manage the harmful or dependent use of SCRAs, and best practice for treatment is still in its infancy. Many of the substances being used in prison today have had little to no research conducted on them. They are unpredictable in terms of dosage, effects and toxicity. People don’t know what they’re getting with these substances or that this is a major problem. But for a section of Spice users in prison, they do know what they’re getting. They’re getting an intense psychoactive experience that will “get their head out of the bars.” For these people, the challenge is not increasing their awareness of the dangers of Spice; it’s tackling their mindset.

There are three main types of harm associated with drug use in prison, all of which need to be addressed in order to minimise drug-related harms and ensure safety and security: Firstly, harms from the drugs themselves, including addiction, and physical and mental health problems; secondly, problems associated with the trade of drugs, including debt, bullying, and violence; and finally, the particular harms associated with prisons, such as staff time and resources involved in policing drug use and responding to problematic drug use. In many ways, the problems associated with the drug trade and the attempts to curtail and control it are more damaging than the drugs themselves. Debt and bullying are often ignored when considering the practicalities of drug policy, despite much lip service being given to the problem that prisoners themselves describe as the main reason for violence.25 When it comes to SCRAs, the economics are more vicious than with traditional drugs. “The traditional power structures have mutated and lots more prisoners are using and running up debts.”26 Lower prices means that more prisoners can afford to run up debts. Those who cannot afford to pay their debts are often used as guinea pigs to test new drug batches. These usually vulnerable people have become known as “Spice pigs”. Many horrific incidents of the abuse of profoundly mentally ill people being subjected to terrifying ordeals have been captured on prisoners’ mobile phones.

DEBT AND BULLYIN ARE OFTEN IGNOR WHEN CONSIDERI THE PRACTICALITI OF DRUG POLICY

NG RED ING IES

Chapter Three: Supply & Demand

“Drugs is what everyone’s thinking about [in prison] not a day goes past when you don’t hear the word ‘drugs’.”27 The prison environment is one in which demand for drugs flourishes. As the prison population has grown, so too has the market for drugs in our prisons, with over 1 in 3 prisoners reporting to have used drugs in the last month.28 A large number of prisoners have established drug problems. Nearly two thirds of prisoners have used illicit drugs in the month before entering custody,29 and 25% of all new arrivals receive treatment from prison medical services for substance misuse within three weeks of their arrival at prison. 30 Of those who do not already have a history of drug use, many choose to use drugs for the first time when they are incarcerated. The prison drug market is well set to prosper.

Demand “When you feel trapped, which is basically all the time, when you smoke [drugs] it makes you feel free, makes the bars disappear, makes you relax and not too bothered about being there.”31 While it is important to remember that a large proportion of the prison population are regular drug users with a history of dependence, previous research has consistently found that the largest driver for drug demand in prisons is boredom and the need to pass time.32 Escapism, relaxation, and stress relief are also commonly mentioned as motivations to use drugs. Other factors include self-medication for both physical and mental health problems, the control of withdrawal symptoms from addiction, and the increasing availability of substances within prison walls.As well as nearuniversal access to NPS, there is widespread access to prescription medications within prisons for addiction, mental health and pain. Many of these medications have psychoactive properties, making them popular for recreational use. Medications are frequently diverted away from those who were prescribed the drugs, into the illicit market. Traditional illicit drugs, particularly heroin and cannabis, are also still commonly used (albeit to a lesser extent than Spice), because they meet the type of drug demand most common in prisons — to alleviate pain and boredom.

Hospitalisations also put a considerable extra strain on emergency services and the NHS. At HMP Bristol this year, there were 35 ambulance call outs for Spice-related incidents in just one week34 at a prison with a population of around 600. To put this in perspective, HM Inspectorate noted in 2014 that Spice was a particular problem, because there had been seven ambulance call outs for Spice-related incidents in six months.35 Prisons are now so overcrowded and understaffed that prisoners’ fear of repercussions for misbehaviour are much lower than they once were. Many are more likely to take the risk of buying drugs, as there’s an increasing belief that prisons are just too crowded, and officers too overstretched, for dealers and consumers to be caught. However, drug use in prisons cannot be understood purely by looking at demand. A sophisticated market has arisen to meet this demand which itself influences demand, and in which suppliers push drugs with a high mark-up and low risk of capture. The rise and fall of usage rates for different drugs can’t be seen in isolation. They are deeply intertwined. If users can’t find a supply of their drug of choice, then they are likely to shift to other drugs to meet their demand.

As prisons continue to suffer from understaffing and overcrowding, more wings have to go into lockdown, often leaving prisoners confined to their cells for up to 23 hours a day. Boredom increases, demand for drugs rises, and so does the likelihood of misuse and serious incidents occurring, such as hospitalisation. Spice is now so associated with hospitalisation that prison slang for an ambulance is a “mambulance”, a reference to a popular brand name for SCRAs, “Black Mamba.” If an inmate has to go to hospital, so too do two officers, which increases prison lockdown time, feeding into the vicious cycle. In 2015, levels of purposeful activity in prisons were the lowest level ever recorded, and have not improved much over the last year in men’s local prisons.33 50

CORRUPT OFFICE WERE RESPONSIB FOR BRINGING IN MUCH AS 80% OF CONTRABAND FOU IN PRISONS.

ERS BLE AS THE UND

“The demand for drugs in prison is so great and the profits so astronomical that a situation exists where economic pressures ensure a supply route will always be found.” 36 Supply Drug markets differ widely from prison to prison. Each individual environment shapes the trade through complex interactions between demand, supply, security, enforcement strategies and treatment strategies. Previous reports have assessed the supply of drugs into different prisons and identified five main routes of entry for illicit drugs: visitors, staff, over the wall, post, and prisoners, as well as diversion of medication onto the illicit market from within the prison. 37 An important part of a prisoner’s rehabilitation is their maintenance of ties with family and friends. However, visits from these people come with risks of smuggling contraband. Visitors may smuggle drugs into prisons to protect their loved ones from debt, bullying and violence whilst others work under duress from organised crime groups or for their own financial gain. Smuggling requires the evasion of a range of security measures. Both the visitor and the inmate must avoid detection from sniffer dogs, CCTV, officer supervision and searches, usually by concealing the drugs internally either in the vagina, rectum (“plugging”), or the back of the throat.

“Many find this process an extremely frightening and exhausting ordeal. For instance, they may have got involved as a result of intense emotional pressure or even physical intimidation. Others, sometimes drug-using friends of the prisoner, may have developed a tried and tested approach which gives them little cause for concern.” 38

While the incidents of supply of drugs into prisons by staff may be lower, staff are able to bring in far higher quantities because they have the unique ability to bypass some of the security procedures that visitors and prisoners have to undergo and so, it seems, are able to go unnoticed. Recent seizures in prisons of up to 5kg of illegal substances 41 have been accredited by some to staff corruption, because packages of this size are highly unlikely to have arrived via any other method. Staff corruption may be motivated by personal gain or connected to wider organised crime groups.

Large numbers of visitors are turned away when “knocked” (where a sniffer dog has a suspicion). Anecdotally, it seems that many people are denied visits despite not being in possession of any controlled substances. Data is not collected in such a way to show the levels of this phenomenon. “Once an officer has been persuaded to bring in Despite extensive security measures, visitors any contraband once, he or she is vulnerable to who are in possession of drugs are particularly blackmail and may find it very difficult to stop difficult to detect, for three principle reasons. doing so.” 42 Firstly, internal concealment of drugs is very hard to tackle, given the legal and moral constraints A report released on 5th December 2016 on intimate searches; secondly, contact visits by Buzzfeed News reveals alleged wide make the passing of contraband relatively easy scale corruption in prisons.43 The number of to achieve; and thirdly, many of the security prison staff expelled or otherwise punished 39 measures are inconsistently enforced. In any for corruption has almost doubled in the last event, the substances causing the most harm in five years, according to figures obtained by our prisons are currently undetectable by sniffer BuzzFeed News under freedom of information dogs, even specially trained “Spice dogs” are laws.44 The Ministry of Justice refused to reveal only able to detect a few of the most common the number of security information reports two hundred-plus different SCRAs. alleging corruption, many of which are alleged to have been ignored. “One officer, who left the Thousands of prisoners arrive at prisons every prison last year, said: ‘Security staff are definitely day; either for the first time, on a transfer from not able to deal with SIRs that come in; they another prison, or from a court or hospital visit. are way too understaffed and overworked.’ He Those who have come straight from a court warned that officers ‘wouldn’t report things hearing will have known they may end up in prison; because it takes too much of your time and it is therefore common among these prisoners nothing would ever come of it anyway.’”45 to hide drugs about their person either to ensure their own supply, as mules for another supplier, “Adrian Lovell, who worked as a drugs prevention or a potential source of income inside the prison. officer at HMP Wandsworth until last year, said Prisoners have also been known to smuggle corrupt officers were responsible for bringing in as contraband when returning from activities much as 80% of the contraband found in prisons.” 46 performed on release on temporary licence. In 2009, the Ministry of Justice stated: “The unpalatable but inevitable conclusion is that corrupt staff constitutes a significant supply route for drugs into prisons.” 40

THE ONLY FORM O REGULATION WHIC OPERATES IN ILLIC MARKETS IS VIOLE AND COERCION.

OF CH CIT ENCE

A market with this scale of demand and potential profit cannot be eliminated through supply reduction methods alone. Applying too much pressure on supply routes increases the incentive to corrupt prison staff, which has a negative impact on the entire prison estate. “It would be astonishing if there was not a corruption problem in prisons. Have we not perfectly constructed an environment where corruption could only flourish? Corruption is crime and crime will proliferate where four things come together: opportunity, motive, gain and low risk of capture… This is not to say we cannot deal with it, minimise its effects, catch and convict the perpetrators and generally improve the safety and security which corruption destroys.” 47 Issues of the corrupting effect of the drug trade on the Prison Service have been raised previously. In 2005 a report by the Metropolitan Police and Prison Service Anti-Corruption Unit led by Lord Blair found that at least 1,000 prison staff were corrupt. 48 However, there has never been sufficient political will to effectively tackle the issue. Suspicions of corruption are now on the rise with an overburdened system that has little capacity for oversight of officers. It is hard not to see the likelihood of prison officers accepting bribes with minimal training, low pay, and an unstoppable drug market. There are instances of officers on only £17,187 per annum accepting £500 bribes to smuggling a mobile phone into a prison. 49 The Ministry of Justice are yet to set out any clear plans for improving the situation of corruption, although the new white paper states they are “developing a new strategy.” 50 Prisons can be busy places, with hundreds of different professionals coming and going during the day, including health professionals, cleaners, contractors and solicitors. As well as uniformed staff, these other visitors are vulnerable to duress or corruption, making the net of potential crime wider and harder to detect.

As towns and cities become ever-increasingly built up, prisons are now in closer proximity to other buildings within busy urban locations. This makes it easy for prisoners with contacts on the outside to throw packages over the wall to be retrieved by those inside. The understaffing problem has made this method easier still, as guards are unable to perform enough routine perimeter searches to secure the building. Traditional over the wall methods have had a modern revamp in recent years, with the advent of cheap drones, capable of flying material over prison walls. This has gained much media attention but there is, as yet, no evidence to suggest it is a major source of supply. 51 Post remains a main route of entry for illicit substances. Various NPS have been particularly insidious because they can be hidden in otherwise innocuous looking items, or sprayed onto paper such as a letter or a child’s drawing. Some prisons have gone to the lengths of re-writing letters for inmates, to ensure that the letter itself isn’t the contraband — a very time and resource intensive process for an already overstretched staff. Some drugs are already inside the prison. Many prisoners are either pressured or motivated into handing over their medications for use on the illicit market. “Drugs prescribed in tablet form and required to be taken under supervision can be stuck under the tongue, by the gum or on the roof of the mouth, to be scraped off later in the cell, or spat down prisoners’ jumpers or tracksuit bottoms for later retrieval.” 52 The supply of drugs into prisons lies in the hands of criminals and organised crime groups. The only form of regulation which operates in illicit markets is violence and coercion. The supply of drugs into prisons is a violent, pernicious business, and the majority of prisoners and ex-prisoners agree that it is the major cause of violence between prisoners. 53

Anecdotal evidence suggests that some prison drug markets have been so dominated by organised crime groups that they are the sole suppliers, while others have just a low level sharing and bartering economy. There are some prison markets, which seem to lie somewhere in between, with moderate involvement of organised crime groups, low level opportunistic vendors, as well as those using or sharing their own supplies. Payment for drugs can take the form of: bartering for canteen items such as tobacco and food; outside payments, with other people using intermediaries in the community; exchanging personal property; swapping drugs for other drugs; providing services (usually as a runner in the drug trade); and rarely — cash. The prison drug trade is now increasingly fuelled by the use of debt. Debts for drug transactions can lead to bullying wand controlling vulnerable inmates. The most vulnerable people, often those with severe mental health problems and no money, will suffer the highest rates of interest. Organised crime groups can tap into friends and family outside the prison as a guarantee for a prisoner’s loan. These pressures can lead to self-harm and suicide among the vulnerable. In extreme cases, prisoners’ families have been known to turn to prostitution to clear their debts. Other families have been blackmailed with footage of violence to their incarcerated family member taken on an illegal mobile phone. 54 Sources, who wish to remain anonymous, state that burglars with heroin problems are able to rack up enormous debts at low rates of interest because dealers are confident in their ability to repay the debts. These same burglars are then under intense pressure to reoffend within days of release to pay off the debts they accrued during their incarceration.

Chapter Four: The Response to Drug Use

“We are not dealing with the problem, it is getting worse and our strategy has failed.”55 The current strategy is about curtailing supply and reducing demand. Supply is dealt with principally through a combination of the criminal justice system and security measures. The demand is addressed by trying to get people not to take drugs through education, awareness, and treatment. The success or failure of these methods is primarily monitored by drug testing and records of drug-seizures. The theory seems rational, and is commonly supported, but the outcome in practice is very bad. “There are two major failings with policymakers — lack of imagination and failure of empathy.” 56 The Ministry of Justice response to NPS was initially paralysis, partly because MDT (mandatory drug testing), the metric designed to monitor drug problems in prison, couldn’t identify these new drugs. It was also clear that traditional supply reduction and punitive approaches were increasingly ineffective. Despite this, early announcements included redirecting testing regimes to NPS, revision of adjudication awards (more punishments), technological innovation in security paraphernalia, new search routines and new sniffer dogs. 57 Then, in November, the MoJ released a white paper on prison reform in which they call for a need to “fundamentally reassess our approach to drug demand and supply.” 58 It is stated that “while good progress has been made against the availability and harm done by ‘traditional drugs (including cannabis and opiates), as evidenced by steadily falling positive test results under mandatory drug testing since the mid-1990s, we have seen growth in the misuse of new, stronger and more harmful psychoactive substances over the past few years.” 59 .

In other words, the â&#x20AC;&#x2DC;progressâ&#x20AC;&#x2122; cited was not progress at all. As no serious, concerted, or systemic effort was made to reduce drug demand in prisons, all the efforts at supply disruption merely helped shift the market towards novel substances and the unpredictable and increased harms entailed in that transition.

The call to fundamentally reassess our approach But instead of offering this strategic approach, to drug demand and supply is very welcome, it states that: but there is as yet no sign that this is what is happening. The MoJ white paper contains no “To improve our response in the short term new approach, just the extension of the failed we will strengthen key existing measures to: policy of MDT, the introduction of more expensive Enhance our drug testing regime, supporting technology, and training sniffer dogs to detect a governors to enable drug testing on entry to few of these novel substances. and exit from prison as part of a more extensive testing programme, increasing the frequency and The MoJ white paper fails to provide a range of drugs tested for. This will better inform comprehensive drug strategy despite noting that: substance misuse treatment needs, making drug “In his July 2016 annual report, Peter Clarke treatment more effective. It will reduce the health [HM Chief Inspector of Prisons] notes that ‘… harms to prisoners and ensure better continuity the simple fact remains that there is, as yet, no of treatment on release into the community. overall national strategy for dealing with the It will also inform assessments of prisons’ problem’. We share his concern and recognise performance; introduce legislation to simplify 60 the need for a more strategic approach.” which psychoactive substances are covered by the existing testing process, allowing new tests to be introduced more swiftly as soon as we become aware of new psychoactive substances on the market. Legislative change will also add psychoactive substances to the list of items that are a criminal offence to smuggle into prison, which could mean a prison sentence of up to 10 years for those found guilty; ensure that the perimeters of prisons are secure and maintained in a state that can help deter items from being thrown into the prison; improve our searching capability with dedicated search teams that can be deployed to target specific problem areas including staff searching at unpredictable times;reduce the opportunity and attractiveness for visitors to smuggle drugs to prisoners; and continue to pursue and evaluate technology that can detect drugs including body scanners and drug trace detectors.” These short term measures are not strategically coherent, but we are assured that the government will “set out our full approach to addressing the problem of drugs in prisons over the coming months.” 61 This will sit within the overarching approach in the new crossGovernment Drug Strategy, due to be published by the Home Office in the coming months.

Supply Reduction

The general public assumption is that we can stop the supply of drugs into prisons with a sufficiently concerted effort. In response to this public perception, the default policy from governments from both ends of the political spectrum has been to present a “tougher response.” 62 This prevailing narrative assumes that we are not only capable of eliminating the supply of drugs, but also that this would be preferable. In reality, we can’t eliminate the flow of drugs, only disrupt it, and even if all contraband were stopped, there would still be a harmful illicit market for diverted medication. There is some benefit to reducing supply to reduce availability, but in order to ensure the costs associated with those policies are not greater than the benefits, these costs need to be better understood and an emphasis on disruption over elimination of supply is crucial to that. The long-standing emphasis on enhancing security measures to combat the drug trade in prisons has demonstrably failed. Drug use and drug-related harms are, by the most reliable measures, at all-time highs. The supply of drugs into prisons is as unstoppable as the global supply of drugs. Both have grown despite concerted supply reduction efforts. Mike Trace, CEO, RAPt — “You’ll catch more with better scanners but the impact will be temporary and negligible, it won’t affect the fundamentals of supply and demand.” 63 Heightened conventional security measures are the primary response to the supplyof drugs into prison. The way in which local enforcement is conducted makes a significant impact on 63

decisions as to how, rather than whether, drugs get into prisons. 64 As a result, the main effect of increased security is merely to change the routes used, as one route is disrupted or closed this increases pressure on other routes, known as the “balloon effect”. 65 “We have long witnessed ‘the balloon effect’ that, for example, saw the ‘crackdown’ on cocaine production in Bolivia more than compensated for by a rise in Colombian production, or similarly how the ‘crackdown’ on Iranian smuggling routes for Afghan opium has pushed trafficking to new routes through the former Soviet republics to the North.” 66 The knock-on effect of these security measures include markets switching to supplying more harmful drugs, increases in outbreaks of disorder, increasing prices, escalating debt, violence and intimidation, and upsets in the status quo, all of which leads to violence between inmates and staff. 67 Back in 2010, many of the possible consequences of increased security were well known, but very few foresaw how these consequences would interact with a rapid increase in chemical innovation. The result of this has been hundreds of novel psychoactive substances being brought to market.

Drug use and drug-related harms are, by the most reliable measures, at alltime highs. In the context of limited resources, it is important to ensure security measures are both effective and cost-effective. All security measures are limited by two main factors; limited resources and unintended costs, for example that certain increases in security impose limits on prisoner activity and interactions with family, treatment, education and training. We have no good data suggesting increased security spending reduces drug-related harms, but good evidence on the harms caused by attempts at supply reduction. More efforts need to be made to count the costs of these security measures and ensure they are cost-effective. Supply reduction methods can be very corrosive, affecting every aspect of prison life for visitors, staff and inmates. They affect how and when people can move around prison, limiting opportunities for education and training, and place a huge time and resource burden on staff. Changes to the physical environment, such as grating over windows to counter drones, can cost hundreds of thousands of pounds, only for people to damage grills in order to circumvent the security, the repairs of which puts pressure on maintenance teams and drains resources needed for essential facilities and to run the prison as a functioning rehabilitative environment.

It is clear that some drugs do get into prisons through visits. That said, there are human rights, logistical and resource barriers to eradicating this flow, and simple steps already taken are sufficient for keeping the passage of drugs at a trickle and not a flow. Arranging employment and accommodation for released prisoners has repeatedly been shown to be key in reducing inmates reoffending, and there is an inherent conflict between the need for control and the rehabilitative philosophy of maintaining family links. 68 “The prison officer has perhaps one of the most complex and demanding jobs in society. He or she has to balance the control and help function towards the inmates.” 69 Research has shown that prisoners who received visits from their family were twice as likely to gain employment on release and three times as likely to have accommodation arranged as those who did not receive any visits. 70 Overly intrusive security measures can be inhibitive to family visits. This inherent conflict can often be ignored in the heat of public clamour for increases in security and supply reduction methods.

The rhetoric in the MoJ white paper is about increasing security measures. Meanwhile, there is a retained commitment to making efficiencies due to reduced funding. Security measures are often expensive procedures that require skilled staff expending a lot of time and money. But as experienced staff leave and prisons are operated at increasingly low staffing levels, it becomes much more difficult to conduct cell searches, perimeter searches, and other security measures, leaving many prisons in no position to administer the proposed expansion of drug testing. In the absence of extra funding, improvements to security are intended to be made through technological advancements in security tools. This is exemplified by the MoJ white paper which proposes solutions to drug problems which are almost universally technical in nature, including the piloting of new body scanners ratcheting up of MDT, testing for “specified psychoactive substances” 71 with MDT, drug trace detectors, etc. There is no information provided on the costs of these measures, let alone the perceived cost-benefit. As well as taking up precious resources, the continued reliance on new detection technologies and sniffer dogs is likely to exacerbate the market shift towards the supply of drugs that can’t be detected by sniffer dogs. This will incentivise the supply to prisons of new chemicals with unknown dosage, risk-profiles and treatment options. Many of the proposed improvements in security seem to be an attempt to appease public perception rather than pragmatic pieces of policy. There is a public perception that the use of drones is a major cause of the increase in supply of contraband into prisons, although there is no data to back this up, and the public perception does not align with the anecdotal evidence from those closely involved with the Prison Service. Even the Ministry of Justice itself, who are keen to appear to be taking strong measures to tackle drones, say that: “The use of drones as a means of smuggling items into prisons is relatively

infrequent compared to throw overs or attempts by those entering prisons to hide items about their person. But the potential for drones to cause harm both to prisoners and staff is very real, and we are making sure we are working proactively to meet this threat.” 72 Behind the rhetoric of increased security is ‘tough’ legislation. Sentences of up to ten years can be handed down to those who are caught bringing prohibited drugs into prisons. These high sentences are intended to deter the supply of drugs into prison, and to incapacitate and punish those who aren’t deterred. Unfortunately, these lengthy sentences have done little, if anything, to stifle the market for drugs. John Shaw, Managing Director, Public Services, G4S — “Although [the Psychoactive Substances Act] is very welcome, I don’t think it’s going to make a jot of difference to us for the foreseeable future.” 73 Punitive legislation remains as central to the government’s prison drug policy as it was before the NPS crisis. More posturing on strength and toughness has ensued, without consideration of how it will affect the situation. These changes have been pushed through, despite the fact that Spice has always been illicit contraband in prison: “We have changed the law to strengthen our approach. We have made the possession of any psychoactive substance in any custodial institution a criminal offence under the Psychoactive Substances Act 2016.” 74 This approach is predicated on a flawed belief that we can legislate a trade with a huge demand out of existence. In reality, “the motivation and ability of prisoners and organised crime groups to use and traffic illegal drugs has outstripped our ability to prevent this trade.” 75 Nevertheless, the Ministry of Justice goes on to commit to the aim of “eradicating illicit drug use in prisons.” 76

The Psychoactive Substances Act 2016 (PSA), which banned the production and supply of all non-exempted psychoactive substances, was a major breakthrough in the sense that it did not make possession a crime for most people. It is the first piece of UK drug legislation since the Misuse of Drugs Act not to employ the tactic of criminalising users in an attempt to reduce supply. Long sentences for possession were a deliberate tactic employed at the start of the modern drug war in the 1970s, the hypothesis being that these draconian measures would deter users and reduce drug demand. It was a catastrophic failure. Drug markets continued to grow, and with them grew the incarcerated population and the burden on the state. Despite the clear failure of the policy, criminalisation of users became the norm. This had little if any effect on demand, created myriad health problems, and caused many other major problems in our prisons. The PSA, after much wrangling, now includes a provision criminalising possession of users in prisons. The inclusion of a crime of possession in a custodial setting punishable by up to two years in prison shows either a profound misunderstanding of the nature of the problem or a token gesture to public sentiment to the detriment of the reality in prisons. The rise of NPS has been a response to the punitive approach to drugs and a rising prison population, both of which, if there are sufficient resources to pursue convictions, will be fuelled by this measure.

And as if that wasn’t bad enough, the PSA now threatens new legislation to “add psychoactive substances to the list of items that are a criminal offence to smuggle into prison, which could mean a prison sentence of up to 10 years for those found guilty.” 77 We simply don’t have the capacity to be sending more and more people to prison for ludicrously long sentences, especially where there is no evidence or reason to believe this will alleviate the problem it purports to address.

“ Better to get cannabis on your canteen. No debt, no violence.” 78 At a recent Volteface event ex-governor Eoin McLennan-Murray made a call for a pilot prison in which we supply drugs to prisoners who need them, in order to remove the violence associated with the trade and monitor the outcomes. 79 There is an overwhelming feeling amongst many experts that so long as the market remains in the hands of criminals, we will never get on top of the problem. Restricting supply would still be part of drug strategy, but it would instead be restricted to ensure that supply is from someone with appropriate training, supplying regulated products with known risk profiles and controlled doses.

It is possible that the PSA could drive up the wholesale price of NPS and materially affect the risk reward calculation for supplying the drug into prisons, but there is no evidence this is happening. Due to the international scale of the market, and limited ability to intercept shipments of NPS owing to inadequate testing equipment, it is unlikely prices will be significantly driven up.

ASK PRISONERS W THEY TAKE DRUGS RESOUNDINGLY, T ANSWER IS BORE

WHY S AND THE EDOM

Demand Reduction

“Prosecution, additional days in prison, segregation, ‘closed visits’ and a range of other potential penalties, are all on the cards for those who flout the rules.” 80 The main response aimed at deterring drug use in prison is punishment, and the threat of punishment. Within this are tools such as testing and searching to create a fear of capture, in the hope that it will reduce people’s willingness to take drugs. This approach can only work if the risk of detection is real and immediate from the prisoner’s perspective — a situation that is far from the reality. It also fundamentally misunderstands the nature of drug dependence. More than half of all prisoners have a history of drug or alcohol dependence, and will therefore be determined to continue using inside, unless they engage in effective treatment. These individuals will not be deterred by the distant risk of detection. Ask prisoners why they take drugs and resoundingly, the answer is boredom, 81 yet our current drug strategy fails to address this. Ask addicts the key to recovery and the resounding response is connection and support, yet far too many of our addicted inmates spend their time in a dangerous environment with little opportunity for connection or support from fellow inmates or staff, or access to meaningful work, education, or other purposeful activities. “A political strategy reluctant to ‘pamper’ prisoners has misunderstood the value of creative and other constructive opportunities.” 82 The available evidence of different legal systems around the globe shows that there is no correlation between the level of punitive measures employed to tackle the drug trade and drugtaking decisions. 83 Research of this nature would be very valuable in reassessing the successes 69

and failures of prison drug policy in the UK. In the last six years, over 1,000,000 days, or nearly 3000 years of additional imprisonment has been imposed on prisoners found to have broken prison rules, despite no research proving its efficacy. The number of additional days handed out increased by 80 per cent from 14,741 in 2010/11 to 26,619 in 2016/17. 84 Andrew Neilson, Campaign Director of the Howard League: “Not all those days will be to do with drugs but a lot of them will be — either possession, failing mandatory drug tests or in some cases the violence and coercion associated with the market... Does any of this change prisoner behaviour? No. We are of course talking about people, many of whom, are inured to punishment.” 85 Well-intended or not, the penal system’s overreliance on punishment creates an environment where drug demand is bound to flourish. It feeds prison population growth and drains resources, leading to more and more prisoners spending longer periods inside prison with increasingly lower levels of purposeful activity. Naturally, punishment makes drug use in prisons clandestine. This, unintentionally, makes open discussion about drug use in prisons more difficult, creates a barrier to drug education within prisons, and stifles the peer-led cultural change that is repeatedly raised as an important part of prison reform. 86

As budgets have been cut and traditional enforcement methods have therefore become even less effective, an even more capricious system of punishment and enforcement has been created. Untrained wing staff are putting people on adjudications for the slightest unsubstantiated suspicion. This has a harmful and corrosive effect on prisoner-staff relations, which reduces effectiveness of intelligence-led security, and undermines the prison as a rehabilitative environment. David Cameron — “We’ve got to sort out mental health treatment and drug treatment. This is one area where I believe that we, as a country, really need to ask some searching questions. There’s been a failure of approach, and a failure of public policy.” 87 It is uncontroversial to say that provision of drug treatment can reduce rates of reoffending. There are, however, problems associated with provision of treatment. The most commonly prescribed drugs in prison (methadone, buprenorphine and benzodiazepines) are regularly diverted and popular on the illicit market. It is therefore important to ensure that the dispensing of the drug is organised in such a way that prisoners cannot keep their dose for diversion. These efforts can never be completely effective, but close supervision of prisoners and sensible dispensing practices to reduce visibility of those in receipt of buprenorphine can have a positive influence. The costs of these measures should be considered when deciding whether to adopt expensive security measures, or prioritise spending on treatment. “A good clinical detoxification regime is of paramount importance in tackling both supply and demand... It is essential that prisons provide adequate detoxification to reduce prisoners’ withdrawal symptoms and alleviate their need to import or purchase illegal drugs or other prisoners’ medication.” 88 The provision of treatment in prisons is inherently difficult. One of the biggest problems is that

the community isn’t set up to support honest peersupport and care, which are fundamentals of recovery: “[Prison’s] brutal reality is far more likely to be damaging and traumatic than healing and rehabilitative.” 89 The provision of drug treatment in prisons is complex and challenging, but the research is clear and uncontentious. Rates of re-offending and other adverse outcomes can be reduced by the provision of quality treatment. Inadequate detoxification and lack of aftercare can leave prisoners vulnerable to the illicit drug trade. Drug-free wings can offer opportunities and positive incentives to addicted-prisoners with a will to change. They provide a sensible riskmanagement approach, which recognises that drug use will continue in prisons, but those who have a willingness to change their habits should have access to an environment where temptations are reduced and positive mutual support is maximised. However, where drug free wings do not have sufficiently qualified staff or resources, opportunistic drug dealers can use the wing as a cover for dealing activity, ironically making drugs more available on drug-free wings than anywhere else in the prison. 90 Drug-free wings need more than just good staff and resources, they need prison culture which provides prisoners with addiction support well beyond the focus of drug treatment itself to address major long-standing areas of difficulty in prisoners’ lives. These wings offer enhanced privileges for those prisoners who commit to being drug-free. This is a rare example of incentivising prisoners to make positive changes to their lives, in a sea of punishment and retribution. The Incentives and Earned Privileges Scheme is frequently condemned by prisoners, who often believe there are no real incentives to try and achieve enhanced privileges.

Monitoring & Testing

“We don’t really know what drugs prisoners take: partly because we have never bothered to find out properly, and partly because prisoners themselves haven’t a clue what they are acquiring through an illicit drug market — a handful of pills wrapped in Clingfilm passed covertly around the wing does not come with an explanatory leaflet… Prisons don’t routinely test the chemical composition of what they find and hospitals tend not to carry out full toxicology reports on sick and violent prisoners. We simply have no real idea what prisoners are taking.” 91 The explosion in the levels of use of NPS took much of the media, academia and the political class by surprise. If we are to make long term improvements to drug policy we need better information at our disposal to spot trends and to be proactive in responding to them. “MDT is the prison service’s primary test of illicit drug use in prison. Eschewed by practitioners in the drugs field as a worthless and easily fiddled figure, the prison service clings to it like glue.” 92

Mandatory drug testing (MDT) involves the random testing of inmates’ urine for evidence of drug use. MDT serves at least two main functions; one is to reduce demand through the threat of sanctions for those caught using drugs, the other is to monitor drug use in prisons. It attempts two functions and achieves neither. Instead the system works to drive prisoners to evade punishment by using drugs, which either do not show up or are only traceable for very short periods, or by falsifying their urine samples. The first change was away from cannabis to heroin. Once the drug of choice in prisons, cannabis remains in people’s system for about 14 – 28 days, whereas heroin only stays for a day or two. The subsequent shift was away from any drugs that could be tested for, towards black market medicines and SCRAs sold as Spice. Previous studies have shown that an overwhelming majority of prisoners believe that the threat of punishment from a positive MDT would not deter them from using drugs. 93 In any event, due to the time and cost involved in the process this can’t be done frequently. During times of low resource, such as now, MDT is one of the first measures to be dropped, 94 making it not only an ineffective means of punishing prisoners for their drug, but also an unreliable and capricious one. As far back as 1996, long before the rise to prominence of NPS, MDT was described as “‘iniquitous’, ‘pointless’, ‘unethical, inefficient, illconceived’ and ‘a complete waste of time and money.’” 95 Yet it has survived decades of near unanimous opposition from experts in the field, and continues at a time where very few of the most popular substances can be tested for. MDT works on one level and one level only, allowing officials to say that drug use has not increased. Positive MDT tests have stuck around 7% over recent years and the steady decline since MDT’s inception in the mid-nineties is repeatedly trotted out by the National Offender Management Service (NOMS) and the MoJ as evidence of a successful drug policy, despite the explosion of drug use and drug related harms we have seen in prisons since 2012.

The MoJ plans to “enhance our drug testing regime, supporting governors to enable drug testing on entry to and exit from prison as part of a more extensive testing programme, increasing the frequency and range of drugs tested for. This will better inform substance misuse treatment needs, making drug treatment more effective. It will reduce the health harms to prisoners and ensure better continuity of treatment on release into the community. It will also inform assessments of prisons’ performance.” 96 Andrew Neilson, Director of Campaigns, The Howard League for Penal Reform — “It is disappointing that the Ministry of Justice seems set on expanding a testing regime that has already failed. Given overcrowding means prisoners are often moved around the estate, testing every prisoner on reception and on release could result in hundreds of thousands of additional tests each year. Even then it’s hard to see what meaningful information such testing would provide. This idea could be a monumental waste of money and staff resources at a time when both are in short supply. Perhaps for that reason the white paper is frustratingly unclear on precisely what the Ministry of Justice plans to do.” 97 The usual line is “NPS are a wide array of relatively new and regularly changing substances for which testing is in its infancy.” 98 Whilst true, this doesn’t go nearly far enough. The MoJ plan to address NPS revolves around the roll out of “new drug testing to track down dangerous psychoactive substances.” 99 New tests are portrayed as an important game changer: “the complex task of combating the widespread violence in the estate will gain extra traction when we have… rolled out new drug tests… until this year, there have been no effective tests available to establish whether prisoners have taken these drugs.” 100

“We want to reduce the level of drug use in prisons, so we will develop for future years a measure to track ‘distance travelled’ by an offender in substance misuse via drug testing on entry and exit.” 102 But rather than give a clear indication of distance travelled in prisoners’ drug use, it will instead give an indication of whether prisoners have used certain drugs at two relevantly arbitrary moments in time. “In the meantime, we will include as a measure the average rate of positive drug tests.” 103 This intermediate measure gives no valuable The Ministry of Justice also claim that these information on either the rate of drug use, or new tests will improve drug treatment outcomes. more importantly, on the extent and nature of Again, logic is absent from this statement. The drug-related harms. This bizarre attitude flies in proposed extension of mandatory drug testing the face of more sensible and pragmatic metrics will have no positive effect on drug treatment. for health success, such as the number of drugThose who seek treatment already declare related medical emergencies. drug problems upon arrival at prison to receive detoxification medication. Those undergoing One of the biggest problems with this policy is treatment already get voluntary drug testing and the lack of differentiation between prisoners who the proposals do nothing to protect prisoners or are on treatment programmes and trying to give ensure better continuity of treatment. up drugs, those who are taking drugs and will continue to do so, and those who have a vested Beyond the extension of MDT’s lack of interest in pushing drugs. Many of those who relevance to treatment, demand, and supply, fall into the third category are not drug users; there is an even more fundamental problem they do not use their product. One mistake is to with the proposed system — that it simply won’t think that by identifying users you will be able to work. The tests can only check for a finite list of reduce supply, suppliers and users are different substances. New tests for substances have to groups. There will be more punitive measures but be developed, and these can take considerably the people involved in the supply and distribution longer than the market takes to discover and won’t be affected by that. supply a new substance in response to tests being created for previous substances. Drug seizures could provide potentially valuable information on disrupting supply chains but the Focus on testing is apparently to help monitor way in which seizures are recorded only makes “progress in getting off drugs.” 101 Even if the mention of the type of drug seized. The weight tests worked as a means of monitoring progress of the seizure isn’t recorded, not even roughly, in getting people off drugs, which they will not, meaning a seizure could be a trace amount or a they could be counterproductive and increase kilo, there is no way to tell; nor is how the seizure the risk of death by overdose on release. The was obtained recorded. On 23 March 2010 focus should instead be on reducing drugquestions were asked in the House of Commons related harms. for clarification but no answer was forthcoming: There is repeated reference in the MoJ white paper to enhancing drug testing regimes as a means to reduce violence. As a means to reduce violence, more testing will do nothing, as tests do not reduce demand for drugs and do little to influence supply, apart from shifting the supply to drugs that are not currently tested for. As a means of performance measurement for prisons they would make sense, if they gave an accurate indication of whether people are abstaining from drugs in prison, but they do not.

“Philip Davie: To ask the Secretary of State for Justice how many and what proportion of illicit drug seizures within prisons was attributed to (a) sniffer dogs, (b) closed circuit television (c) strip searches, (d) intimate searches, € searches of prison cells and (f) police intelligence in each of the last five years? Maria Eagle: Information is not recorded in the format requested and would require requests for and detailed analysis of data returns from all prisons in England and Wales. To do so would incur disproportionate costs. Mr Vara: To ask the Secretary of State for Justice how many (a) visitors, (b) staff and (c) prisoners were caught attempting to smuggle illegal drugs into prison in England in each of the last five years; and what steps have been taken in respect of those caught? Maria Eagle: The data are not available in the form requested.” 104 Without this data, the wealth of reports calling for increased security measures of one type of another are simply not grounded in evidence and there remains no reason to suggest that these methods are effective in reducing the supply of drugs into prisons. It is perhaps unreasonable to expect officers to gather this data in challenging times of low resources, but it is even more unreasonable to continue to expend considerable resources (to the detriment of demand reduction measures and rehabilitation) on increasing the use of these measures, with no evidence that increased activity works to reduce drug supply or demand.

Prison as a Microcosm of Society

Prisons are a place where, in theory, the state has more control than anywhere else and yet the zero tolerance policy on drugs can be contrasted with the fact that nowhere are drugs more rife than in prisons.” 105 If we were able to stem the supply of drugs anywhere, you would think that maximum security prisons would be the place. High walls, razor wire, security gates, sniffer dogs and extensive CCTV have not worked. Prisons are the place in our society in which drug use is most rife and drugs are most readily available. As in wider society, failed and unimaginative policies with poor or no grounding in evidence have failed to reduce the harms associated with drugs and created myriad new problems. The same economic analysis applied to the failure of attempts to enforce supply controls on illicit drugs nationally and globally can be applied with even greater force to prisons: “Where there is demand for drugs, but no licit supply, a potentially huge profit opportunity is created for criminal profiteers... is that sort of profit that encourages the kind of entrepreneurial cunning that can get literally tonnes of drugs into high security prisons, year after year, crackdown after crackdown.” 106

Our prisons are to a large extent microcosms of broader society. Prisons are busy places often with large numbers of new prisoners entering the gates on a daily basis along with hundreds of visitors, officers, staff, volunteers, health workers and others coming and going on a daily basis. Security in such dynamic environments presents a serious challenge.

“Despite the billions hosed into supply side drug enforcement each year, the illicit trade thrives, drugs are more available and cheaper than ever and the violent gangsters selling them get richer and richer. Not only is the analysis of supply and demand in an unregulated illicit drug trade the same at prison, national and international level, so evidently are the responses: announce a big crackdown, unveil some new technology, produce a new strategy, create a new agency (or rename an old one), then announce your process successes to show you are ‘doing something’... Regardless of scale all such efforts that attempt to defy economic reality are equally futile.” 107 As with wider society, if prisoners are going to do drugs they are going to do drugs, but an acceptance of this does not mean the market will necessarily be whatever it will be. We can regulate the market to encourage low-risk forms of drug use and minimise harms. Attempts to eradicate the market lead to counter-effective shifts in the market, just as we saw with NPS, but there are alternatives. “I don’t think there will be any real progress until drug use in prisons and in the wider community is treated as primarily a medical and social challenge. I think prisoners who are motivated to detox need to be accommodated in drug free units and offered appropriate support but simply relying on prosecutions and external adjudication system, adding extra days is not going to work. The question is: what evidenced-based approach can we take to get to grips with it?” 108

Recommendations

“It is unlikely that the supply of drugs into l be cut off completely, especially given the drugs by both prisoners and visitors on rec as well as the importance of maintaining o all prisoners. However, this realism should pessimism; there is much that can be achi and treatment in order to continue to gain of drug supply and demand in prison.” 109 Risk Management not Zero Tolerance “This is not a marginal problem which if you tidy it up, we can solve, this is intrinsic to prison life.” 110 Zero tolerance originates from the idea that if you work to eliminate all crime, however petty, it becomes easier to maintain a crime-free area, however, nowhere could this be a less viable approach than in prisons. Prisons are naturally a hotbed of criminality. Prisons are full of drug users, people with mental health problems, and those with little to do to escape the horror of their situation than turn to drugs. This unrivalled demand creates economic incentives for suppliers too strong to be eradicated by heightened security measures, more or greater sanctions, or any other available supply reduction technique. A chasm exists between policy as it purports to be and how it is conducted in practice. We need pragmatic problem-solving, not a moralistic

approach. The lack of an intelligent approach to drugs in prisons undermines all the other proposed reforms — prisons will not be safe until we recognise drug use in prisons and try to manage it. The crisis in our prisons is not a tragedy because it is insoluble, we have solutions and people who are willing and able to put those solutions into effect, but they are stifled and obfuscated by counter-effective policies. The aim should be to reduce drug-related harm, not drug use per se. “There is this massive gap between rhetoric and reality. We need to narrow that gap.” 111 There is public rhetoric around zero tolerance, but in practice it is clear to many working in the Prison Service that this is practically unachievable and undesirable in principle. Ex-governors and officers frequently talk of tolerance towards the smoking of cannabis and

local prisons will ever internal concealment of ception and social visits, open contact visits for d not be confused with ieved in terms of security ground in the reduction

other forms of drug use. A pragmatic approach to focus resources on reducing the most harmful forms of drug use and the drug market should be commended, rather than being something confined to the shadows. Zero tolerance has failed and is not merely impractical, expensive or unfeasible, but also fundamentally misguided and counterproductive. Even the best managed and funded prison would still have prisoners with health problems requiring medication, people with drug addictions and other people who may, as in wider society, want to take a variety of different drugs for a wide array of different reasons.

When we focus on eradicating drug supply it necessitates creating a high-security, restrictive environment that dramatically increases the cost of engagement, and creates an environment that is totally alien to the outside world. It also directly negatively affects building and maintaining the relationships that are crucial to rehabilitation, increases costs, and drives up drug-related debt. As potential sanctions go up so must levels of violence (the market’s only regulation) to ensure compliance. As the main drug supply routes are narrowed, the value of a corrupted official to organised criminals rises.

There is a huge disparity in the levels of training, education and policy, which is to be expected where the best policy is in fact not to follow official policy but to use some common sense. This policy vacuum leads to a patchy approach. Because everybody says they have a zero tolerance approach to drugs, they can’t talk sensibly and openly about potential solutions and develop best practice which can be adopted nationwide.

Drug use always carries risks and potential harms and these risks need to be managed. Seeking to eradicate these risks creates perverse incentives, counter-effective policies and dangerous and unpredictable evolutions of the drug market.

Reducing drug-related harms makes prisons safer places in which rehabilitation is more effective. Helping addicted drug-users, who are willing to change, to turn their lives around is proven to reduce re-offending rates. It is integral we move policy towards integrating harmreduction and treatment into every aspect of prison management:

Prisons are not perfectly managed or funded. They house disproportionately high numbers of people in poor health, people with addictions and those with motivations to use drugs. Prohibition cannot work in prisons, but more than that, it is the most dangerous place in which to pursue absolute prohibition. Whilst wrongheaded drug policy created a small but significant market for NPS in broader society, in prisons where we can exercise more control and supply reduction measures are more keenly felt, it created the environment necessary for NPS to become the most widely used drugs, and a vicious industry built on unsustainable debt that further fuels criminality.

“This is not just about accepting the need for substance misuse services in prison, but about fully integrating it into the management of the prison at every level. In our experience this process works best where specialist drug recovery staff have a presence at all key functional meetings, some of which include Drug Strategy meetings, Safer Prisons, Equalities, Health and Safety, Security, Reducing Reoffending and management morning meetings. By integrating substance misuse staff in this way, joint working, communication and information sharing become a smoothly facilitated process. The result is that change happens.” 112

Despite public indignation at drug use in prisons, policy makers must resist overly simplistic socalled solutions. The issue must be tackled with long term evidenced-based policies. Proven, effective, pragmatic and simple harm-reduction measures, such as needle exchanges, are anathema to the zero tolerance approach. The zero tolerance attitude also stifles people from acquiring meaningful data and openly discussing issues.

Focus on Reducing Demand

“The only way to stop drugs coming into prison is for prisoners not to want them. Bringing that about would be true prison reform.” 113 There needs to be an acceptance that supply reduction measures are there to disrupt supply, they are not there to eradicate it. A shift of emphasis towards demand reduction is required to make prisons more effective places at tackling problem drug habits and rehabilitating offenders. “The reason people are using drugs is because they are banged up all day.” 114 There is a clear link between a lack of purposeful activity and the uptake of drug use. In Bedford Prison, the scene of riots in early November, purposeful activity levels have declined steeply over the last five years, and with that we have seen 14% of the population develop drug problem in prison, having not had one prior to their incarceration.115 In HMP Hindley, which was deemed to have one of the worst regimes seen by HM Inspectorate, “most prisoners often spent less than half an hour out of their cell in a 24-hour period” and 16% of prisoners developed a drug problem while in prison.116 Overall, 8% of men in prison in England and Wales report developing a drug problem since they had been in prison.117

spent out of their cells engaging in purposeful activity.” This is a very loose commitment to a fundamental metric. Abandoning wasteful and ineffective testing could provide the funding to move at pace with these important metrics. The long-held emphasis on supply reduction over demand reduction creates a number of unintended consequences including an increased burden on staff, logistical and management difficulties and associated difficulties in implementing new policies, supporting work, training, education and treatment schemes. These costs too often go on uncounted. As all forms of purposeful activity are reduced, as monetary and staff resources are focused on increasingly onerous security practices, the demand for drugs increases and those profiting from the market find innovative new ways to supply the market. “You can’t solve people’s problems by punishing them and that applies to people’s drug problems.” 120

As the rhetoric in the MoJ white paper notes “a transformation away from offender warehouses to disciplined and purposeful centres of reform where all prisoners get a second chance”118 is needed and we need to introduce “a new way of working in prisons to help prisoners spend more time on purposeful activity and less time in their cells.”119 However, the closest to anything more than rhetoric in the report is that “in future years, we intend to measure and publish the time prisoners spend out of their cells, including time

As well as focusing on reducing drug demand through the creation of busy prison routines, it is important to improve incentives for those who voluntarily stop using drugs. The removal of custodial sanctions for possession of drugs may be politically impossible at the moment in the context of the criminal justice approach in wider society. However, in the long term, the weight of evidence points to re-evaluating this. In the short term, it is entirely feasible to switch the prioritisation and focus of resources. “Banged up 23 hours a day in a large toilet with someone you have never met before — who wouldn’t want a mind-altering substance? Meaningful work, education and training with a purpose all help. So too do positive interactions with staff, and modern-day access to family and friends outside. All these tactics can aid treatment.” 121 We need also to provide those people who have a genuine desire to abstain from drugs with a positive incentive to do so. Better standards of living on drug free wings can do this. The problem is that drug free wings need to be well staffed so that staff can spot the drug dealers and the chancers who have ulterior motives. Building relationships with those in treatment is also essential for successful treatment. Without enough staff you can’t create an environment where people want to keep drugs out, you can only do so with sufficiently well-trained staff and resources.

“I think it might be an interesting experiment to see a correlation between NPS activity, time out of cell and purposeful activity… the way people are using these drugs is also part of a social and cultural norm when in prison, and it is part of an activity which is occupying time which can be, in some cases, displaced by more purposeful activity.” 122 As well as reducing demand by getting prisoners out of their cells, it is important to provide activities within cells. The MoJ white paper has missed an opportunity to put forward proposals such as fine cell work and internet-enabled study. Provision of computers in cells could be limited to restrict prisoners only to sites relevant to their study and provide meaningful activities to replace drug use. Demand reduction also needs to continue outside of prison. The three most important factors to prisoners’ perception of their own ability to not reoffend are housing, employment and drugs. 123 In the MoJ white paper the section on preparing for life after prison only mentions work, housing and education. We need more effort to ensure people have access to drug treatment and support in the community to help reduce reoffending rates.

Overhaul Monitoring of Drug Use

“Lessons should be learnt from the emergence of NPS at a national and local level to ensure that a dynamic, responsive and well-coordinated whole-system and whole-prison strategy is in place, both to reduce the harm of current use and respond effectively to future needs.” 124 An essential part of effective management is appropriate and reliable metrics for measuring success and failure. The MoJ’s recommendations to monitor prison’s drug policy outcomes via drug testing prisoners on arrival and exit from prison is unlikely to provide reliable or useful data. This should be replaced with a system, the sole function of which is to monitor the drug market and drugrelated harms and not to punish those who use drugs. The new metrics must focus on monitoring drug-related harms in prisons and the nature and scale of the drug market. MDT statistics are not reliable indicators of levels of supply and use of drugs in prisons. Regular anonymous audits of drug use and the drug market could provide valuable information on which to judge the successes and failures of local policies as prison governors gain increased autonomy under the current prison reform plans. Information should be drawn annually from treatment staff, prison officers, current and ex-prisoners. Evidenced-based Home Office research has called for similar surveys since 2005. 125 There is an understanding that this data is useful for safety yet it isn’t suggested for drugs. The MoJ white paper sensibly notes that prison safety and order are important and that there therefore needs to be a monitoring process — “We want to use the measure of the rate of assaults on prison staff and the rate of assaults on prisoners. This knowledge will also help us improve the stability and culture of our prisons and provide a safe working environment. To monitor the success of a prison’s strategy for dealing with vulnerable prisoners we will also include the rate of self-harm by prisoners in performance standards… We will supplement this through additional measures of staff and prisoner perceptions of safety measured through a structured survey to better understand the culture and atmosphere in our prisons.”

Understanding drug use and drug markets in prisons is an important aspect of understanding prison safety due to the complex interaction between the two. These proposed surveys must also address drug use because this is a key component in understanding prison culture, atmosphere and safety. It is essential for integrity that these measures are used strictly for evaluation purposes and not as a performance measure. Absolute confidentiality and discretion will be needed to ensure accurate reporting. In order to move from ideologically and anecdotally driven practice towards evidencedbased policies we need to improve the collation of relevant data. Substantial benefits could be made in shifting the focus from reducing drug use to reducing drug-related harms. A reduction in the level of incidents of violence, drug-related deaths, self-harm, voluntary segregations for protection and hospitalisations are good proxy indicators of the level of success of a prison’s drug policy. Viewing prison drug policy from the perspective of rates of positive drug test results ignores the levels of these harms and even if it were an accurate measure of rates of drug use, which it is not, it is not an accurate measure of successful harm reduction or risk management. Re-offending rates, levels of purposeful activity, levels of education, measures of the quality of life of prisoners and time out of cells may also provide useful information in assessing demand for drug use within prisons. Further research is needed in this field to understand the relationship between drug demand and use, and these other metrics. Much has been made by the MoJ of both the shift away from traditional drugs to novel psychoactive substances and of new tests and sniffer dogs which, it is claimed, will be able to detect these NPS. In reality, prisoners are themselves unaware of precisely which drugs they are selling and using. Prisons do not routinely test the chemical composition of what they find and

hospitals tend not to carry out full toxicology reports on sick and violent prisoners. Toxicology reports are done on prisoners who die in custody but this only gives a very partial view of which drugs are being used in prisons. New dogs have been trained and new tests devised to identify certain SCRAs, but at the moment we simply don’t know which drugs are in circulation. As noted previously, there are over 200 known SCRAs in European markets, and SCRAs only make up one type of an incredibly varied market of novel drugs. Despite legislative changes making the supply and distribution of these substances a criminal activity, these drugs are likely to remain attractive to both suppliers and users, as the vast majority of them are not able to be tested for or detected by sniffer dogs. Attempting to develop tests for all of them is not remotely feasible but monitoring which are in circulation is. Monitoring circulation means that if testing continues it can be targeted, as well as providing valuable information for the treatment of people who have ingested dangerous substances, and better information for staff to understand the nature of the drugs with which they are dealing. Drug testing has been blamed for incentivising users and suppliers to switch from cannabis to heroin and more recently to diverted medications and novel psychoactive substances. Where testing continues to be employed these unintended potential consequences ought to be recognised and reversed. We know that we can’t test for all drugs, so we should test for the most dangerous drugs most likely to cause the most harm in order to ensure that if testing does incentivise people to use and supply certain drugs which aren’t tested for, that those are also the lowest risk drugs.

Overhaul Monitoring of Drug Supply Current supply-reduction and security measures are not grounded in reliable evidence. New proposed measures focus on drones and visitors when there is insufficient evidence that these are the primary sources of supply. Anecdotal and historic evidence indicates that corrupt staff may be a major source of supply. Evidence gathering is needed on drug seizures to assist in determining the drugsâ&#x20AC;&#x2122; providence, as well as a new regional peripatetic task force within the Prison Service to oversee periodic spot checks and searches of staff.

The current approach in the white paper to propose measures tackling drug supply without a coherent strategy to combat corruption fails to recognise the balloon effect on supply routes and could have pernicious unintended consequences. A roaming task force focused on investigating potential corruption could provide an affordable alternative to the searching of all staff on entering prisons. Prisons are often highly dynamic environments so searching everybody is not always possible or preferable. There ought, however, to be a national strategy to provide some oversight of staff owing to their potential role in the supply of drugs into our prisons.

In order to best target limited resources to reduce the supply of drugs into prisons, it is imperative to understand which routes of supply are being favoured by suppliers. At the moment we simply donâ&#x20AC;&#x2122;t know what prisoners are using or how they are getting drugs into prisons. The data gathered in relation to drug seizures is very minimal. An understanding of the specific drug seized, its weight, and details about where and how it was found would help improve understanding of the market and provide valuable information in attempts to combat the market. Whilst more information is needed in this regard, it is important to caution that drug seizures are not a reliable metric for assessing drug policy success. Due to the nature of different regimes, the number and scale of drug seizures in a prison provides more of an operational measure than a reliable indicator of the scale of drug use in any given prison. However, the more information gathered about seizures, the better intelligence will be with which to combat the supply of drugs.

Improve Staff to Prisoner Ratio Through Reducing the Prison Population

Ministry of Justice — “Our analysis shows a statistical correlation between the numbers of staff and the level of violent incidents. We now need more frontline staff, and we need to change the way they work to better support offenders and respond to new threats as they arise.” 126 The MoJ white paper on prison reform acknowledges the importance of improving the relationship between officers and staff but makes no mention of plans to reduce prison numbers. Instead it sets out a plan to invest £1.3 billion in new facilities with an additional 10,000 prison places. 127 England and Wales already have a per capita prison population of 148 prisoners for every 100,000 people, the highest in Western Europe. Prison standards have dropped unacceptably. When prisons are understaffed and overcrowded we cannot ensure the safety of inmates and prison staff, which is a prerequisite to achieving rehabilitation. Prisoners must instead go into lockdown, which means that training, education and work cannot be undertaken. We cannot continue to cut funding whilst more people are sent to prison and for longer sentences. To do so will condemn our prisons to become warehouses, as seen in some parts of the USA. 128 These warehouses temporarily incapacitate inmates from some forms of crime whilst doing nothing to tackle the root causes of their criminality and feeding the growth of a harmful illicit trade in drugs and organised crime. It is clear that there needs to be either an increase in funding or a reduction in prison population to effectively handle the current crisis. Significant savings may be made through sensible policies and efficient management, but there is an immediate threat to the safety and security of our prison estate and more immediate measures are needed to alleviate overcrowding and improve the staff to prisoner ratio.

We also know that sending people to prison increases their chance of reoffending 129 so surely the better approach is to reduce prison numbers, however politically unpalatable that is. The alternatives are either to allow the crisis in prisons to escalate, or to substantially increase spending on prisons; both equally unpalatable and also likely to result in higher crime rates. There are a number of potential criminal justice reforms which cannot go without mention when discussing potential solutions to the problems faced by our Prison Service. Areas, which need immediate focus and public debate, include problem solving courts, liaison and diversion, sentencing reform, alternatives to local prisons for prisoners on remand, and alternatives to custodial sanctions. The Howard League for Penal Reform are currently calling for reductions in prison numbers by sensibly making more use of release on temporary license, changes to recall, and by making it easier to get parole. 130 There is also an opportunity to make some gains through sentencing reform of non-violent drug offences. Prisons are often environments which drive the demand for drugs. People receiving residential drug treatment are 43% less likely to reoffend on release than comparable people sent to prison. 131

14% of men and women in prison are serving sentences for drug offences. 132 With many problems driven by prison overpopulation, alternatives to custodial sanctions for those guilty of non-violent drug offences would be a sensible and pragmatic part of reducing the burden on the prison system. Understaffing has been particularly relevant to the increased harms associated with drugs in prisons over recent years. Low staffing

levels reduce prisons capacity to undertake an intelligence-led approach to security. The MoJ’s commitment to the fact that in order “to improve prison safety we need a fundamental shift in the way in which prison staff support and interact with prisoners” 133 is something the government simply cannot afford if it continues to avoid the issue of reducing the prison population, instead aiming to increase the prison estate’s capacity by 10,000. 134 In Norway, there has been success in reducing drug-related harms and controlling and restricting the prison drug market in large part due to both their high staff to prisoner ratio and the extensive training in intelligence-led/ dynamic security. This policy of officers engaging with prisoners in order to spot those with drug problems, those involved in criminal activities within prison and those vulnerable to either selfharm or exploitation, could not be much further from the current practices in UK prisons. It is this sort of security, not technological advancements that presents the best opportunity to reduce drug-related harms in prisons. One of the most crucial benefits is that it seems to encourage a sharing economy by limiting the opportunity for drug dealers to establish themselves. 135 It has the corollary benefit of being likely to assist with both rehabilitation and drug treatment through better relationship forming and support. The Ministry of Justice has committed to improving the capability of staff. Unfortunately, it doesn’t include any increase in the basic training of officers, or an increase in the base rate of pay. In order to have staff performing a complex, sophisticated, multi-faceted role, pay will need to be increased to attract sufficient talent for the roles. More will also need to be done to retain experienced staff, who for the 12 months ending September 2016, left the profession at a higher rate than new staff were recruited. 136

BLACK SHEEP AN INVESTIGATI EXISTING SUPP PROBLEMATIC C PROBLEMATIC C PROBLEMATIC C PROBLEMATIC C Lizzie McCulloch

ION INTO PORT FOR CANNABIS USE CANNABIS USE CANNABIS USE CANNABIS USE 88

Statistical Snapshot • I t has been estimated that 2.6% of the adult population (aged 16 or over) showed signs of cannabis dependence, which is up to 1,150,000 people, though it is expected that the actual number of people who meet the threshold for clinical dependence will be far lower. • 2 1% of adults going through treatment are citing cannabis as a problematic substance. • 7 9.7% of adults listing cannabis as a problematic substance are entering treatment voluntarily. • N ew presentations among adults for cannabis treatment increased by 55.2% between 2005 to 2014. • A mong adult non-opiate clients accessing treatment, cannabis users were the most likely to have unchanged use at the six-month review, which equates to 42% of those who entered treatment. • A mong people showing signs of cannabis dependence, only 14.6% had ever received treatment, help or support specifically because of their drug use, and 5.5% had received this in the past six months.

Executive Summary Cannabis is a neglected drug in public health discourses, a reality which is at odds with the growing number of people in England who are now seeking support for problematic cannabis use. The disparity of how cannabis is prioritised by drug and alcohol service providers, wider community services, local authority commissioners and public health bodies has limited the amount of support available and impeded quality • Among people experiencing problematic cannabis use, there is a perception that their needs will not be effectively met at treatment centres. • Some drug and alcohol service providers and commissioners are being attentive to cannabis but overall, cannabis has not been appropriately prioritised.

• Research into the social costs of problematic cannabis use by Public Health England would provide justification for commissioners to appropriately prioritise cannabis within treatment. Commissioner specification of cannabis would incentivise providers to utilise existing resources and supply innovations targeted towards people experiencing problematic cannabis use.

• One to one interventions relating to cannabis are mostly confined to drug and alcohol treatment centres. Wider community services reported that they do not have the capacity or the ability to offer brief, initial interventions.

• A shift towards holistic service provision and promotion by drug and alcohol service providers and wider community services, would aim to increase interaction and engagement with support.

• There are limited amounts of public resources available, some of which are lacking in levels of quality and accessibility.

• A move towards a regulated marketwould offer a targeted dialogue with people experiencing problematic cannabis use, providing opportunities for harm reduction advice to be delivered at point of purchase and persons in need of support relating to their cannabis use to be linked into reformed public health measures. There would also be the emergence of wider opportunities for more public guidance, packaging controls, products which vary in potency, research into cannabis culture and consumption to improve interventions,and reduced stigma to enable access to services.

A wider structural barrier is that the sector does not have a clear strategy for linking people experiencing problematic cannabis use into support and guidance. With the current illegal and unregulated market reducing the visibility of cannabis use, practitioners reported that ‘we’re just fumbling around in the dark trying to find them’. Responsibility for change does not just fall to drug and alcohol service providers, and a unified, multi-faceted approach is needed. Evidence of good practice within the sector and contributions from stakeholders and experts has been used to formulate sensible, innovative policy options tailored to the needs of people experiencing problematic cannabis use.

Effective support requires public health measures which appropriately prioritise the needs of people experiencing problematic cannabis use and a regulated market which targets these measures to their intended audience. 90

Chapter One: Background It should be emphasised that cannabis is not as dangerous as many other drugs, 1 with treatment centres historically focusing on opiates and crack cocaine which have higher associated harms. 2 As with many other substances with a potential for dependence and misuse, most people do not develop a problematic relationship with their cannabis use, 3 but for a proportion of people, usage can become problematic and may stop them from living meaningful and fulfilling lives. It is these people who are the focus of this report. 4

Scale The most recent Adult Psychiatric Morbidity Survey has estimated that 2.6% of the adult population (aged 16 or over) showed signs of cannabis dependence, 5 which is estimated to be up to 1,150,000 people. 6 Caution should be taken with this figure, however, as the Adult Psychiatric Morbidity Survey defines signs of dependence as responding positively to any one of the five criteria for dependence it lists. It should be noted that responding to three or more of these criteria is closer to the threshold for drug dependence defined in ICD-10. Volteface have issued a Freedom of Information request to establish the figure corresponding to this tighter definition of dependence from the Adult Psychiatric Morbidity Survey, which is expected to be substantially lower than the survey’s definition for signs of dependence. The 2015 England and Wales Crime Survey estimates 3.7% of 16–59 year olds in England and Wales are frequent cannabis users, which corresponds to 800,000 people, and only a subset of these will fit ICD-10 criteria for cannabis dependence. 7 91

This is at least an indication of the smaller number of people likely to fit a tighter definition of cannabis dependence Explaining Problematic Cannabis Use The International Statistical Classification of Diseases and Related Health Problems provide widely used clinical definitions of cannabis use disorders and cannabis withdrawal which have been integrated into the diagnostic criteria for substance misuse (DSM-5). 8 However, problematic cannabis use can be more widely defined as ‘use leading to negative consequences on a social or health level, both for the individual user and for the larger community’, 9 with various other concepts encompassed within it such as misuse, abuse, and dependence. 10

Winstock et al.’s guide 11 on the assessment and management of problematic cannabis use in primary care highlights that the patient, will likely be a long term, heavy daily user, who may experience: • ‘ Respiratory problems, such as exacerbation of asthma, chronic obstructive airways disease, wheeze or prolonged cough, or other chest symptoms • M ental health symptoms, such as anxiety, depression, paranoia, panic, depersonalisation, exacerbation of an underlying mental health condition • P roblems with concentration while studying or with employment and relationships

The are also wider social difficulties associated with problematic cannabis use, with international evidence cautiously indicating that people who are dependent on cannabis are also at greater risk of downward social mobility and financial difficulties when compared to those who use cannabis but are not dependent. The NZ Dunedin Longitudinal Study 16 studied participants from birth to age 38 and found that those with regular cannabis use and persistent dependence experienced downward socioeconomic mobility, more financial difficulties, workplace problems, and relationship conflict in early midlife. It should be noted that this finding was modelled on a small sub-sample as only 23 participants were assessed as being dependent at all study waves.

• Difficulties stopping cannabis use • Legal or employment problems (arising from use of cannabis)’ The exacerbation of schizophrenia), 12 has been the most widely reported adverse effect of cannabis but less attention has been paid to the less severe mental health problems associated with problematic cannabis use, such as anxiety and depression, which are far more common. 13 Taylor et al have also concluded that after controlling for tobacco, ‘significant respiratory symptoms and changes in spirometry occur in cannabis-dependent individuals at age 21 years, even though the cannabis smoking history is of relatively short duration’. 14 The physical health impacts then become more pronounced when considering that the majority of cannabis users consume cannabis with tobacco. 15

Chris’s Story “For me drugs are all about how a person is brought up. Growing up my parents didn’t set boundaries and they didn’t educate me to build resilience needed for adulthood. So, like many other of my mates I got drunk for the first time when I was 12, and smoked cannabis at the age of 13”.

“I was smoking cannabis during my time at the navy as there was plenty of trips ashore where you would be able to smoke, but it was just recreational. It wasn’t really till I left the navy that I became a habitual smoker but I would never have considered it a problem, it was just part of the smoking culture. “But it was having a problem on my life. I was smoking and inhaling for longer so in terms of my health it was having an effect and I knew the quantities I was using wasn’t good. “I was using cannabis to calm down the other drugs I was taking and I was blocking out the negative consequences of those drugs. It became a substance within all those other substances I had to deal with. “Your life revolves around getting up in the morning and playing cards and having a big spliff with your flatmate. There are other people that can wake up in the morning and take a spliff, but that didn’t work for me. All drug taking has risk and cannabis is no different.”

I became a habitual smoker but I would never have considered it a problem. I became a habitual smoker but I would never have considered it a problem. I became a habitual smoker but I would never have considered it a problem. I became a habitual smoker but I would never have considered it a problem. I became a habitual smoker but I would never have considered it a problem. 94

Rising Demand for Treatment Between 2005–2014, new treatment presentations where cannabis was the primary drug of use have increased by 55.2% (see Figure 1.1). 17

Figure 1.1 New cannabis treatment presentations in England from 2005 to 2014.

There has been no clear agreement on why cannabis referrals have increased in recent years, and though many reasons have been espoused, none have been fully substantiated. Firstly, there is the ‘build it and they shall come’ explanation, with the argument that additional funding given under the Blair government and a declining number of opiate users in treatment has allowed services to accept more referrals for people experiencing problematic cannabis use. However, though there was substantial funding given during the Blair government, the rise in referrals continued despite subsequent reductions in funding for cannabis related treatment. Moreover, even though there are fewer opiate users entering treatment, the aging heroin cohort have higher levels of complexities and require more resource and innovation from services to engage in treatment. 18 The second commonly cited argument is that high potency cannabis use is associated with increased incidences of harm, 19 with a correlation emerging between prevalence of high potency cannabis and numbers in treatment, as illustrated by Figure 1.2. 20 However, this evidence is not conclusive as there have only been three recorded data points on cannabis potency, 21 and criticisms have been made of the data collection practices. 22

Figure 1.2 Prevalence of high potency cannabis and number of adults in cannabis treatment over time.

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Referral Routes What is known is that the 79.7% of adults listing cannabis as a problematic substance are entering treatment voluntarily. An FOI request showed that among the clients who cited cannabis as a problematic substance, the majority of referrals came from the client, family and friends,â&#x20AC;&#x2030;23 with recently released statistics from the National Drug Treatment Monitoring System also confirming that non-opiate users were most likely to enter treatment voluntarily.â&#x20AC;&#x2030;24 It is worth considering that the proportion of self referrals may be overestimated, as contributors reported that some clients may have been told by probation that they must seek treatment or other action would be taken. However, it was also noted that this example would only reflect a very small number of cases and it was rare for services to receive a referral for non-problematic use. Furthermore, a combined referral source of self, family, and friends does leave unanswered the question of whether significant numbers of clients are coerced by family or friends. While it is possible that some clients are being pressured into treatment, the client group are adults who are ultimately free to make their own decisions. Moreover, even if a person were coerced into treatment, this does not mean that there is no problem, nor that meaningful work cannot take place. Proportion of Client Group Though the increase in clients citing cannabis as a problematic substance is worthy of further investigation, the data which is perhaps of most interest is simply the proportion of people who 97

are citing cannabis as a problematic substance in treatment centres. NDTMS data shows that cannabis accounts for 21% of all problematic substances cited in treatment centres.â&#x20AC;&#x2030;25 Contributors highlighted that many clients will be citing other substances such as alcohol, opiates, or crack cocaine, and their cannabis use (even though deemed problematic) might be incidental to them being in treatment. Even though cannabis may not be the primary need for many clients, it is being cited as a problematic substance by a significant proportion of clients and should not be disregarded even if it is a secondary need. Methodology Volteface undertook unstructured interviews with a broad range of stakeholders and experts to better understand the public health response these trends. Interviewees were asked how current public health measures were engaging people experiencing problem cannabis use and whether the measures were addressing the full spectrum of need. This paper reports on the key themes emerging from these discussions and consultations. Interviewees were selected through Voltefaceâ&#x20AC;&#x2122;s network of contacts, including stakeholders who were not engaged with drug policy reform. A limitation to the research is that drug and alcohol service providers are operating in a competitive market and may have been reluctant to disclose information which could be viewed negatively by their commissioners or risk their reputation. To encourage interviewees to speak candidly, contributions have not been attributed to individual persons. Providers who offered

specific examples of good practice have been named to enable information sharing within the sector. After conducting an initial consultation with professionals and identifying key themes, a public survey of open questions was launched, asking people who had experienced a problematic relationship with cannabis, for their opinion on the validity of these findings. The survey received 41 responses.â&#x20AC;&#x2030;26 Drawing from these consultations and wider literature, this paper will examine the public health response to cannabis and identify the barriers and opportunities for effective support. Stakeholders who we believe will find this report useful include drug and alcohol service providers, commissioners, GPs, Public Health England, the Home Office, the Department of Health and the ACMD, with different sections of the report relevant for different audiences. The conclusions of this report are not intended as guidelines for clinicians but rather aim to highlight policies which would improve the public health response to problematic cannabis use. Though wider structural problems, such as cuts to service provision, do impede effective support, only findings which specifically relate to cannabis will be included in the paper. The first section will address how well the current system engages and supports adults experiencing problematic cannabis use, whilst the second section will make practical policy recommendations. 98

Chapter Two: Existing Public Health Measures The relevant public health measures which emerged in the context of problematic cannabis use, were non-residential treatment centres offering formal support in the community, brief or informal interventions and publicly available resources to be used independently. Different levels of intensity of support are useful as they allow people to engage with the support and guidance which is appropriate to their level of need. Whilst some people may reach their goals relatively independently, others may require more support. The three forms of support will be examined below to assess how effectively they are engaging and supporting people experiencing problematic cannabis use.

Problematic cannabis use in primary care highlights that the patient will likely be a long term, heavy daily user, who may experience:

Difficulties Difficulties Difficulties Difficulties Difficulties

stopping stopping stopping stopping stopping

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use use use use use

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use use use use use use use use use use use 100

Treatment Centres Treatment centres are the most common way in which people access some form of formal support for their problematic use. However, there is a tendency for cannabis to be given a low priority by providers and commissioners. Among people experiencing problematic cannabis use, there is a perception that their needs will not be effectively supported at treatment centres.

Clients An overarching theme emerging from an open survey conducted for this report was that people experiencing problematic cannabis use or who had experienced it in the past, are unlikely to perceive treatment centres as somewhere they would go to for help. Any respondents who had not attended a treatment centre for support were asked how they would feel about attending. The responses revealed there was stigma against heroin users with respondents saying that they would be reluctant to enter a service that is associated with heroin users. “I wouldn’t [go] as these centres are associated with heroin addicts.” Treatment centres highlighted examples of clients presenting to treatment for cannabis related support, fearing intimidation from other service users or using derogatory language about other service users. One contributor commented that ‘cannabis users don’t want to mix with users of “harder drugs” as they have preconceived ideas of what kind of people they are’. Another contributor reported that cannabis users have said they ‘don’t want to 101

sit with a bunch of junkies’ and people entering treatment for cannabis would prefer to access a centre which exclusively offers a service to cannabis users. There was secondly the concern among people that there would be a stigma attached to them if they were to attend a treatment centre. Though there is evidence that cannabis has become normalized in certain sections of society, 27 one respondent highlighted that, ‘it’s still a taboo to be a ‘pothead’ and is still looked at as the dregs of society are the users of this evil.’ Respondents have cited concerns that there would be a record they have used a controlled substance and the adverse impact this could have on their future prospects. A third barrier to entering treatment was people’s own perception that their cannabis use wasn’t sufficiently problematic to warrant formal support. One respondent replied that if it was suggested that they attend a treatment centre, that ‘even if maybe I did [need it]. I would feel it’s probably a little extreme.’ These findings highlight the perception that the treatment centre model exclusively offers support to users with high complex needs, despite contributors highlighting examples of inclusive services not targeted towards opiate users.

These perceptions that treatment would be an inappropriate place for people experiencing problematic cannabis use coincided with a belief that austerity had reduced the effectiveness of service delivery or that service delivery was generally poor. A recent review of drug and alcohol commissioning has cited increasing concern over the sustainability of drug and alcohol services with commissioners facing uncertainty over resources and reporting concerns about the unstable political environment and how this may potentially impact on services. 28 “Utterly opposed [to treatment] given that I know how poor drug treatment is.” These responses highlight that the image of treatment centres could do more to appeal and engage people experiencing problematic cannabis use. Commissioners Despite rising numbers in treatment, Local Authorities are inconsistently prioritising problematic cannabis use among adults. A review of 12 current LA Drug and Alcohol strategies from across England found that only two Local Authorities raised cannabis as a substance which the borough should address among adults. 29 Contributors suggested that commissioners are not prioritising cannabis as it is not clear to them how problematic use has an impact on the wider community in terms of cost. Justifying an investment in an intervention requires the case to be made for how it will save costs for other local services. This lack of awareness can be attributed to the lack of guidance that is offered to commissioners, indeed Public Health England neglected to mention cannabis in its document entitled Alcohol and drugs preventions treatment and recovery: why invest?. 30 This omission is in opposition to an ACMD report reiterating that cannabis has ‘unquantified, but real, economic costs to society’. 31

As drug and alcohol service providers are operating in a competitive market, there is little incentive for them to be attentive to problematic cannabis use and invest in interventions, particularly in the face of shrinking budgets, if there is no stipulation from commissioners for them to do so. This neglect of cannabis is at odds with the attention commissioners are paying to smoking cessation in treatment centres, in response to research highlighting that smoking rates are far higher among people who require support with their substance use in comparison to the wider population. 32 This move reflects a broader trend, with NICE guidelines advising services to identify people who smoke, offer and arrange support, and implement a comprehensive smoke-free policy. 33 Public Health England have requested that services begin collecting data on smoking. It is reasonable for commissioners to pay greater attention to tobacco as smoking is highly prevalent among drug and alcohol users. 34 However, it is inconsistent for commissioners to only be attentive to tobacco, when cannabis is most commonly consumed with tobacco, 35 making the two substances inherently interlinked in a treatment context. “The only way I could stop smoking cannabis was to stop smoking cigarettes.” Put plainly, if a person is being encouraged to cease smoking, they should also be encouraged to cease using cannabis.

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Treatment Practitioners For the people who enter treatment for problems relating to cannabis, it was highlighted that some practitioners working in adult services will consider cannabis to be a low priority. The neglected state of cannabis has been observed both within and outside of England, 36 with contributors suggesting it was typically older practitioners, who had become accustomed to working with opiate or crack cocaine users, who were less likely to acknowledge cannabis as a problematic drug.

“There is a real variety of perceptions and knowledge around cannabis which can be dependent on age. Workers who have been around cannabis are more clued up.” “Staff attitudes don’t help, they see it as ‘just a joint’.”

Despite an ambivalence about problematic cannabis use, which is still prevalent in treatment centres, provider and non-provider sources have noted that in the past 2–3 years, high THC and low CBD strains of cannabis have changed practitioner perspectives and the nature of conversations they are having with their clients.

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“Cannabis was previously seen as bottom priority but unpleasant new versions have changed the dialogue around cannabis.”

Moreover, one practitioner commented that due to the rise in referrals, there is a greater expectation that problematic cannabis users will enter the service. Out of the four survey respondents who indicated that they had attended a treatment centre, three highlighted that their key worker did recognise that cannabis had become a problem in their life and offered them support which met their needs. The remaining respondent felt that practitioners ‘do not have the experience necessary to empathise with someone who uses a substance as a crutch’. Though these responses highlight some good practice being undertaken in treatment, the response rate is not a representative sample.

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Cannabis users are the most likely to have ‘unchanged’ consumption at the 6 month review and are one of the groups who are most likely to deteriorate. Cannabis users are the most likely to have ‘unchanged’ consumption at the 6 month review and are one of the groups who are most likely to deteriorate. Cannabis users are the most likely to have ‘unchanged’ consumption at the 6 month review and are one of the groups who are most likely to deteriorate.

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Outcomes When analysing outcomes data for people entering treatment, outcomes for people experiencing problematic cannabis use are relatively poor in comparison to other substances. Cannabis users are most likely to fall into the non-opiate client group and within this category, cannabis users are the most likely to have ‘unchanged’ consumption at the 6 month review and are one of the groups who are most likely to deteriorate. They are also one of the groups who are the least likely to be abstinent at the end of their 6 month review, although not reaching abstinence should not automatically be seen as a benchmark of failure. By contrast,within the non-opiate category, cannabis users are the group who are most likely to show some level of improvement once hitting the 6 month mark. The largest reduction of an average day’s use was observed for cannabis, though the proportion of days reduced actually showed the smallest drop. Among users of other substances, average days of use drops by more than half, whereas for cannabis users, average days of use drops by less than half. The picture is mixed, and while there is clearly good work being undertaken in treatment, the figures do also show that more could be done to support people with their cannabis consumption. 37

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Brief Interventions For people who do not engage with formal treatment or feel they do not require formalised treatment, there is an absence of informal, brief interventions for them to turn to.

Contributors also highlighted that GPs have not been given enough training to confidently support a person who is using cannabis problematically.

Informal, brief interventions would most typically occur in a primary care setting, yet contributors have reported that in response to efficiencies, GPs do not have the time to offer these interventions in-house, with a recent BMA survey finding that 57% of GPs find their workload unmanageable. 38

“GPs should have the knowledge to respond to problematic cannabis use and not just refer to a treatment center.”

“GPs not spending enough time with patients- it doesn’t take 8 mins to understand a complex cannabis problem but they are swamped under pressure and don’t have the time.”

This is particularly problematic for medical cannabis users who use cannabis therapeutically and who are seeking guidance from their GP on how to manage their unwanted symptoms of cannabis consumption or how to consume cannabis most safely. Medical cannabis users have reported that managing their medical cannabis use has been an individual experience of trial and error.

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Figure 1.3 Outcome data from Public Health England, 2016 107

Jacob’s Story “The first time I had a hint of using cannabis as a medicine was in the hospital from the surgeon who performed on me. When he described to me that I would be facing a bit of discomfort in the future, he did the whole smoking gesture, and said if I ever feel a bit uncomfortable, just have a smoke. I thought he meant cigarettes, which didn’t make any sense to me; obviously a couple of years later it did make sense.” I see cannabis as useful, as it is able to replace a lot of drugs which have bad effects on patients that take them, like opiates, but I need some support on taking it and how to control the negative side effects that it will, and does, bring. I get anxious, and obviously you lose your short term memory. You can do things to try and make that better, but it does affect your metabolism and it does affect your personality to a certain extent.

due to the perception that they do not have the capability to offer support relating to cannabis. This is unfortunate when considering there is evidence that brief interventions influence a recipient’s likelihood of reporting abstinence, fewer cannabis related problems, and less concern about their cannabis use.

“GP wise, no one’s offered me support, they don’t know what they’re talking about and I’ve never met one that does. I’ve had to teach all my GPs everything they know about cannabis and most of them pushed me onto another doctor.” The situation is similar in non-substance community services, where understanding of how to support a person with their cannabis consumption is still specialised to treatment centres. As problematic cannabis use can encompass and be a symptom of a wide range of needs, the person may already be seeing a professional at a Job Centre Plus, accessing a mental health service or other community service. Yet contributors have reported that wider services are mostly not offering brief interventions,

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Publicly Available Resources Information and Self-Help Resources There are limited amounts of public resources available for people experiencing problematic cannabis use, with mixed levels of quality and accessibility. There are no leaflets which GP’s can offer patients experiencing a problematic relationship with cannabis, though there are NHS webpages on cannabis. 40 It was reported that Talk To Frank is one of the sites GP’s will signpost their patients to, yet the site was criticised by both practitioners and survey respondents for being filled with misinformation and lacking harm reduction advice.

“The public information cannot be trusted, ask Frank is obvious propaganda.” “Guidance would be helpful, i.e. not getting misinformation (Frank) and getting a positive balanced view from PHE / Govt sites.”

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“We stopped signposting due to the lack of harm reduction and some misinformation we have found over the years. There has also been a lack of updates, materials and joined up work with policy, health, and other services to promote or produce relevant and up to date information. We’d say that it is okay to have a quick look and reference but to always seek a second and third opinion, and if possible talk to an expert about the specific issue or scenario that is in question.”

However, other contributors highlighted that there had been significant improvements to the website in the past few years, with more harm reduction information being offered.

“I know they’re useful [digital interventions] but I prefer to use paper.” “I don’t use digital interventions, I’m not aware of them.”

Digital interventions and resources, such as Breaking Free Online, are being used by practitioners, yet contributors have reported that take up has been relatively low among practitioners despite a rise in new sites and recognition that digital interventions are a potentially effective and underutilised resource. 41 New or alternative media forms also have potential to be useful resources, examples including podcasts such as Say Why To Drugs 42 and web applications such as The Drugs Meter 43 and Safer Use Limits. 44 Such resources could be more widely utilised, although it should be noted that these resources have not yet been independently evaluated for their efficacy, and so their utility is currently unknown.

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“I generally find online forums to be the best way of delivering information as you can get feedback from other people.”

Forums A second site that GP’s can refer their patients to is a UK based forum entitled ‘Marijuana Anonymous’. This is a twelve step programme which offers users the opportunity to ‘share your experience, strength and hope or ask questions about the 12 Steps’, with meeting times and public information also publicised. Online forums are useful as they can act as platforms for peer support, which can offer knowledge, social interaction, emotional assistance and practical help 45 for users, families and friends; while restricting incorrect or offensive information. Fitzrovia Youth in Action, a youth action charity, which offers drug and alcohol programmes, recommended peer support as a highly effective intervention for engaging people in support and guidance.

As these forums were driven by people with lived experience, respondents explained that the forums were able to offer balanced guidance relating to cannabis. Research also indicates that anonymised user forums and online chat rooms ‘encourage and facilitate information sharing about drug purchases and drug effects, representing a novel form of harm reduction for drug users’. 46 However, there is also an issue of access as knowledge of these forums are confined to the online cannabis community, which limits the reach of any useful information and guidance. Moreover, as the information is unregulated, respondents have acknowledged that the quality of the information can be inconsistent, with practitioners reporting that their clients had been misled by information posted on online forums or other unregulated websites, also making them inadvisable sources of information for professionals.

A criticism of the website is that a requirement for membership is the desire to stop using cannabis, which excludes any person who is looking to reduce their cannabis consumption. It is problematic that any benefits to be gained from using this website are advertised as exclusive to “There is plenty of information [on forums] people who are seeking abstinence. which should be consolidated into fewer sources of better quality.” Alternatively, survey respondents reported that there is a plethora of useful guidance There is a need for more accessible and dispersed through forums within the better quality public resources relating to online cannabis community. cannabis as practitioners have reported 111

that the normalisation and benign image of cannabis in some communities has led to an acceptance of symptoms of problematic cannabis use. People with lived experience of problematic cannabis use 47 highlighted that there is not enough information available on the negative effects of cannabis and how those effects can be managed, with 14 respondents reporting they thought cannabis was a harmless drug before it became a problem later in their lives. “I thought what I was smoking was natural’ which most street cannabis isn’t.” Limited available public resources are not meeting the needs of people experiencing problematic cannabis use if they provide inconsistent levels of quality, and can be difficult to access.

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Chapter Three: Effectiveness of Support in an Unregulated Market

Each of the measures discussed offer different opportunities, yet the current illegal, unregulated market restricts their ability to engage people experiencing problematic cannabis use. As consumption and purchasing is currently an illegal activity, people who consume cannabis are less visible, making it difficult to target interventions and establish a dialogue with those most in need of support. The Adult Psychiatric Morbidity Survey has highlighted that ‘over a third of adults with current signs of dependence on ‘other’ drugs (36.2%) had received treatment, help or advice specifically because of their drug use at some point’. However, those experiencing cannabis dependence were half as likely to have received support. 48 Cannabis is a substance which requires a unique response as for other substances with a potential for dependence and misuse, service designs has been implemented which can operate effectively in the current legal framework. During the interviews, needle syringe programmes were praised by practitioners as they gave drug injecting users a motivation to interact with treatment. Their incentive to enter the centres providing injecting equipment was to receive clean needles but during the interaction, the practitioner could offer harm reduction advice and, if appropriate, directly link them into support services. 113

Reviews have highlighted that needle syringe services effectively offer harm reduction interventions, advice on safer injecting, prevent overdoses and reduce injection risk behaviours. 49 By effectively creating a decriminalised space (where service users are not criminalized for using illegal drugs), needle syringe programmes are able to offer incentives for interaction and then utilise this opportunity to offer information, guidance and links to relevant services. Needle syringe programmes operate successfully within the current legal framework because they are able to offer incentives for people to engage in their services. Yet due to the nature of cannabis and how it is consumed, there is not a similar ‘carrot’ which can be offered. Cannabis consumers may be interested in testing the potency and quality of their cannabis yet unlike the needle syringe programme, users are not facing an acute health risk if they chose to forego this service. The few treatment centres who are attempting to link problematic cannabis users into support and guidance are frustrated that their services cannot reliably access cannabis users. “Right now, we’re just fumbling around in the dark trying to find them.” Providers reported that they would attempt to offer support and information at festivals and

university events, yet they were unconvinced that these attempts resulted in successful engagement. Contributors also questioned whether untargeted outreach was reaching those who are genuinely affected or extending a net and bringing people in unnecessarily. “Outreach hasn’t been effective as we don’t know where to target.” There is no clear point of contact for cannabis users and while cannabis use remain hidden, public health responses are at risk of being untargeted. Those who do have a regular dialogue with cannabis users are people who sell cannabis illegally with the EMCDDA reporting that ‘a significant minority of cannabis users consume the substance intensively’ (2013a, p.31). The people to whom professionals face difficulty offering support, are the same people who will have the most contact with criminal individuals and organisations, as well as being the same people from whom those criminal individuals and organisations stand to profit most. This can lead to exploitation of disadvantaged groups as research has found that frequent cannabis users are more likely to have lower socio-economic background and experience mental health problems. 50

Slim Pickings The contributions have revealed that there has been an inadequate public health response to the rising demand of support for problematic cannabis use. • A mong people experiencing problematic cannabis use, there is a perception that their needs will not be effectively supported at treatment centres. • S ome drug and alcohol service providers and commissioners are being attentive to cannabis but overall, cannabis is not being appropriately prioritised. • O ne to one interventions relating to cannabis are mostly confined to drug and alcohol treatment centres. Wider community services reported that they do not have the capacity or the ability to offer brief, initial interventions. • T here are limited amounts of public resources available, some of which are lacking in levels of quality and accessibility. • A ttempts to target public health measures to people experiencing problematic cannabis use can be best described as a shot in the dark, with the current illegal and unregulated market reducing the visibility of cannabis users.

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Problematic cannabis use in primary care highlights that the patient, will likely be a long term, heavy daily user, who may experience:

Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. Anxiety, depression, paranoia, panic, depersonalisation. 115

Chapter Four: Turning on the Light Supporting problematic cannabis use requires a two stage approach: reforming existing public health measures to appropriately prioritize the needs of problematic cannabis users and the introduction of a regulatory framework that links these public health measures to their intended audience.

â&#x20AC;&#x153;One provider is not going to approach another with an amazing group intervention, theyâ&#x20AC;&#x2122;ll want to keep it secret to keep themselves competitive.â&#x20AC;?

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Prioritisation Since the dissolution of the National Treatment interventions can effectively reduce problematic Agency, commissioners have been given more cannabis use and can be used as a resource freedom to mold public services around the to overcome barriers to treatment. 56 needs of the Local Authority and purchase services which cater to those needs. As 21% A concern raised by some contributors was of clients are citing cannabis as a problematic providers not sharing innovation, in a bid 51 substance, commissioners have a responsibility to remain competitive in the market. to commission services which are attentive to those needs. Moreover, as cannabis is “One provider is not going to approach most commonly consumed with tobacco, another with an amazing group intervention, commissioners cannot draw providers attention they’ll want to keep it secret to keep to smoking cessation without also focusing on themselves competitive.” cannabis, unless they choose to wilfully ignore cannabis consumption. Some Local Authorities This concern was not shared by other are already recommending that smoking contributors, including providers, who asserted cessation and cannabis treatment should be that any learning and innovation which benefited 52 considered as joint initiatives and the EMCDDA service users would always be made publically has advised a synergy between cannabis control available. Whether or not information sharing 53 and tobacco control policies. FWD, a young is a concern, the chances of useful learning people’s drug and alcohol service in Camden, being confined to small pockets of services highlighted that they will use smoking cessation has declined owing to a greater practice of as an entry point for initiating conversations large scale commissioning under one service about cannabis. provider. For example, Change, Grow, Live (CGL) is contracted to deliver all drug and alcohol To ensure that cannabis is appropriately services in Birmingham. 57 prioritised, more research is needed to investigate the social costs of cannabis, as While utilisation of the competitive market has been done for heroin, crack cocaine and may risk untended consequences, if there is alcohol. Current publications which explain why purchaser expectation that services should commissioners should invest in drug and alcohol meet the needs of problematic cannabis users, 54 treatment make no reference to cannabis. providers have an incentive to innovatively supply services which meet this need. With commissioner prioritisation of problematic cannabis use, would come an incentive for drug and alcohol providers to pay greater attention to problematic cannabis use, challenge perceptions that cannabis cannot be a problematic substance, and make better use of existing resources. Providers would also be incentivised to innovate and improve cannabis interventions to stay competitive in the market. The EMCDDA have highlighted that digital interventions are a promising area for further development 55 with a review from Hoch et al. concluding that digital 118

Holistic Provision and Promotion

No Wrong Door Supporting problematic cannabis users requires a transition away from the traditional treatment centre model, where clients would expect to access a specifically ‘drug’ treatment service and the treatment centre is the only place they could go to receive that support.

An initiative which started in North Yorkshire children’s services was for there to be a ‘no wrong door’ policy, where a range of support was brought under one umbrella. 59 Under the ethos of ‘no wrong door’, Change, Grow, Live (CGL) and the West Lothian Drug and Alcohol service have implemented outreach programmes to train other professional agencies to deliver initial interventions relating to cannabis, thus diversifying and dispersing skills sets.

Many people will not need to enter formal treatment to overcome their problematic use of cannabis and should be able to receive brief, informal interventions from non-substance specific community services. If a problematic “We want to empower other professional cannabis user is presenting to a mental health agencies so any service can respond service, their primary need may be mental health to cannabis.” and it may be more appropriate for their key worker to offer low level support around cannabis Drug and alcohol service provider Forward rather than refer them to a treatment centre. Leeds and mental health service Aspire A GP may be in the best position to offer holistic have also both signed up to the Leeds Dual brief interventions as they can support the Diagnosis project. The project offers access person around a range of needs and will to training and networking events, likely be the first point of contact. where mental health workers can become skilled in offering interventions relating to “It can be better for a GP to support in cannabis and drug and alcohol workers house rather than refer to a specialist.” can become skilled in delivering mental health interventions. The EMCDDA offers a case study of how more holistic service provision is being A wider use of ‘no wrong door’ would aim offered in Finland: to enhance professionals’ confidence in delivering low-level interventions and increase “In addition to the units providing specialised the amount of people interacting with support services for those with substance use problems, and guidance. Public Health England are soon increasing numbers are treated within primary to release a briefing on brief psychosocial social and healthcare services, including social interventions for problematic cannabis use welfare offices, child welfare services, mental which will better support professionals’ health clinics, health centre clinics, hospitals deliverance of brief interventions. and psychiatric hospitals.” 58 119

“We want to empower other professional agencies so any service can respond to cannabis.”

There is the concern that even after receiving training, professionals will not deliver brief cannabis interventions as it is not considered part of their ‘core business’. For example, despite significant attention being given to alcohol Identification and Brief Advice (IBA), the extent of effective routine implementation has been questionable. 60 A response to this implementation barrier has been the planned adoption of CQUIN contracts within primary care services, where a percentage of the total value of an NHS contract with a provider will be allocated in accordance of the sufficient delivery of a specified activity. 61 If this measure effectively moves people away from ‘core business’ thinking, it may be policy which can be appropriately transferred to brief i nterventions relating to cannabis Marketing For those who require more formal treatment, contributors reported that clients would prefer to receive support from specialist cannabis services rather than present to existing general treatment centres. However, there is no evidence that specialist services produce better outcomes than general treatment. 62 There has been a trend towards providers offering support which targets support towards the behavior, rather than the drug, with all drug and alcohol service providers contributing to this report highlighting that they are offering support which is grounded in building resilience and positive coping mechanisms.

Rather than syphon problematic cannabis users into separate services, providers would be best placed to ensure their marketing reflects the holistic service provision which is being offered. Turning Point advised that a move towards ‘hiding in plain sight’, where marketing language is grounded in skills sharing, resilience, wellbeing and positive coping mechanisms, and away from directly referring to substances, would challenge the perception that treatment centres are only places for people seeking support for opiates and crack cocaine, and lessen the attached stigma of attending a treatment centre. Excluding the 16 who skipped the question, half of the survey respondents agreed that they would be more likely to attend a treatment centre if it was advertised that they would receive support around a range of needs rather than just drug use. “I would prefer a more general approach to my health, then to specifically focus on cannabis use.” “Any support centre should look at the whole person and why they are using drugs.” By moving beyond the constraints of the traditional treatment centre model, a public health response can be adopted which interacts and engages with a broader range of people.

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People experiencing problematic cannabis use. People experiencing problematic cannabis use. People experiencing problematic cannabis use. People experiencing problematic cannabis use. People experiencing problematic cannabis use. People experiencing problematic cannabis use. People experiencing problematic cannabis use. 121

Move Towards an Appropriately Regulated Market A move towards a regulated market would offer a targeted dialogue with people experiencing problematic cannabis use, providing opportunities for harm reduction advice to be delivered at point of purchase and any person in need of support relating to their cannabis use to be linked into reformed public health measures. There would also be the emergence of wider opportunities for more public guidance, packaging controls, products which vary in potency, and research into cannabis culture and consumption to improve interventions.

Targeted Interventions Similar to initiatives such as needle syringe programmes, points of purchase would offer opportunities for harm reduction advice and support services to be directly targeted to their intended audience. However, direct comparisons should not be made between the former and the latter. Needle syringe programmes rely on service users not being criminalised so that they may offer them services which mitigate against high risk harms like blood borne viruses. Decriminalisation would not offer this same opportunity for cannabis use because common problems associated with cannabis do not pose an immediate or acute risk which needs to be mitigated against. A regulated market is the most effective model because the purchase of cannabis offers an incentive for consumers to interact with guidance and different public health measures, with those who consume the most having the most interaction. When respondents to Volteface’s survey on problematic cannabis use were asked

if they thought cannabis should be regulated so that it can be sold legally, 12 skipped the question, 3 were undecided and 26 agreed. No respondents disapproved of cannabis being a regulated substance. “I think advice from a professional is far better than advice from a dealer.” “I believe the policy of prohibition is more harmful than any drug or use of them.” Regulatory public health models have been published that envision how a public health framework would be adopted if cannabis became a regulated substance. Transform’s framework for the regulation of cannabis has laid out mandatory, enforced, responsible vendor guidelines which ensure vendors act as gatekeepers to a controlled substance and deliver public health interventions and education during the customer interaction period. 64 Volteface’s report on the online regulation of cannabis expands on this blueprint by mapping out a framework of age restrictions, health questionnaires, 122

limits on users’ monthly purchase, and helplines and chatbots to direct those who felt their use was becoming problematic to local support services. 65 When respondents to Volteface’s survey were asked if they would have managed their cannabis use better if advice and information had been available on point of purchase, 12 skipped the question, 3 were undecided, 18 approved of the initiative, with the remaining 8 feeling they did not want or need guidance, they would have prefered more choice instead, or that the advice would not have made a difference. There is research from Burton et al, who after undertaking a rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies, concluded that providing information and education does not produce sustained behavioural changes. 66 However, due to contextual reasons, direct comparisons between alcohol and cannabis should be undertaken cautiously. Firstly, Burton et al. clarified that any attempts to inform or educate may have been overshadowed by marketing from the alcohol industry. Comparisons may not apply as Transform have highlighted that ‘cannabis regulation offers a unique opportunity to build a regulated market model from the start, making decisions in the public interest’ and ensuring the mistakes from the past are not repeated. 67 Secondly, the normalised and benign image of cannabis among regular users, reported by practitioners and survey respondents, 68 indicates there is a need for more information on the harms that cannabis can pose and how they can be managed. Thirdly, it is challenging to measure the effectiveness of an intervention in isolation when considering Michie, Atkins and West’s theory that behaviour change is a complex process that depends on interactions between necessary conditions for change: capability, motivation and opportunity. 69 Wider Opportunities The first of these wider opportunities is that regulation increases attention relating to cannabis and encourage more balanced, accessible, quality resources to be made available to the public. Volteface’s survey 123

respondents highlighted that more guidance would only be useful if it was driven by evidence and suggested that useful guidance would be to avoid mixing tobacco with joints and consuming cannabis which is low in CBD and high in THC, recommendations which have been approved by established or emerging literature. 70 There are also greater opportunities for consumers making informed purchases relating to strength and content and being able to chose from a broader range of greater quality products. 71 Survey respondents highlighted concerns that ‘street’ cannabis is highly potent yet there is often little else to choose from. Curran et al has recommended that ‘if handled carefully from a harm‑reduction standpoint, a regulated market might...inform accurately about dosage and increase the availability of more balanced cannabis (that is, with lower levels of Δ9‑THC and higher levels of CBD) to maintain desired effects while reducing the incidence of harms’. 72 A regulated market would also aim to reduce the stigma surrounding cannabis consumption by removing the association with criminality. The social stigma that can be attached to cannabis was a reason why some people were reluctant to access support from professionals. Finally, the emergence of new points of contact with cannabis users could be used as opportunities for research into cannabis culture and consumption, thus improving the quality of interventions. Contributors highlighted that the current legal state of cannabis has limited how much research has been undertaken into brief interventions. Regulation Concerns Within the context of the regulation of cannabis, there is the concern that ‘the increased availability that will accompany a regulated market, will lead to increased use and increased harm amongst those least able to cope.’ 73 These concerns are grounded in alcohol and tobacco being legal substances which have the highest consumption among those in lower socioeconomic groups and those who are experiencing a mental health illness. 74

“Do you think customers should buy super strength skunk made on the streets or organically, safely grown cannabis with varying strengths, allowing the consumer to make a healthy choice?”

Moreover, as problematic consumers are likely to be heavy users there would be an incentive for firms to target their product towards problematic users. 75 Yet in the current illegal market, there is already a high consumption of cannabis among certain disadvantaged groups, 76 who criminal individuals and organisations have an incentive to target. One survey respondent highlighted that illegal growers only ‘care for quantity and profit.’ The difference between cannabis and regulated substances such as alcohol and tobacco, is that there is not a targeted public health infrastructure in place which regulates supply and purchasing. There is also international evidence from regulatory models which suggests that increased consumption need not inevitably lead to increased harm. When considering cannabis regulation in Vermont, Caulkins et al. state that in most cases the likelihood is that use will rise if sanctions are lifted, but this does not equate to harm and should not be a benchmark of policy failure. 77

Compton et al’s 2002–2014 analysis of annual cross sectional surveys highlighted that though consumption has increased across the US, cannabis use disorders have remained relatively stable among adults in the general population and have even decreased among regular users of cannabis. 78 Hasin et al.’s analysis of two nationally representative samples found similar results, with the prevalence of cannabis use disorder among cannabis users decreasing significantly from 2001–2002 to 2012–2013. 79 This data should however be treated cautiously, as the reports were not able to assess the impact of state level regulatory cannabis laws. When considering regulation we should be cautious; of course a move towards a regulated market poses risks, and it would negligent to claim otherwise but it is worth considering that ‘our relationship with risk is frequently restrictive, driven more by the fear of getting things wrong. While this approach is a rational response… it denies us many positive opportunities.’ 80 Certain groups who are least well served by the current system have the most to gain from an appropriately regulated market, regulation is a risk which needs to be taken. 124

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Conclusion A widening and diversification of support which utilises different opportunities for interaction would aim to better meet the ranging needs of problematic cannabis users and increase the number of interaction points. Current interventions are mostly limited to formal treatment, a model which has barriers of accessibility, and inconsistently prioritises problematic cannabis use. Briefer interventions from other community services are not being fully utilised as professionals lack the capability to offer these interventions. Publically available resources have had a limited presence in key frontline services and offer varying levels of quality and access. All of these challenges have impeded the support available to people experiencing problematic cannabis use. A wider structural problem is that the current legal state of cannabis has constrained how different interventions can be targeted to people experiencing problematic cannabis use. Even with a sufficient public health response to cannabis, it would be challenging to offer targeted interventions as cannabis use is less visible in an illegal, unregulated market.

centres would challenge ingrained, negative perceptions of the treatment centre model by ‘hiding in plain sight’, while the adoption of the ‘no wrong door’ policy would aim to increase the number of brief interventions being delivered, by ensuring that expertise is not confined to specialist services. A regulated market would increase accessibility to these reformed public health measures as users would be buying their cannabis from a retailer, where they would be able to receive harm reduction advice and be linked into a variety of interventions if their cannabis use began negatively impacting on their day to day lives. Reforming existing provision within the framework of a regulated market would aim to have the effect of increasing exposure to public health measures which are responsive to the needs of people experiencing problematic cannabis use.

Attempts to target public health measures to people experiencing problematic cannabis use can be best described as a shot in the dark, with the current illegal and unregulated market reducing the visibility of cannabis users. Policy options that recognise the needs of people experiencing problematic cannabis use are needed alongside the introduction of an appropriately regulated market. Research into the social costs of problematic cannabis use by Public Health England would justify to commissioners why cannabis should be prioritised. This would incentivise drug and alcohol service providers to be attentive to the needs of problematic cannabis users and to utilise existing resources that meet those needs. Offering a more holistic image of treatment 126

THE GREEN SCR AN ONLINE CAN MARKET Mike Power

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REEN NNABIS

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Chapter One: We Propose Digital Cannabis Market Objectives

• To outline a novel strategy for controlling the cannabis market, making it safer through the creation of a regulated digital marketplace model • To limit access to this system, by technical design, by underage cannabis users through industry-leading identity control and verification procedures that will be enforced upon both purchase and delivery. • To offer a roadmap to legislators looking to act in the public interest and modernise and formalise this chaotic and archaic industry.

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Assumptions This paper assumes that the so-called Tide Effect of cannabis policy innovation seen in the US, Canada, Uruguay and elsewhere will soon be witnessed in the UK, and stands prepared in full readiness for such a rational time when cannabis law reform has been enacted. It includes in its ambitions the fostering of a political, cultural and technological climate whereby such conditions will come to exist.

Arguments We believe that Britain’s multibillion-pound cannabis market should be developed and operated exclusively online by a private sector that is stringently controlled and regulated by democratically elected governments.

As cannabis law increasingly liberalises internationally, whether for medicinal or recreational use, political pressure for its legalisation in the UK is likely to continue building – especially when proper consideration is made of its potential as a net contributor to the public purse via taxation, rather than the current burden it places upon public finances through the cost of enforcement. It is beyond this paper’s remit to make the case for cannabis law reform in the UK or globally; we believe that position has been argued successfully by many notable organisations, whose valuable work has informed our own and to whom we are grateful.

A controlled and regulated online market is both essential and long overdue in order to protect users from the risks of the illicit market; to limit access to younger users; to offer safer products and increase consumer choice; to develop less harmful products and safer routes of administration; and to control marketing and advertising in any eventual legal context.

By almost any metric, a digital and legal solution such as the Online Cannabis Market (OCM) we propose offers many significant improvements upon all current models for the production, distribution and use of the drug.

While cannabis remains illegal in the UK, use rates – including rates of problematic use — remain roughly stable, with almost 6.5% —or 2.1 million adults in England– using the drug every year. 1 Yet that market is currently served by three models, all of them illicit, that present, in descending order, a number of undesirable sociocultural, practical and medical impacts. The three models are: 1. T raditional dealer networks, ranging from anonymous street-dealing to more formalised, organised criminal networks and neo-social supply. 2. Illegal suppliers on the dark web, who use the encrypted web browser Tor, encryption software (PGP or Pretty Good Encryption) to obscure user data and cryptocurrency (generally, if not exclusively, Bitcoin) to obfuscate payees’ and vendors’ identity. 3. S mall-scale homegrowers and their associated socio-commercial supply. 130

We will explore these models and their negative effects in depth later in this study, and outline the ways that an OCM might address and solve these problems using free-market principles to influence consumer choice.

Stronger strains of cannabis, such as the badly named “skunk” varieties, now dominate the UK market, since they offer a better commercial return for operators in an illegal environment. Research suggests that strains such as these with high levels of tetrahydrocannabinol – the psychoactive chemical in cannabis that causes its distinctive “high” – can increase the harms that may be associated with cannabis use in those with pre-existing mental health conditions. Given a favourable legal climate, OCMs would offer users a range of products with a balanced cannabinoid profile, including higher-strength products and even concentrates, and propose the creation of new strains bred specifically with Dutch, Spanish and American expertise to increase the cannabidiol (CBD) content of each variety, since CBD has been demonstrated to act as an antipsychotic. 2

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Conclusions The central aim of this paper is to provide practical, workable suggestions for the online supply of cannabis in what we consider to be the inevitable event of cannabis law reform in the UK and similar countries. We believe that, in common with many digital disruptors, the current, so-called dark web model of online cannabis sales and delivery offers a precursor to what we believe will be the final, preferred model: digital marketplaces for cannabis sales, using standard delivery mechanisms to answer market needs. The effect of such a model would be to protect users; to eliminate incentives for an illicit marketplace through a combination of convenience, pricing, quality and choice; and to create incentives for the uptake of less harmful products and consumption practices through pricing, tax and regulatory models.

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Chapter Two: Sector Analysis — UK As outlined in the introduction, the UK retail cannabis market is currently fulfilled by the following participants:

1. Traditional dealer networks, ranging from anonymous street-dealing to more formalised, organised criminal networks and neo-social supply. 2. I llegal suppliers on the dark web, who use the encrypted web browser Tor, encryption software (PGP or Pretty Good Encryption) to obscure user data and cryptocurrency (generally, if not exclusively, Bitcoin) to obfuscate payees’ and vendors’ identity. 3. Small-scale homegrowers and their associated socio-commercial supply.

NB: W e have not included the workings of organised crime gangs operating major/ multiple growhouses for the purposes of this paper, since small, private, retail-level customers, upon whose needs and behaviour we will focus, do not access the market at that level of the supply chain.

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1. Traditional Dealer Networks This is the most commonplace, profitable and socially disruptive model of cannabis supply. First, we have the chaotic street-dealing scene common in various parts of most cities in the UK. Given the associated social costs of violence between customers and dealers, internecine gang fights over territory and custom, and simple robbery, this model – with its links to organised crime on the supply side – is the least preferable under current prohibitionary measures. Customers face theft, fraud and arrest, as well as exposure to more dangerous drugs and criminality. Consumer choice in this most distressing of distress purchases is non-existent, with quality, weight and freshness of product all at a minimum, or non-existent, standard. Policing costs drain the public purse and divert already curtailed resources from other crime. Next, many dealers operate from private premises, usually their homes. Without legislation to cover opening hours, and with dealers operating outside current business zoning laws, such arrangements cause significant disturbance to neighbourhoods, with irregular hours being kept by both dealers and customers.

Delivery services are common in major cities, with increased prices reflecting the extra time and effort made. Cannabis is often a sideline for dealers offering a wider range of drugs, often, but not exclusively, cocaine powder and MDMA (ecstasy) pills or powder and prescription tranquilisers. Finally, we have the use of commercial premises under cover of some other business. One such example is the infamous Green Leaf cafe in Clapham, south London. At the 2004 trial of owner Errol Anderson, the prosecution noted pithily that the cafe’s £620,000 revenue “could not possibly be accounted for by the sale of jerk chicken and patties.” 3 Customers noted that cannabis deals were “just handed out … from bin liners full of the stuff”. While such setups – which are replicated by many current market operators – cause less social disturbance, it is still not sustainable, or socially acceptable, to have illicit drug dealers operating in an uncontrolled public marketplace with only the mild threat of discovery and punishment serving as a deterrent to both market operators and opportunistic thieves.

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2. The Dark Web Digital cannabis markets exist today and are hugely profitable, although they remain completely illegal, untaxed and unregulated. Yet their choice of products and systems of overnight delivery and customer feedback offer major upgrades on all other current fulfilment models. These systems, if seen through a lens of digital entrepreneurship, rather than as acts of criminality, can guide any interested party looking to create a roadmap towards a regulated online cannabis market in the future. Darknet Markets (DNMs) use the closest model of online cannabis sales in the UK to the digital solution we propose, with several significant differences. The most important distinction is that these sites also offer far more dangerous drugs – heroin, cocaine (in both crack and powder form) and benzodiazepines are a few curious mouse clicks away from the cannabis offerings. We propose a strict market segmentation that would prevent cannabis users of all ages from casual exposure to addictive and dangerous drugs. History and Functionality DNMs first came to prominence in October 2013, when the FBI arrested Ross Ulbricht for operating the Silk Road, a site connecting dealers and users both nationally and internationally that had been running since February 2011. Ulbricht is now serving life imprisonment for money laundering, computer hacking and conspiracy to sell narcotics. The Silk Road was a sprawling bazaar, wherein users could buy any drug they desired and have it shipped to them by regular mail. Such mailorder drug services had existed before, but the Silk Road perfected the form in a number of groundbreaking ways.

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The site was hosted on the encrypted Tor network, meaning users needed specialist software to access the site. It also meant that law enforcement could not easily discover the hosting server’s whereabouts. Bitcoin offered users and dealers pseudonymity in relation to payments, and the use of PGP encryption software meant addresses for postal delivery were shared only with their intended recipients. The Silk Road sold every drug imaginable, via a storefront reminiscent of the early iterations of web retailers such as Amazon and eBay, and dealers paid a percentage of each sale to the site’s owner. The market operated pretty much unhindered, with more than 1.3m sales generating $1.2bn in revenue and $78m in commission in just over three years, according to the September 2013 criminal complaint. There were 146,946 buyers and 3,877 vendors. Since Ulbricht’s arrest, dozens of markets have risen to prominence as public awareness and adoption of the technology underpinning them has grown. All of these DNMs have absconded with customers’ funds upon closure, which are held in centralised Bitcoin wallets controlled by market operators, with two noble exceptions: a site named Agora, which warned users of its imminent shutdown and allowed the withdrawal of funds held in the site’s escrow system; and Black Market Reloaded, which allowed users to withdraw millions of pounds, dollars and euros before closing due to security concerns. Criminals, it seems, are not always dishonest. Markets operating in late 2016 include Dream, Valhalla, Hansa, AlphaBay and dozens of others. URLs for these markets, and site status, can be seen at deepdotweb.com. How Do They Work? Users make deposits and purchases using Bitcoin, a pseudonymous cryptocurrency, then await delivery via standard mail systems. Vendors deploy great ingenuity to prevent the smell of drugs escaping from the packages, such as

using moisture-barrier bags (MBBs) and vacuum seals, with many swabbing the packages between wrappers using alcohol. Anti-x-ray materials are used in some cases, as well as professional mailing packages common to internet shopping services, ensuring that the contents are not easily visible and in many cases are indistinguishable from standard commercial mail. How Big are the DNMs? Turnover has risen from an estimated $15–17m in 2012 to $150–180m in 2015, according to data cited in the Economist in July 2016. However, that underestimates the true picture as discovered in the police capture of the Silk Road server, as noted above. The number of American drug takers who used DNMs jumped from 8% in 2014 to 15% this year, according to the Global Drug Survey, an online study of 100,000 drug users. The UK figure stands at 12% of users who responded to the 2015 Global Drug Survey. 4 A system scrape of one of the busiest markets, Dream, on 25 August 2016 revealed 32,283 separate offers for drugs. Of those, cannabis accounted for 8,896 listings – almost a third of all listings on the site.

Why do people use DNMs? What are the benefits of buying online compared with buying from a street or social-supply dealer? The technical difficulties of acquiring Bitcoin, accessing the markets and learning encryption are fairly steep barriers to entry. The threat of an exit scam, non-delivery or interception are further material risks that buyers face, along with the inconvenience of waiting for a delivery to be made. Nonetheless, Darknet Markets have grown exponentially since their inception. An analysis of users’ motivations would reveal the qualities any new offering in the digital cannabis space must emulate in order to compete. Benefits of Online Sourcing Free-market competition Price Quality Choice of products Verification of product and service Reliability Speed of delivery Later, we will analyse which of these characteristics could be taken forward and used in our model.

Within cannabis, herbal cannabis accounted for 3,825 of the 9,000 or so listings. The remainder were split between hashish and other concentrated forms of the drug. How Many Users Do DNMs Have? The markets have hundreds of thousands of users every month, with the most popular products being cannabis, ecstasy and cocaine. Other drugs, such as methamphetamine and heroin, are permanently available, as well as more exotic offerings, such as DMT and LSD. Every country in the EU now has some kind of local variant on the market, with individual vendors setting up stores rather than trusting an escrow model. 136

3. Small-Scale Homegrowers The final participant in the UK retail cannabis market is perhaps the most benign: the homegrower and his or her associated personal/ social supply. In contrast to the commercial use of residences and premises for large-scale growth, the homegrower of 2016 tends to produce enough cannabis for his or her own needs, with a small amount saved for sale or barter to friends and relatives. Operating like an informal version of the ad hoc cannabis clubs of the EU â&#x20AC;&#x201C; Spain, in particular â&#x20AC;&#x201C; these producer-consumers cause little social ill or distress and are included here mainly for the sake of completeness. For indoor crops, high energy costs, electricity theft in some cases, the danger of fire or disturbance from the noise from exhaust fans and the associated odours of flowering cannabis are among the annoyances and dangers caused by this model to residents and neighbours. Growing a small number of plants either indoors or outdoors, these operators tend to produce no more than a few hundred grammes per year. As a rough guide, one gramme of cannabis, depending on potency, can be made into about three or four joints, depending on the usersâ&#x20AC;&#x2122; taste and tolerance, meaning many homegrowers aim mainly for self-sufficiency. Vaporisation and edibles are more economical means of consumption, but it is accurate to say that the majority of regular, casual cannabis users smoke between 3g and 7g a week. The motivation of many homegrowers is to supply themselves or associates with cannabis for medical use, such as multiple sclerosis patients, cancer patients and HIV patients who need to stimulate their appetite following chemotherapy, and others with chronic pain or migraines.

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Chapter Three: International Legal Changes Cannabis prohibition worldwide is crumbling. The Tide Effect 5 of legal changes has already headed north from the US, where four more states voted to legalise cannabis in November this year: Canadian Prime Minister Justin Trudeau aims to implement radical cannabis law reform in spring 2017.

He told Canadian politicians in April 2016: “We believe in legalisation and regulation of marijuana, because it protects our kids and keeps money out of the pockets of criminal organisations and street gangs.” 6

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The Canadian task force’s discussion paper, “Toward the legalization, regulation and restriction of access to marijuana: discussion paper” laid out the following objectives that its new policy must achieve: • Protect young Canadians by keeping marijuana out of the hands of children and youth. • Keep profits out of the hands of criminals, particularly organized crime. • Reduce the burdens on police and the justice system associated with simple possession of marijuana offences. • Prevent Canadians from entering the criminal justice system and receiving criminal records for simple marijuana possession offences. • Protect public health and safety by strengthening, where appropriate, laws and enforcement measures that deter and punish more serious marijuana offences, particularly selling and distributing to children and youth, selling outside of the regulatory framework, and operating a motor vehicle while under the influence of marijuana. • Ensure Canadians are well-informed through sustained and appropriate public health campaigns, and for youth in particular, ensure that risks are understood. • Establish and enforce a system of strict production, distribution and sales, taking a public health approach, with regulation of quality and safety (eg: child-proof packaging, warning labels), restriction of access, and application of taxes, with programmatic support for addiction treatment, mental health support and education programs. • Continue to provide access to qualitycontrolled marijuana for medical purposes consistent with federal policy and Court decisions. • Conduct ongoing data collection, including gathering baseline data, to monitor the impact of the new framework.

The wave is heading south, to Latin America, where countries including Uruguay, Mexico, Brazil, Colombia and Chile 7 are either creating new, legal markets for medical cannabis or relaxing rules on possession and cultivation. Meanwhile, the tide has reached the shores of the EU, where Germany is preparing for full medicinal legalisation in spring 2017. 8 While in the past all discussion of the benefits and practicalities of a legal cannabis market were by necessity hypothetical at best and fanciful at worst, researchers can now draw conclusions from hard data or valid projections by studying the US market and consumer behaviour there. Following a vote on 8 November 2016, California – the fifth-largest economy in the world and home to tech giants Apple and Google – is expected soon to have a recreational marijuana market bigger than those in Colorado, Washington, Oregon and Alaska combined, according to Ethan Nadelmann, executive director of reform advocate the Drug Policy Alliance. “When I talk to everybody from allies to government officials in Mexico and I ask them what’s it going to take to transform the debate,” he told the Guardian, “the response to me is when California legalises marijuana.” 9 The votes by US citizens in California, 10 Massachusetts, Maine and Nevada in November 2016 have not only transformed the debate, but also redrawn the battle lines in the War on Drugs. The citizens of these states now join those of Alaska, Colorado, Oregon, Washington and Washington DC, all of whom have voted in favour of similar measures in recent years, meaning that about 20% of the US population is now free to use cannabis (although citizens in DC are not technically free to use cannabis, due to Congress opposition). In addition, Arkansas, Florida and North Dakota legalised medical cannabis in November 2016, meaning that the US now has 29 states offering legal medical marijuana and eight states with legal recreational cannabis markets.

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Given the nature of US law, a patchwork of differing regulations and restrictions apply. Depending on your state, personal possession limits can vary by as much as 150% (people in California may carry an ounce, or 25 grammes, while in Maine more than double that quantity may be carried). Likewise, laws on personal cultivation of the plant differ from state to state, as does legislation on where or whether stores selling the drug can legally operate. Age Limits and Child Protection What all the US states to have legalised cannabis have in common is an age limit set at 21, rather than 18. This should be adopted as an international standard in the event of wider legalisation, and as a legal requirement for purchase in the OCM model. We agree with Californian legislators who, in the Adult Use of Marijuana Act 2016, noted: “Currently, children under the age of 18 can just as easily purchase marijuana on the black market as adults can. By legalising marijuana, the Adult Use of Marijuana Act will incapacitate the black market and move marijuana purchases into a legal structure with strict safeguards against children accessing it. The Adult Use of Marijuana Act prohibits the sale of non-medical marijuana to those under 21 years old and provides new resources to educate youth against drug abuse and train local law enforcement to enforce the new law. It bars marijuana businesses from being located within 600 feet of schools and other areas where children congregate. It establishes mandatory and strict packaging and labelling requirements for marijuana and marijuana products. And it mandates that marijuana and marijuana products cannot be advertised or marketed towards children.” 11 While we support and applaud US voters’ democratic choices to enact rational cannabis controls, we believe that any physical sales of cannabis through bricks-and-mortar stores create a new, distinct and unaddressed set of challenges and problems.

where children congregate”, it seems probable that cannabis stores, no matter where they are located, will quickly become locations that attract young people, along with cannabis users of any age. This will increase the likelihood of secondary markets and antisocial behaviour, as well as increased levels of public consumption and intoxication. Given that public consumption of the drug is barred in all US states where cannabis is legal, punishable by fines from $100 (Alaska) to $999 (Colorado), it seems contradictory and incoherent to offer the drug for sale in public spaces. As we reduce the burden on lawmakers to pursue citizens for the choice to consume a mainly benign plant by controlling its production and distribution, it seems irrational to create spaces where new laws are overwhelmingly likely to be broken. This problem, we argue, is best solved by virtualising the industry, removing the market from our streets and neighbourhoods completely and reducing its visibility to zero for all but those who actively intend to participate in it – online. To the Canadian taskforce currently deliberating legal changes that will make the production, distribution and sale of the plant legal, we would suggest that the proliferation of retail premises selling cannabis, under whatever guise, in many US cities has normalised use of the drug to such an extent that even regulations forbidding the advertising and marketing of the drug, to discourage greater uptake by young and vulnerable users, cannot and do not achieve their goals. These scenarios are no longer purely hypothetical: they are urgent public health and law-and-order issues that need to be addressed urgently.

For example, although the Californian law “bars marijuana businesses from being located within 600 feet of schools and other areas 142

Chapter Four: Practicalities Governing Principles The solution to cannabis sales we propose would operate entirely within the constraints of regulated market economics. OCMs’ goal is to limit young people’s access to cannabis by undercutting black markets on price, choice and convenience, and to supply pure and dosemeasured herbal cannabis, cannabis resin and edibles to adults for use in their homes. All products should be taxed. Taxation should be higher on higher-strength products, as in the alcohol model. Age Limit The age limit for users should be 21, initially, until evidence is gathered to demonstrate that a lower age limit would not increase harm. Harm Reduction Information It is important to note that, in a liberalised cannabis model, it is possible that some users would try the drug for the first time, or for the first time in many years, and that they might have a difficult or challenging experience. As such, OCMs have a responsibility to ensure that users have a safe and enjoyable experience, which is best achieved through education and information. Also, we note that young and inexperienced users would be in the vanguard of legal use; they, too, would need clear guidance on how to use the products safely and enjoyably. Simple advice, such as never using cannabis with alcohol, before driving or operating heavy machinery or looking after children, should be included with every purchase, in common with the documentation supplied with tranquilisers, sleeping tablets and alcohol. OCMs should offer users detailed information on the safest use of the products on sale, from dose size and strain choice to ideas about pulmonary and respiratory health. OCMs should also advise

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the sale of low-price vaporisers that heat the herbal cannabis, allowing the user to inhale the THC vapours from the plants and avoid tars and carcinogens. OCMs should not recommend daily or heavy use of cannabis; indeed, they should counsel strongly against it in all labelling. They should offer tools such as online questionnaires, helplines and chatbots to direct those who felt their use was becoming problematic to local health or mental health services, and impose limits on users’ monthly purchases. OCMs should offer drug-driving test kits similar to those used by law enforcement worldwide so that users could check their ability to drive, along with the advice that UK drug impairment levels have been set so low that they risk losing their licence if they drive within even as much as 24 hours from last consumption. They should follow the precedent set by guidelines on medicines, such as those for medicines containing opiate-based analgesics such as codeine, muscle relaxants and tranquilisers such as benzodiazepines, and drugs in the Zoplicone class. OCMs should include a dose and duration-ofeffects chart for all edibles and, in a move the alcohol industry may like to emulate, publish accurate data regarding how long the effects of the drugs they sell will last. A 2015 study by Honda found that one in three British people admitted to driving the morning after heavy drinking and that 40% of them may still have been over the limit. 12

Quantity and Frequency of Purchase We propose a limit on each customer’s account of 30g of herbal cannabis or 30g of cannabis resin a month to discourage resale on secondary markets, thus limiting resale and increased access to younger users. Regulation around concentrates should follow similar guidelines: the sale of no more than 3g of concentrate per person a month should be permitted. In terms of edibles, OCMs should allow adults to buy up to a limit of 30 doses per month.

Helplines/Chatbot Many people who seek help from emergency services while using cannabis suffer feelings of dread and imminent danger and can become fearful. We propose that a helpline, staffed by bots and human operators offering calming advice, could help prevent extra pressure being applied to hard-pressed emergency services. Those who feel their use is becoming problematic, or dependant, should also be offered advice.

These limits are set deliberately low, and it must be acknowledged that any limit in such unexplored territory as this is by its nature arbitrary. It is proposed that these limits would be subject to revision in years following any law change, which should be accompanied by a research programme evaluating the impact of those legislative changes on users’ physical and mental health, and, for example, the incidence of cannabis-related road traffic accidents. It is conceivable they could be increased or decreased; these self-imposed limits serve as a starting point from which future research could be measured and monitored, and take as their lead the limits imposed by many of the US jurisdictions where cannabis law reform is in place.

Website User Journey Registered and age-verified users would choose from a range of products offered in a typical web store interface and add items to a basket. After reconfirming their ID and making payment, they would check out and choose a delivery service, which could be same-day, overnight, signedfor or via regular mail, depending on the level of ID verification they have provided and any exemptions sought. Receiving addresses should be limited only to territories that have similarly regulated their cannabis markets.

If users continue to buy cannabis from illicit suppliers, a case could similarly be made to increase these levels, thus denying criminals income sources and protecting users from unsafe products.

Standard web sales procedures should be followed, such as email contact upon purchase, dispatch and receipt. Feedback could then be offered by customers with proved purchases against the following categories:

• Quality • Freshness • Weight • Aroma • Effects • Packaging • Delivery time • Ease of purchase/customer service 144

OCMs should incentivise detailed customer feedback, especially with regard to effects, to increase the public knowledge base around strains. OCMs should include categories such as: onset of effects; dose size; duration and nature of high, especially in regard to euphoria; motivation levels; paranoia; hunger; lethargy; racing thoughts; and anxiety, since these effects can be caused – or reduced – by cannabis. These incentives could be offered as goods and services, such as free delivery or discounts, and would increase users’ status in the eyes of fellow market participants. Leafly.com’s cannabis strain reviews currently offer much useful information to users in the US; a UK-specific version is not hard to imagine and would not be difficult to produce, given the right legal environment.

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Products for Sale OCMs should sell the following categories of cannabis: Herbal A variety of strains from indica-dominant, for more physical effects, to cerebrally stimulating sativa-dominant to balanced hybrids should be offered. A range of different strengths should also be offered, from low THC options, common to African commercial cannabis, up to 20% THC, typical of many sensimilla/skunk-type products. Strengths would be clearly signposted and would require user opt-in via check boxes or similar, and should carry appropriate and consistent warnings. Varieties could rotate through the year. We propose the sale of high-CBD strains and varietals that can address anxiety, mood and sleep problems. An example of this is Charlotteâ&#x20AC;&#x2122;s Web, a cannabis strain with less than 0.3% THC that has gained popularity among medical users in the US. It was first cultivated by the Stanley Brothers breeders in Colorado for a young epileptic patient named Charlotte. This strain has no psychoactive effects. Pre-rolled joints containing only cannabis may be popular with some users and should also be offered for sale.

Hashish A range of different hashes from Morocco, Afghanistan, India and Pakistan should be offered. Their compact size makes them ideal for posting, and their effects profile is more balanced than many modern herbal cannabis varieties. Edibles A range of simple, edible cannabis products with clear doses and instructions for use should be offered. For fuller details on this, see below. Tinctures Three strengths, from mild to strong. Sold in labelled medical bottles, with safety seals, minimal branding and no medical claims. Ethanol extractions of certified goods only should be permitted, with clear information on THC quantity per standardised 5ml dose. Vape or E-Juice Cartridges Should be sold in a wide range of strengths and varieties, including high-CBD strains. Concentrates Including oils, shatter and rosin. NB: all solvents will be purged from finished products in professional labs. For more on this category, see below. 146

Ointments and Salves Some users have reported strong antiinflammatory and analgesic effects from ointments and salves. As such, we believe sites should be able to sell them. Accessories Vaporisers and childproof storage cases should be available. Caps: Edible Cannabis “We consider 10mg to be a unit or dose of THC,” said Christie Lunsford, director of operations at leading Colorado-based retailer 3D Cannabis Center. 13 We feel it is too early to suggest that a UK cannabis edibles market should not be strictly regulated, especially online. The number of emergency medical cases in jurisdictions with legal cannabis models has risen, 14 often in line with the use of edibles – sweets, candies or cakes which contain a set, stated quantity of THC. Since the drug is more efficiently metabolised via this route of administration, many people find it takes practice to dose accurately. Equally, many users seldom ingest cannabis in this way and can be taken aback by the strength of the experience. The slower impact of the drug when eaten can also surprise new users. As such, it should be advised, on packaging, that the onset of the drug can be slow, especially if taken after heavy food such as a dessert.

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Cannabis edibles should not come in childfriendly sweet, cake, biscuit, drink or chocolate form, as is common in the US and on the black market. Instead, we propose that OCMs sell small pastilles or gums, with the THC quantity they contain labelled clearly on each item and on all packaging. The size of the pastilles or lozenges should reflect the size of the dose. They should contain no added sugar or flavourings, except strong peppermint, menthol or cardamom oils, for example, to dissuade infant palates that accidentally come into contact with them. High-cocoa content chocolates of over 70% are also unappetising to most infant palates and would appeal to adult users. We believe that, if edible cannabis were not sold online in dose-controlled and clearly labelled packages, a secondary market could quickly flourish. These higher-potency products could easily be produced by customers – but without any labelling. We believe it is better to have a regulated market than an unregulated one. The simplest solution to this issue is to test, regulate and clearly label all edibles and to offer them in sealed, prepared packages. While a standard dose of THC is 10mg, the effect can vary greatly in users.

Concentrates A similar argument applies to the rationale behind the supply of concentrates and oils. With the internet buckling beneath the weight of user videos showing dangerous techniques for extracting the THC from fresh cannabis using explosive gases and powerful solvents, we feel it is futile – indeed, irresponsible – to limit users’ access to these products while selling them the raw materials to produce their own, stronger forms independently. Butane honey oil, the base ingredient for the stronger, more novel forms of concentrated cannabis such as shatter, is made by exposing cannabis to butane under pressure, which can have disastrous consequences. 15 OCMS should instead offer lab-tested and purified shatters and rosins – an oleoresin extracted at heat and under pressure using no solvents – at prices that undercut the black market. This would not be difficult, since the price for such products on the dark web now can exceed £50 a gramme for what is, after all, a simple herbal extraction. In common with the sale of stronger forms of herbal cannabis, we propose that all concentrates should be sold with explicit warnings, opt-ins and consumption guidelines.

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Prices In any new market, setting the price is perhaps the hardest question. This is even more the case in the cannabis sector. Users have become accustomed to paying about £8 a gramme for high-quality hashish and £10-12 a gramme for high-quality herbal cannabis. Given that the prices for these products reflect those of luxury goods, such as single malt whiskey and champagne, only by dint of their illegality, we believe price-setting should be a simple matter of undercutting black market operators by at least 10% – and coupling that with guaranteed delivery. ID and Age Verification Users will be offered a range of options for delivery, each designed to prevent the drug falling into the hands of anyone but the intended recipient and to limit access to the drug by young people. The online paid-pornography and gambling industries currently verify the age of users; we suggest that OCMs adopt best practice from these market leaders. All standard commercial data protection guidelines should be observed and adhered to. Each OCM should be responsible for the safe storage of all user data, including industry standard encryption and salting of usernames, passwords, personal information, and purchase history.

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Delivery and Receipt ID and age must be proved both at the point of purchase and at the point of delivery. This presents logistical problems that are complex, but surmountable. Delivery could be made to customers’ homes or work if they have proved identification while registering via an app. We propose that, in the early stages of OCMs, delivery in most cases should be made to local stores, following Amazon’s Pass My Parcel system, offering maximum convenience for the buyer and maximum ID and age verification for the OCM via a bespoke app linking age, ID, payment details and phone ownership. An ID-verification app for each OCM could be created whereby users would grant app- or device-level access to their credit-record data, such as that provided by Experian and Equifax and used by banks to grant loans and mortgages. The app would then tie this information to the user’s mobile phone ID, creating a simple, scannable ID-verification solution that could be used by the store or parcel-holding employee. This could also be done via driving licences, passports or other age-verified ID, as is common with alcohol sales. In most cases, the packages would be small and indistinguishable from most internetshopping packages, meaning no great storage space or extra security would be required on the part of shop-owners. In more remote areas where the Amazon-like delivery option is inconvenient, small letters such as these could be tracked in the postal service much like regular signed-for or special delivery items, with appenabled ID and age verification a condition of delivery.

Payment We propose standard credit card, debit card and PayPal procedures common to all online retail interfaces. Packaging No package containing cannabis should easily be identifiable from the outside. Vacuum sealing and MBBs can prevent aromas escaping and revealing the contents of the package. Precision tools for weighing are widely used in many other industries and could be adopted here. OCMs should be compelled to provide medicalstandard, self-sealing bottles and vials for the relevant products sold, along with safety instructions common to the medicine industry regarding infantsâ&#x20AC;&#x2122; access. Website Designs This will be covered in detail in later documents, but we suggest a classic, minimal look without excessive branding. A simple, regular layout and high-quality macro photography would enable users to examine the buds, resins etc. No advertising of any kind should be permitted in the earliest iterations of OCMs. Refunds Refunds would only be offered if an item arrived damaged or incomplete or if it went missing. Cannabis is a complex drug and many varieties may not be to usersâ&#x20AC;&#x2122; tastes, either physically or mentally, but that would not be a valid reason for a refund. Unused edibles or concentrates could be returned via registered mail in their original packaging, as could other products. This would all occur under existing customer-protection legislation. Customer Protection Industry-standard encryption measures should be taken to ensure confidentiality of orders, customersâ&#x20AC;&#x2122; payment details and identification. All standard data protection law should be observed. 150

Market Structure We envisage a market structure that involves a limited number of licensed OCMs at the end of a supply chain into which feed individual growers, state or privately owned farms or importers. All would have to comply with licensing requirements yet to be created. Suppliers into OCMs would be stringently vetted by multiple government agencies, tied under an umbrella grouping, speculatively named â&#x20AC;&#x2DC;the Cannabis Production and Distribution Agencyâ&#x20AC;&#x2122;, which would incorporate expertise from the agricultural, food, medicine, and chemistry sectors. The strength and purity/freshness of each batch would be bought into licensed OCM storage and distribution facilities and tested before sale. Additional random purchases would be made anonymously by external agencies to ensure quality is maintained. We propose a supply chain whereby growers can submit samples of dried and cured crops or ready concentrates to a governing agency that has the analytical capabilities to check the samples for strength, purity and contaminants. Upon receiving certification against a crop, any grower could then supply the OCM of their choice.

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Distribution

1. C annabis growers apply for supplier licences to a new Cannabis Growersâ&#x20AC;&#x2122; Licencing Agency, which defines who may or not participate in the market.

1. C ompanies or individuals apply for licences to operate OCMs. (These may be growers). Sites have to comply with all requirements laid out in this white paper, with particular reference to age and ID and crop-strength purity.

2. S uccessful growers submit dried and cured crops to a new Cannabis Testing Agency, which determines strength, purity and lack of contaminants, and issue certificates on each crop. Open, transparent accounting systems linked to sales and inventory systems (yet to be created) that would track each gramme sold of each crop. Each kilo would have to be accounted for with sales and tax receipts, ensuring no OCM or grower could pass off bad crops as good. 3. G rowers win approval to sell certified crops into licenced and approved OCMs.

2. O CMs invite licenced growers to regularly submit full, certified crops for sale and distribution, and adhere to accountancy and tracking standards detailed above. 3. O CMS sell the cannabis to users and are regularly inspected, anonymously, by new Online Cannabis Market Monitoring Agency, to ensure crops sold comply with sales regulations and age/ID standards. We also envisage government-run grows adhering to the above regulations. Since we do not yet have a legal model in the UK or the EU against which to compare this, it is beyond the remit and expertise of this paper to suggest limits and detailed regulations on matters as complex as safe levels of mould, nutrient residue, pesticide and bacteria levels, or to set the acceptable margins of error across a crop on, for example, THC strength. These call for further research and investment.

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Chapter Five: Benefits, Challenges, Remedies Benefits of the Proposed OCM Model The presumed benefits of OCMs have been noted throughout this paper where relevant, and are added again here for the sake of completeness. Note that most of the benefits discussed here are specific to the distribution model we propose; the wider benefits of cannabis law reform itself are, in the main, outside this paper’s scope. It does bears repeating, though, that the cost to the public purse of arresting 471,202 cannabis users in the past five years, 16 and imposing criminal charges and records on 126,789 of those, for the use of a herbal relaxant, is unsustainably expensive in these austere times. Legalising cannabis would confer instantaneous and measurable cost and time savings and enable police to focus on crimes with a tangible negative impact to a larger number of people. It must, however, be recognised that all drug use, including that of cannabis, remains a minority interest and pursuit, with most use concentrated in younger age brackets. According to the Crime Survey 2014, 17 (“among younger adults aged 16 to 24, cannabis was also the most commonly used drug, with 16.3 per cent having used it in the last year.” This compares with just 6.5% – or 2.1 million adults in England– using the drug every year (Statistics on Drug Misuse England, 2016 ) Given that majority social approval brokered via some form of political settlement would be needed before any legal change, the concerns, fears and apprehensions of those who would prefer the drug to remain illegal must be heard, and accommodated in a compromise acceptable to all stakeholders. The OCM model answers the concerns of those who reject cannabis-law reform on the basis that they do not want cannabis dispensaries or Dutch-style coffee shops in their neighbourhood, thanks to its intrinsic design as a digital-only marketplace. 153

We argue that our OCM proposal could persuade some of the 14% of British people who are undecided on cannabis law reform, and some of the 39% who reject it outright, to join the 47% who support the call for cannabis legalisation, as made by the Liberal Democrats in 2016. 18 Many cannabis-law reform advocates believe the drug is completely harmless. However, the evidence base contradicting this claim is well-established, with Cannabis Use Disorder included in the latest DSM-5 Criteria for Substance Use Disorders. It is anecdotally accepted that excessive cannabis consumption can have negative effects on individuals, families and relationships. With that in mind, our proposal has at its heart users’ wellbeing and health and would provide help, information, advice and guidance to them in new and innovative ways. The emergence of the dark web, its continued growth and the wider public awareness of the DNMs underpins this whole proposal: cannabis is already being sold online, hundreds of kilogrammes of it, every day in the UK. A legal OCM model would operate a similar fashion, albeit at a larger scale and to the benefit of the public purse, rather than costing the public money through enforcement, while ringfencing cannabis use away from other drugs.

Age-Controlled Our proposal to verify ID on purchase and on delivery via an app compares positively with all existing sales models, in which the only barrier to consumption of any quantity of cannabis is financial. Out of Sight, Out of Mind An OCM model treats cannabis consumption as a respectfully private pastime that need not become part of our urban landscape. By operating the cannabis markets online – instead of at high-street dispensaries and “clinics”, as in the US, or in stores selling the plant for recreational use – we would reduce its visibility only to those who were already actively seeking the drug and who likely intended to buy it anyway. Digital distribution would also reduce opportunistic purchasing by first-time users walking past stores on high streets. It seems imaginable that public consumption of cannabis might proliferate around stores selling the drug on the high street; again, the digital model answers this question by design. Feedback System Feedback systems have revolutionised online retail transactions, enabling customers to make informed choices between a vastly increasing range of consumer goods sold online. OCMs’ cannabis strain feedback systems would help customers save money, avoid unpleasant or undesirable experiences and create a culture of informed use, rather than forcing them to trust in pot luck, as they do currently.

Purity Controls OCMs should be subject to stringent quality control and purity tests at every step of the supply chain, with vendors who failed to comply facing bans and fines. Street dealers and commercial growers offer nothing but a sales pitch, and are driven to maximise weight and cost to increase profit in a risky, illegal trade. Mouldy, contaminated or overfed plants containing fertiliser residue are common in the black market. Consider that wine and beer drinkers never have to worry if their drug of choice has been contaminated with methanol, rather than ethanol, as is common in developingworld economies. The same protections must be offered to cannabis smokers. Control of Secondary Market We propose that any customer ID database be centralised and accessible to all market operators, in order to prevent users from buying more than the permitted limits of cannabis by registering at multiple sites or under multiple identities. Fewer Targets for Criminality A bricks-and-mortar cannabis store, with its valuable, portable and tradable inventory, would present significant opportunities for armed robbery, burglary and extortion, as well as attacks on staff. By contrast, an OCM, with its whereabouts unknown, would mainly be vulnerable to digital attacks, such as hacking of user data or DDoS attacks, both of which are easily preventable using modern security methods. Of course, should the location of any OCM become known, it could face the attacks detailed above – but with fewer single physically points of attack, the OCM model is by design more robust and cheaper to defend than a widespread dispensary model, with its distributed targets.

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Easier Monitoring An OCM model would be easier for law enforcement, trading standards, advertising bodies and other involved parties to monitor and ensure compliance with any eventual legislation, since physical site visits by multiple agencies to high-street cannabis stores would be expensive – perhaps prohibitively so. Any website that registered under the OCM model could be checked on a regular basis by a compliance team and would be required to be hosted on standard IP addresses. Anonymous purchases, to ensure compliance, would also be easier to achieve online, rather than in real life, since the decision-making process in approving a sale would be verified with third-party data and goods delivered could be tested anonymously. Health Benefits Cannabis users’ health would be better protected under the OCM model relative to the status quo, since we propose that all products are sold with a clear, stated dose, with printed recommendations on means of consumption that protect the lungs and heart through vaporisation. Social Benefits A reduction in street-dealing, growhouses and domestic premises being used to sell drugs with no regard for neighbours’ right to peace and security, plus reduced enforcement costs, have been noted and offer undeniable social benefits.

User Behaviour Most cannabis users in the UK have never bought their drug online, and only a minority have consumed it in jurisdictions such as the US, Spain and the Netherlands, where the drug is sold more or less openly to anyone prepared to make the effort. Given that cannabis users judge a purchase by its smell, look, feel and size, it may be that OCMs face initial resistance, since users will not be able to verify vendors’ claims. However, through observation of the dark web, user feedback has been shown to add value to “brands” there, with honest appraisals of the drugs made by objective consumers in a spirit of communal altruism or simply good manners. We contend that, as soon as users experience the convenience of postal-delivery cannabis – which in our model would be a day after purchase, or same-day at a premium rate – most doubts and fears would fall away. Consider, too, that online grocery sales in the UK, a comparable market in many ways, with users demanding freshness prepared to forego physical shopping for the convenience of online solutions, are forecast to reach £9.8bn in 2016, up 13% from an estimated £8.6bn in 2015, according to a 2016 survey by Mintel. 20

Challenges and Remedies We do not argue that the OCM proposal offers a panacea to any difficulty that may arise from a regulated cannabis market. Consider the 2m hospital visits made each year by users of alcohol, 19 and it is clear that even a tightly controlled industry in intoxicants can harm its consumers. Since cannabis is an inherently safer substance than alcohol, we believe these risks can be mitigated and avoided as cultural norms around cannabis change.

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Chapter Six: Economic Analyses Market Forces The enormous and exponentially growing value of the cannabis trade has already changed the political climate and debate around medical and recreational legal reform. Politicians, in common with investors, can now observe a growing body of evidence that a regulated and state-controlled industry can act as a potential income stream through taxation and increased wider economic activity. It is difficult to estimate the size and potential growth opportunities in the UK for any kind of cannabis market, including our proposed OCM model but the best -respected study of this complex and subject, The Institute for Social and Economic Research at Essex University’s 2013 paper ‘Licensing and regulation of the cannabis market in England and Wales’, puts it at between £500m and £800m per year. That study does not take into account any specific cannabis tax, as has been imposed in Colorado, for example, and may therefore be underestimating the total somewhat. Lower criminal justice costs would also be a net benefit to the public purse, through lower enforcement costs. The numbers of offenders in prison for cannabis-related offences in England and Wales would also drop. As noted in The Tide Effect, there are currently 1,363 inmates serving time for cannabis offences, which costs the taxpayer £50m a year. 21 International parallels offer a view of the current and potential size of the cannabis market more generally. Legal cannabis sales in the US jumped 17%, to $5.4bn, in 2015 and are expected to grow by 25% this year, to $6.7 billion, according to Arcview Market Research, the leading national network of high-net-worth investors looking to capitalise on the legalisation of cannabis. “By 2020, legal cannabis sales in the United States are projected to hit $21.8bn,” it said in its latest report. 157

In 2015, Colorado reported that it had raised more revenue from cannabis taxes than from alcohol: it earned nearly $70 million in tax revenue from cannabis between July 2014 and June 2015, while alcohol sales taxes bought in just $42m. 22 The growth is unabated: in the first nine months of 2016 alone, Colorado’s cannabis sales revenue topped $974.3m, with new higher taxes recently imposed. In Washington, the first year of legal sales generated $70 million in tax revenues from sales of $257 million. These figures, though, tell only half of the story. In every US state, business dealing in cannabis faces enormous difficulties opening bank accounts and accepting payment from customers, due to the incoherent federal intransigence on cannabis law. 23 As such, many businesses operate cash-only marketplaces, presenting opportunities for fake accounting and tax evasion. With the online-only model we propose, every transaction would be recorded and taxed, eliminating cash sales and tax evasion, while every transaction would be linked to individuals’ real-world identities, ensuring access only to adults, rather than children and minors.

LEGAL

CANNABIS SALES

IN THE US

JUMPED 17%

TO $5.4BN IN 2015

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Chapter Seven: Conclusion Cannabis law reform, both in its medical and recreational guises, is spreading inexorably across US, the birthplace of the failed and discredited War on Drugs. Our next moves to control and regulate this new trade are more important than any drug policy reform since President Nixon opened hostilities against various molecules and plants.

Even in the UK, where drug law reform took a great leap backwards in 2016 when the government banned every substance in existence that affects human consciousness, green shoots of change are sprouting through the hard surface of prohibition in the east of the country. In Norfolk, 18 hectares – equivalent to 23 football pitches – of greenhouses owned by British Sugar will soon house tens of thousands of cannabis plants, which GW Pharmaceuticals is cultivating to produce enough of its experimental epilepsy treatment for children, Epidiolex, to help 40,000 children worldwide. Although the low-THC/high-CBD form of the plant that will be raised in Norfolk is used exclusively to treat medical conditions and offers no recreational benefits, the tide, it seems, is turning conclusively, even in Europe’s most reform-resistant corner.

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It seems inevitable, that at some point in the near future, British lawmakers will assess and replace the dysfunctional and evidence-free legislation that keeps cannabis illegal. This white paper offers them a roadmap – and a rationale for such a journey. The Lib Dems, in their recent consultation paper on cannabis legalisation, noted that an online marketplace model would one day be required: “We are conscious that people with health conditions and people who live in more remote rural communities may not be able to visit traditional shops or access CSCs [cannabis social clubs] easily, and we would not want these people to be arbitrarily denied access or have to fall back on the illicit market. “It also seems inevitable that some sort of online market will need to exist and that it is therefore preferable to bring it under the purview of the regulated framework early on, to prevent informal online markets filling the void. For this reason, we consider some form of regulated online retail and delivery service a necessity, even if it is part of a ‘phase two’ market development. We suggest that, as far as possible, any such online retailing should seek to maintain the key benefits of face-to-face vending.” 24

However, the Lib Dems failed to identify the reasons that the OCM is in fact the essential, and preferable, model. This is because the party located its rationale in the perspective of users, who form the minority, rather than wider society. Cannabis, it must be repeated, is still a minority pursuit. We, that is to say, drug-law reform advocates, cannot reasonably expect wider civil society to suddenly and with minimal protest accept a complete overhaul of drug policies that have been in place for decades, and the opening of cannabis-dispensing businesses in their back yards or street corners. The fears of many people of all drug use are real, deep-seated and valid: they see cannabis use as dangerous and antisocial and do not wish to propagate a commercial culture that would lead to greater, and more visible, use. But these more conservative and fearful views exist within a wider democratic context: one of global legal changes and scientific research that destroys, completely, any scientific rationale for the perpetuation of the status quo. A compromise must, therefore, be reached, and it is our firm belief that the best way to achieve this compromise is to formalise the dark web model that has been functioning so successfully, so peacefully and so discretely for at least five years. Cannabis should be made available for purchase to consenting adults to consume in the privacy of their own home, with minimal interference from the state – other than to gather the millions of pounds in taxes that such a market would present to any government radical – and clearsighted enough – to implement it.

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Executive Summary There is a huge amount of conjecture around the issue of cannabis use and mental health in the UK. The relationship between the drug and how it can impact both positively and negatively on someone’s mental health is a complex one. Debate on this issue is often polarised, with one camp proclaiming cannabis is so safe that it should be legalised and made available to all, and another stating that cannabis is more dangerous than some might think and that we should have harsher sentences for those both growing and consuming it. This report addresses the issue head-on and explores in depth the difficult question of how cannabis impacts a consumer’s mental health. Its findings paint a problematic picture, which can only be addressed through considered reform.

Our study, carried out in partnership with Dr Oliver Sutcliffe, Senior Lecturer in Psychopharmaceutical Chemistry at Manchester Metropolitan University, shows how street cannabis is now exceptionally potent in comparison to previous years. Buying it is a ‘lottery’ in which the consumer has next to no control over the product they are procuring. As this report examines, cannabis of this nature appears to be deeply problematic for many people because it greatly increases the risk of a deterioration in mental health and the chance of forming dependency. Academic research in this area is supported by data and expert testimony from frontline services which suggest that street cannabis is having a direct impact on the number of people accessing mental health services and presenting at drug treatment centres

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There are three risk indicators to consider when examining how problematic street cannabis is, the academic research suggests. The first is the level of THC. Higher amounts have stronger correlations with dependency and problematic side effects from paranoia to psychotic episodes. The second factor is how much CBD is present. This appears to be a protective chemical, which mitigates against the negative effects of THC. Finally, the age of the consumer is important when considering longer-term effects on cognition and brain development. Research indicates that, during the period when someone’s brain is developing and growing, cannabis can h ave a detrimental effect on this process. In the UK’s illicit cannabis market, all three risk indicators are present. The young people we spoke to and surveyed told us that they can obtain cannabis more easily than alcohol. Frontline services indicated that young people are experiencing a wide range of mental health problems linked to their consumption of street cannabis. These groups of young people, who are often disengaged from frontline services, are rarely explored by academia and more needs to be done to examine the impact street cannabis is having on their mental health. Reports from the frontline and disclosures from young people themselves suggest that the relationship is problematic. The relationship consumers can form with cannabis can be exceptionally complicated. While the research outlined in this report suggests that cannabis can lead to a deterioration in mental health, many people state that it helps them to cope with their mental health. Cannabis is used by largecohorts of people to deal with anxiety and problematic thoughts, and to these consumers it is medicinal in its nature. While this relationship is complex, and in many respects highly personal, what we have found is that street cannabis is rarely cited as being beneficial for mental health.

It appears that two distinct groups exist: those who are informed about the cannabis they are buying, and those who have no idea and are essentially in the dark. The latter present far more of a concern as they are using forms of cannabis that seem to carry with them higher rates of addiction and dependency, and in the absence of resources, knowledge and understanding, problematic patterns of use remain, and the consumer’s mental health can suffer. This report acknowledges that a variety of factors impact on the mental health of consumers, and that the relationship someone forms with cannabis cannot only be explained by reference to THC and CBD levels. The reality, however, is that we can regulate and control THC and CBD to reduce the risks, inform consumers and offer choice. Markets are emerging around the world in which this is taking place. The UK’s illicit cannabis market is out of control and dominated by more problematic forms of cannabis. Systems that bring the market into check, take it out of the hands of criminals and could generate vast tax revenues for government exist. Enforcement of this market has not worked and police forces, failing to see either the benefit or purpose of attempting to enforce it, are surrendering. The tip of the iceberg is becoming clear to see as mental health presentations for cannabis-induced psychosis increase, but the majority of problematic use remains hidden in people’s homes and away from treatment services. We need reform and new drug policies before the crisis deepens.

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Key Terminology and Definitions

Skunk Due to a lack of education and awareness, the term Skunk is causing confusion and misinformation. New terminology is needed, along with a recognition that cannabis is a highly complex product that people can form a wide range of relationships with — from beneficial ones to those which are problematic. The use of the word Skunk hinders this understanding. When it comes to cannabis, the term Skunk causes a great deal of debate and disagreement. This is not only a distraction from the real issues at hand, but is creating further misinformation around a subject requiring clarity. Use of the term is damaging the debate and creating confusion with young people in drug education and on their perception and understanding of cannabis. What is problematic about the term Skunk is that it can mean very different things. Academics and journalists have used the word Skunk to describe a new type of cannabis that is high in THC and low in CBD. To many connoisseurs of cannabis, Skunk is just one strain with similar THC and CBD content to many other available strains. To many young people smoking cannabis, Skunk is just a word used to describe ‘good weed’. Using the term Skunk to describe high THC, low CBD cannabis also creates a problem in the way wider society understands other forms of cannabis, such as Hash. By using the term Skunk to describe a ‘problem’ strain of cannabis, an impression is created that other forms are safer, when - in reality - they may contain far higher levels of THC and have no CBD. The use of the word is damaging societal health and wellbeing by spreading misinformation. Consumers who encounter Hash may not realise that it can contain extremely high levels of THC, far beyond that of Skunk, whatever their understanding of the term is.

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Street Cannabis This report will use the term ‘street cannabis’ to describe the strains of cannabis that are bought through the illegal market. We acknowledge that cannabis bought on the street varies in nature with regards to the specific strain, but there is no doubt that, in the UK, street cannabis tends to be high in THC and low in CBD. The impact of this is that, in most cases, people are not given a choice or the opportunity to avoid more potent strains, which present an increased risk to their psychological wellbeing. 1 Potency The term potency will be used in this report in reference to the concentration of THC and the ratio of THC to CBD in cannabis. When using the term ‘high potency’, we are referring to strains of cannabis which have a high level of THC and little CBD. Defining Mental Health The focus of this report is to examine the way in which cannabis impacts on the mental health of consumers, both positively and negatively. The report will consider addiction as a mental health condition in line with its acknowledgement and definition in the Diagnostic and Statistical Manual for Mental Disorders fifth edition (DSM5). The report will also look at how cannabis can impact on cognition and the brain development of consumers and classify impairment in this area as an issue of mental health, in line with the DSM-IV-TR.

Defining Psychosis This report will go on to explore the link between cannabis consumption and psychosis. Before doing so, we need to provide a definition and highlight the broad spectrum of experiences that can occur. The term psychosis covers a variety of symptoms from a relatively minor aberrant experience to a more serious episode of schizophrenia. The definition provided by Gelder et al. is that, when medically diagnosed, psychosis is a descriptive term for hallucinations, delusions and impaired insights that someone may experience for an undefined period. 2 A psychotic episode may be drug-induced and last for a short period or several weeks. People’s experience of a psychotic episode can therefore vary greatly and our understanding of it needs to reflect this. Drug-induced psychosis is a term used to describe psychotic symptoms occurring after intoxication of a substance, which can last for any length of time. The discussion around psychosis must recognise that experiencing it as a condition does not always result in a hospital admission or medical diagnosis. We should view psychosis as a broad set of symptoms which could last for a short period of time, sometimes just due to the intoxication of the substance, and that many consumers of cannabis who experience disorganised thinking, hallucinations or delusions have in effect experienced psychosis. If we are to effectively discuss and evaluate the role that cannabis has on someone’s mental health, we need to recognise that the debate must take place on a broader level. Even if there is a causal link between cannabis and psychosis, most consumers will not experience a psychotic episode. Far more, however, may be experiencing other issues such as addiction and dependency, which could gradually decline if not addressed, and affect their health and wellbeing on a significant scale.

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Chapter One: Reframing Mental Health

A Combination of Confusion Cannabis is a complex substance capable of inducing a vast spectrum of experiences, from enjoyable euphoria to distressing anxiety. This complexity is exacerbated when the impact it can have on someone’s mental health is considered. ‘Mental health’ might be a term we think we all understand, but, just like cannabis, it is far more complicated than many would imagine. Unfortunately, many people, consumers of cannabis included, see mental health as something that is ‘black and white’ - you either have a mental health problem or you are okay. The debate around cannabis can, at times, fall into the same trap - cannabis is seen as either safe or causing psychosis. The reality is that, mental health, just like physical health, is a spectrum. To progress the debate around cannabis and mental health, we need to reframe our understanding and recognise the complexity of the issue, rather than accepting simple labels and diagnoses.

Gaps in Policy and Perception Despite the growing number of cannabis presentations in drug treatment services and increased hospital admissions for drug-related psychosis, the 2017 Government Drug Strategy, published in July, makes no attempt to address the issue. Vast reductions and cuts to drug treatment services instead reveal an ignorance of the problem. While the Prime Minister Theresa May recognised that cannabis could impact negatively on someone’s mental health 3 in the 2017 general election campaign, no clear plan has been outlined on how to tackle the issue. The latest Government Drug Strategy placed more emphasis on enforcement, which has thus far not proved to be effective, and provided no solution for those with ongoing dependency. The strategy also brought harm reduction back onto the agenda and recognised the importance of gendered experience, which was mentioned little in the previous strategy. The issue, however, is finding the funding for any new ideas or ways of working. The Government’s official mental health strategy is now six years out of date and therefore unable to respond to the emerging picture around problematic cannabis use. While the Government has said that mental health is a priority, no new strategy has been forthcoming. As this report will discuss, mental health is too often seen as a ‘black or white’ issue, which severely limits our understanding and response to it. We will now explore a more productive way of thinking about it before returning to the role cannabis plays on a consumer’s mental health, both positively and negatively.

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A Spectrum Rather Than a Label “Our current system [of mental health service provision] was designed from the wrong end of the telescope, focusing on provision, funding, demarcations and organisation of a particular set of professional services for one in twenty people, regardless of how they became ill. The design ignored the fact that one hundred per cent of people have mental health and that, as with physical health, they are on a spectrum from the super-fit, through to the healthy, the unhealthy and the moderately ill to the severely ill.” —Paul Kirby 4 As Paul Kirby notes, everyone has a level of mental health that can fluctuate from moment to moment, day to day, and year to year. Just like physical health, our mental health can improve or deteriorate based upon our experiences and biology. Although this concept seems easy to relate to, the fact that mental health cannot be seen in the same way as physical health, or understood as simply, makes the matter more complex. The problem with mental ill health is that its treatment relies upon the diagnosis or labelling of a specific condition, such as anxiety, depression, or schizophrenia. While this may assist in the administration of medicines, insurance and disability benefits, it can create the impression in society that you either have one of these conditions or are completely well.

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Issue 1 People do not always notice a deterioration in mental health If we view anxiety or depression as a purely “I didn’t realise something was wrong until I couldn’t singular condition, without progressive leave the house. I ended up just being a complete deterioration, then we miss out on the chance to recluse who couldn’t even walk to the shop without get help early on or change patterns of behaviour. someone going with me. The mad thing is I was a The gradual decline of someone’s psychological confident guy and used to play in front of people wellbeing presents opportunities for intervention at gigs all the time. But slowly this fear just started throughout, but if the individual does not see to set in… when I look back I can see I was slowly it as such they may wait for far too long before getting worse and worse, but I was just smoking all seeking help. This keeps people away from day and escaping from stuff so it was pretty hard to services and treatment, leaving them out in the notice at the time.” community, unaccounted for and without support. — M ichael, cannabis This becomes a key issue when the impact consumer for 15 years of cannabis on someone’s mental health is considered. As the debate has focused “I have no doubt that people presenting for so heavily on episodes of psychosis, many cannabis-induced psychosis are the ‘tip of the consumers of the drug do not consider that iceberg’ of people adversely affected by heavy they could be experiencing mental health cannabis use. In our study in Dunedin (Arseneault problems that fall lower down on that same et al 2002), cannabis use increased not only spectrum. Should someone’s mental health be psychotic disorder but also minor subclinical gradually deteriorating (or even remain stable psychotic symptoms such as paranoia among at a problematic level), the regular consumption people in the community.” of cannabis will make this harder to recognise. The relationship between such a problem and — P rofessor Robin Murray, the consumption of a drug can also become Institute of Psychiatry, entwined as the experience of consuming King’s College London cannabis can mask, create, amplify or suppress the problem itself. We need to educate consumers of cannabis that mental health, just like physical health, can fluctuate. While conditions such as psychosis or schizophrenia are higher up on this spectrum in terms of severity, they are not the only type of problematic experience.

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Issue 2 Academic debate heavily focused on psychosis The subject of cannabis and mental health is hotly debated both in and outside of academia. Its focus, however, seems to be on the most severe psychological conditions and their labelling, rather than on exploring issues that are more common in the cannabis consuming population as a whole. By looking only at the more serious conditions — the tip of the iceberg — the debate is misleading and serves to reinforce a simplistic way of discussing mental health. If the debate instead discussed a wider range of conditions and viewed such problems as on a spectrum, there could be several benefits. As outlined earlier, it could help to educate those consuming cannabis to be aware of changes in their mental health and would also push academia to look beyond the easily accessible group of hospital admissions and groups seeking treatment.

“Researchers try their best to access cannabis users but it is too convenient to recruit from treatment centres. The majority of people don’t make it into a treatment centre, they sort things out on their own and find their own way. We are almost blind to the largest number of people who don’t get into treatment. Research has shown again and again the vast majority, almost 90%, who do develop a problem don’t make it into treatment for a whole variety of reasons.” — I an Hamilton, Lecturer in Mental Health, University of York 170

Issue 3 The media are missing the bigger story

Issue 4 Physical health and mental health are linked

Media reports focus heavily on the relationship The World Health Organisation states that between street cannabis and psychosis, with ‘there is no health without mental health’ 5. readers being provided with accounts of the Poor physical health can cause pain, most alarming stories. Regardless of the discomfort and create limitations on relationship between cannabis and schizophrenia, someone’s ability to function. This lack of by reporting solely on this upper tier of mental functioning and discomfort can then impact health conditions, the general population is left on how a person feels about themselves and, with a message that cannabis is either safe or in some cases, leads to a deterioration in sends you into a psychotic episode. mental health. This becomes especially relevant when discussing cannabis and mental health. We need to create a dialogue and raise Even if cannabis has no impact whatsoever awareness with the media that it should be on a consumer’s mental health from a biological discussing far more than simply schizophrenia perspective, if it was to contribute to physical or psychosis when it comes to cannabis and limitations, or to a change in their social mental health as the scale of the problem might integration, mental health may well be going under the radar. The issue should be affected. also be handled with more subtlety and nuance by the press to reflect its complexities. One important factor to highlight when discussing cannabis use in the UK is the prevalence of tobacco in joints. The Global Drug Survey 2017 showed that in the UK 77% of cannabis smokers who responded to the survey used tobacco with their cannabis. This is far higher than Canada (17%) and the US (8%), and relatively close to many other European countries (range 58-94%). The introduction of tobacco alongside cannabis adds many additional risk factors to consumption, from an increased risk of dependency to the impact on the consumer’s physical health. The harms of tobacco are exceptionally well researched and the impact it has on a consumer’s physical health is well known. 6

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Regardless of the relationship between cannabis and schizophrenia, by reporting solely on this upper tier of mental health conditions, the general population is left with a message that cannabis is either safe or sends you into a psychotic episode.

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It is important to recognise that the majority of cannabis users consume the drug for pleasure and enjoy using street cannabis. Intoxication from THC can be a euphoric and relaxing experience, enjoyed by millions of people around the world.

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Two-Way Street We must also recognise the positive role cannabis can play in managing someone’s mental health and the complexities that exist when evaluating the intoxication of a substance. Many consumers of cannabis state that it is highly beneficial for their mental health. Cannabis is medically prescribed in more than ten countries and 29 US states. It is used for a range of ailments, both physical and psychological, and there is a comprehensive research base to support its prescribed use. A research review carried out by Mike Barnes found that there was an evidence base for CBD as a treatment for anxiety, but the same could not be said of THC which appears to exacerbate the condition. 7 It is important to recognise that the majority of cannabis users consume the drug for pleasure and enjoy using street cannabis. Intoxication from THC can be a euphoric and relaxing experience, enjoyed by millions of people around the world. People who consume high THC, low CBD strains are likely to state that it does improve their mental health as it makes them feel good during consumption and that they experience few problematic effects. “The reason I like weed is because it feels great. I love the feeling of being stoned and the stronger the better to be honest. It’s not like I do it all the time but when I do, I want to get pretty high rather than it just be relaxing.” —A nonymous male, 18, North Yorkshire What complicates this relationship further is the fact that any drug-induced experience is reliant upon, not only the drug itself, but the environment in which it is used in and on the individual. Norman Zinberg’s ‘drug, set and setting’ model highlights how both the environment and individual play a major role in defining a drug-induced experience. 8 For this reason, high levels of THC and low CBD are

just one factor in assessing the experience someone might have consuming cannabis. Having a predisposition to a mental health condition, living in deprivation, going through a particularly difficult time in life, or smoking the drug to excess all impact on the likelihood of a problematic relationship. Addiction itself is not ‘black or white’, it is a complex relationship and, just like mental health, exists as a spectrum. Anecdotal evidence suggests that medical users of cannabis seek strains of cannabis with high levels of THC to help with the management of pain, whereas the recreational consumers seek strains which contain higher levels of CBD to reduce anxiety. The relationship, however, is complex and ultimately down to personal experience and desired effect. According to the United Patients Alliance (UPA), which represents many medical cannabis consumers in the UK, CBD oil is often used to supplement street cannabis in order to reduce the problematic effects of the latter. Jonathan Liebling, the UPA’s Political Director, told us that many cannabis consumers use CBD oil before taking street cannabis to help mitigate against negative effects from the high levels of THC it contains. A survey carried out by the UPA found that 36% of medical cannabis consumers in the UK used the drug to help manage a ‘mental or behavioural disorder’, which was the largest stated reason of all available categories. The same survey also indicated that the main method of procurement was to buy from street dealers (52.6%), which suggests many medical users of cannabis may not be obtaining a strain of cannabis that is ideal for their condition. In an unregulated market, the consumer is given no choice of strain and procurement is a lottery in which the acquired drug could do more harm than good.

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Beyond Psychosis There are other factors besides cannabis use that could impact on a consumer’s mental health and wellbeing. The social implications that can come with taking any illegal drug, especially for many young people in the UK, can have a negative and life-changing impact. Research by the charity Release shows that, despite lower rates of drug use, black males are five times more likely to be charged with possession of cannabis than white males. 9 The result of this is that many young black males are particularly susceptible to being arrested for possession of cannabis and must deal with the consequences of this both psychologically and socially. 10 Many people on the frontline of deprived communities in the UK, who were interviewed for this report, spoke of the many young people lost in a world of procuring cannabis, consuming it daily and committing crime. This lifestyle is distressing, dangerous and can quickly result in lifechanging consequences. The lifestyle that comes with dependant cannabis use consistently puts the consumer at risk of arrest and the stigma attached to offending can have a detrimental effect on a consumer’s mental health. Those using the drug medically must still procure it through the illicit market and regularly offend. Should someone already be struggling with anxiety and using cannabis to manage this, the added stress of committing a criminal act is likely to make them more anxious.

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â&#x20AC;&#x153;One of the things from our patient survey was that when we were asking patients about the side effects of cannabis, about 50% of those who said they used cannabis to help with anxiety, also said the main side effect of using the drug was the anxiety and paranoia caused by using the illicit market. As far as we can see, almost all of our patients are experiencing severe and chronic illness, and the fact they have to procure a drug that helps them so much illicitly puts them at greater risk.â&#x20AC;? â&#x20AC;&#x201D; Jonathan Liebling, Political Director, UPA

In an appropriately regulated, legal market, young people would not face the same level of criminalisation for possession and those who use the drug medicinally would not have to risk prosecution and the stress of procurement. By eradicating the illicit market, young people would also not be as easily drawn into patterns of offending and criminality. To obtain cannabis, a young person must currently interact with the illicit market, which brings with it the chance of exploitation and abuse. We need policies that reduce the risk of young people getting lost in lives of crime, not those that present the risk of doing so as a necessary gateway to procurement

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By eradicating the illicit market, young people would also not be as easily drawn into patterns of offending and criminality.

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Summary This chapter has highlighted how mental health, just like physical health, is a spectrum. The discussion around cannabis should reflect this and refrain from focusing purely on the diagnosis of one condition to quantify harm. We should recognise that mental health is fluid and cannabis can play a key role both positively and negatively. The work of Zinberg shows that the experience of using cannabis is also dependant on factors outside of its chemical components - crucially the environment and the individual. This means that any problematic relationship between a consumer and a drug should look beyond the drug itself. Regardless of this, the chemical components of cannabis could be controlled and consumers could be educated about them. The wide-ranging environments in which people use, and the vast demographic of consumers, are far harder to control.

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Chapter Two: Risk Factors Cannabis and Mental Health Now that we have established a broader understanding of mental health, we can examine the key risk factors that are present in the consumption of street cannabis. As highlighted earlier, the drug itself is not the only factor to consider when assessing the impact of cannabis on someoneâ&#x20AC;&#x2122;s mental health. There are a host of variables that can make someone more or less susceptible to poor mental health. From underlying poor mental health or predispositions, to polydrug use, cannabis is never impacting on someoneâ&#x20AC;&#x2122;s mental health in isolation. The focus of this report, however, is on cannabis itself, its major psychoactive and neuroprotective constituents - chiefly the levels of THC and CBD â&#x20AC;&#x201D; and the age at which someone starts to consume it. The reason for this is that these are the factors that can be controlled and regulated by the state to lessen the negative impact of cannabis use. They are also areas in which we can give clear and informed educational messages on consumption, allowing consumers to make more informed choices.

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Three Key Risk Factors

• High levels of THC (increased rates of addiction and problematic use) • Low levels of CBD (decreased protective mechanisms against addiction and mental health problems including psychosis) • Early onset of consumption while the brain is developing; consuming before the age of 20 Cannabis with a high level of THC and very little CBD, that is used by young people, would therefore present the highest risk.

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1. The Protective Nature of CBD A study conducted by Professor of Psychiatric Research, Sir Robin Murray, of King’s College London suggests that individuals smoking street cannabis every day are five times more likely to develop psychosis. The study looked at the association between the consumption of high THC cannabis and psychosis by interviewing 410 south London hospital patients diagnosed with first time psychosis. The research found that those who had used mostly ‘Skunk’-like (high potency THC) cannabis were twice as likely to be diagnosed with a psychotic disorder if they had used it less than once per week, nearly three times more likely if they used it at weekends, and five times more likely if they used it every day. 11 The same was not true for Hash, which did not appear to increase the risk regardless of the amount smoked. This research presents an interesting comparison between high potency THC cannabis and Hash. While both are forms of cannabis, one typically contains far more THC and less CBD - the result of which looks to significantly increase the risk of psychosis. “..use of high-potency cannabis (Skunk) confers an increased risk of psychosis compared with traditional low-potency cannabis (Hash)” — Murray et al.

The reasons for this differential risk level could be that cannabis with high levels of THC has a more harmful effect on a consumer’s mental health. Research has been conducted into the effects of THC which, when administered intravenously, can create psychotic symptoms increasing in severity with the dose. 12 This would suggest that cannabis with high levels of THC is the most problematic in terms of increasing the risk of psychosis and such a risk increases with the amount someone is consuming. The other key factor at play could be the interaction of CBD, as the study stated it was ‘Skunk’ (high THC / low CBD) which carried the most risk. The study suggests that ‘Skunk’ has a high level of THC and next to no CBD. Strains can vary widely in terms of their THC content, which is why we recommend the term ‘street cannabis’. Regardless, the report draws the conclusion that ‘Skunk’ or street cannabis has little to no CBD and high levels of THC. “cannabidiol (CBD) ameliorates the psychotogenic effect of THC and might even have antipsychotic properties. The presence of cannabidiol might explain our results, which showed that hash users do not have any increase in risk of psychotic disorders compared with nonusers, irrespective of their frequency of use.” — Murray et al.

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The study acknowledged some limitations in the data, as the readily available high-strength THC cannabis in south London might have resulted in an over-representation of the general population. The study also notes that it did not explore how much cannabis was being used by participants, which means that we cannot be sure how much THC was being consumed. Research exploring the effect of CBD in cannabis has shown that, when it is administered alongside THC, it can significantly reduce problematic effects both cognitively and psychologically. 13 When administered in isolation, THC can induce cognitive impairment and psychotic-like symptoms, but when given alongside CBD, research has shown that these effects significantly diminish. 14 In a study carried out by Karniol et al, volunteers were given either a high dose of THC or both THC and CBD together. Those who received both THC and CBD together found the psychological reaction of THC to be significantly reduced. 15 A hair sample study by Morgan et al also showed a similar link between THC and CBD, finding that those who tested positive for both THC and CBD in their hair had far fewer psychotic-like effects, than those who tested positive just for THC. 16

In an unregulated market, the level of CBD in cannabis cannot be controlled. Furthermore, the harm reduction message that CBD appears to be protective and mitigates against a problematic experience is absent from the procurement of cannabis. Anecdotal evidence from consumers of cannabis also suggests that CBD plays a key role in moderating the harmful effects of THC and reducing problematic experiences. “In my experience I have found that when taking CBD alongside cannabis with high levels of THC it has not only reduced my overall level of consumption, but the problematic side effects such as anxiety or paranoia.” — J onathan Liebling, Political Director UPA There is, however, further research to be carried out on CBD to establish, in more detail, at what ratio the protective element comes into play. Although academic studies suggest CBD is protective, we do not know at what point this takes place and how research carried out in this area can be practically applied to consumers of cannabis. 18

While research suggests that increasing the level of CBD in cannabis reduces the problematiceffects of THC, it does not seem to impact on the feeling of being ‘stoned’ or high from cannabis. Multiple studies have shown that high doses of CBD do not change the experience or pleasurable effects of THC. 17 This suggests that CBD is simply protective in nature and does not detract from the pleasurable experience of smoking cannabis.

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2. THC and Addiction While most academic research has focused on cannabis and psychosis, addiction is a far more prevalent issue among those who consume it. 19 Curran et al estimated that cannabis consumers are nine times more likely to become addicted to cannabis than experience psychosis. 20 Although addiction remains a debated term, Curran et al recognised it to be the “ongoing and compulsive consumption of a substance, despite clear negative consequences to doing so”. 21 To better understand the implications of cannabis addiction, the Diagnostic and Statistical Manual for Mental Disorders fifth edition (DSM-5) is a good point of reference. The DSM-5 amalgamated the terms cannabis abuse and cannabis dependence into cannabis use disorder and provided the below symptoms.

DSM-5 definition of cannabis use disorder: • Cannabis is often taken in larger amounts or over a longer period than was intended. • There is a persistent desire or unsuccessful efforts to cut down or control cannabis use. • A great deal of time is spent in activities necessary to obtain cannabis, consume cannabis, or recover from its effects. • Important social, occupational, or recreational activities are given up or reduced because of cannabis consumption. • Cannabis consumption is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cannabis. • Tolerance, as defined by either a need for markedly increased cannabis to achieve intoxication or a desired effect or a markedly diminished effect with continued consumption of the same amount of the substance. • Withdrawal, as manifested by either the characteristic withdrawal syndrome for cannabis or cannabis is taken to relieve or avoid withdrawal symptoms. 22

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These conditions are commonplace with those who consume cannabis problematically. A key contributing factor in their development could be the consumer’s exposure to THC. Freeman and Winstock carried out research examining the relationship between cannabis with high levels of THC and dependency. They found that cannabis with high levels of THC is associated with ‘an increased severity of dependence, especially in young people’. 23 They also noted that cannabis with high levels of THC was the preferred choice of young people, with participants reporting that it produced the best high. However, it was also associated with stronger memory impairment and paranoia. 24 As THC produces the desirable effects of cannabis, a higher dose can create a strong compulsion to consume again, which is likely to be the reason why a correlation between dosage and dependency is observed. 25 If someone is consuming cannabis problematically for the pleasurable experience of THC, then it is understandable that cannabis which provides this to a greater extent becomes more appealing to use.

Research by Freeman et al suggests that those who smoke cannabis with low levels of CBD are more prone to consuming it problematically, and that CBD could act as a protective agent against dependency. 26 It could also, according to work carried out by Crippa et al., reduce symptoms of cannabis withdrawal. 27 CBD appears, both from academic research and consumer anecdotes, to reduce the problematic side effects of THC and create a more balanced experience. The drug itself is used in isolation to reduce anxiety and improve people’s psychological wellbeing around the world. We need to understand cannabis as a drug that can take many forms, some more harmful than others. The evidence suggests that CBD could be key in reducing this harm. The illicit cannabis market has no obligation to care for the health or wellbeing of its consumers and provides them with no choice.

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3. Cannabis and Young People Due to the way in which brains develop and grow, young people could be at an increased risk of the harmful side effects of cannabis. Research on young people’s consumption of cannabis suggests that, the earlier the onset of cannabis consumption, the more likely they are to experience problematic effects. Dragt et al. in their study, ‘Cannabis use and age at onset of symptoms in subjects at clinical high risk for psychosis’, concluded that “younger age of onset of cannabis consumption is associated with earlier symptoms of anxiety, social withdrawal, derealization, memory impairment, and difficulties in concentration, with effects being more pronounced in patients with heavier cannabis use”. 28 As the brain is growing, regular cannabis consumption impairs its development and maturation. 29 The result of this could be that the young person is more susceptible to a mental health problem and issues with cognition. Research carried out by the Centre for Brain Health at Texas University found that earlier consumption of cannabis results in slower brain development in the prefrontal cortex, which is responsible for judgment, reasoning and complex thinking. 30 Interestingly, those who began consuming cannabis after the age of 16 experienced the opposite effect, in that their brains showed signs of accelerated ageing.

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Research carried out by the University of Montreal supports this by showing that young people consuming cannabis before the age of 17 experience brain impairment in the areas of verbal IQ and specific cognitive related activities, all of which occur in the frontal cortex. 31 In the study, participants who smoked cannabis before turning 14 performed worse by 20 points on cognitive tests and were more likely to drop out of school earlier. 32 The research noted that underperformance in verbal abilities might actually be due to the social implications rather than neurological effects. It is important to understand this ‘window of vulnerability’ both socially and biologically. The research outlined above highlights how cannabis can impair brain development in young people, but the social factors and lifestyle choices it results in can also play a key role. Young people who are consuming cannabis are less likely to engage in systems of education and, as Castellanos Ryan states, this results in reduced opportunities to develop. The lifestyle that comes with consuming substances from an early age limits educational growth via reduced engagement in school, with young people then becoming isolated from opportunities for development. Those who work on the frontline of drug treatment also find this same link.

Young people are at an increased risk from smoking cannabis, both biologically and socially. There appears to be an evidence base to suggest early consumption of cannabis is detrimental to the brain, and that the lifestyle choice that comes with cannabis results in decreased opportunities to develop. While this relationship is complex and young people who are socially disengaged may be more likely to consume illicit drugs,â&#x20AC;&#x2030;34 cannabis is clearly not increasing their chances or potential for growth. The research highlighted in this report suggests that the most vulnerable age group of cannabis smokers are those under the age of 20 who should still be engaged in systems of education.â&#x20AC;&#x2030;35 Young people in the UK currently have easy access to a strain of cannabis which appears to carry the highest risk.

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“In the early onset group, we found that how many times an individual uses and the amount of marijuana used strongly relates to the degree to which brain development does not follow the normal pruning pattern. The effects observed were above and beyond effects related to alcohol use and age. These findings are in line with the current literature that suggest that cannabis use during adolescence can have long-term consequences.” —F rancesca Filey, lead researcher

“The results of this study suggest that the effects of cannabis use on verbal intelligence are explained not by neurotoxic effects on the brain, but rather by a possible social mechanism. Adolescents who use cannabis are less likely to attend school and graduate, which may then have an impact on the opportunities to further develop verbal intelligence.” —C astellanos Ryan, lead researcher 33

“The kids I have worked with in school who smoke loads of cannabis nearly always struggle to engage in education. They become less interested, can’t really be bothered with the lessons and say that the work is becoming too hard. Eventually it becomes a vicious cycle in which they just can’t keep up with the work and don’t believe in themselves anymore.” — Becky, young people’s substance misuse worker, North Yorkshire.

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Summary In this chapter, we have shown how three key risk factors are present in the use of street cannabis in the UK. The evidence indicates that cannabis containing little to no CBD presents the highest risk, and is more likely to induce the problematic side effects of THC. CBD seems to provide an element of protection, without compromising the pleasurable effects of THC. While further research does need to be done on CBD, the evidence and experience cited from consumers indicates its protective nature should be taken very seriously. The illicit market is not focused on the health and wellbeing of the consumer and the consequences of this are deeply problematic.

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Chapter Three: The Current Picture A multitude of factors paint a complex and problematic picture with regards to cannabis and mental health in the UK. Not only are treatment and mental health services experiencing an increased demand from cannabis consumers, but funding has been significantly reduced. There is also a severe lack of awareness and policy solutions on this issue in either the latest drug strategy or mental health policy. No clear plan exists to eliminate the illicit cannabis market and police forces are de-prioritising this issue across the country; enforcement continues to fail.

This failure of policy and ongoing erosion of services is taking place at a time when street cannabis is more potent, dominates the UK market more than ever before, and is exceptionally easy for many young people to access. The Weed on our Streets Volteface, in partnership with Dr Oliver Sutcliffe of Manchester Metropolitan University, tested the THC and CBD levels of fifty samples of cannabis flower seized by Greater Manchester Police. This data provides an up-to-date snapshot of the content and variation of street cannabis in the UK today.

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Content (%w/w) of THC and CBD in Cannabis Samples

Cannabis Sample

Ratio of THC:CBD in Cannabis Samples

Cannabis Sample

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Key Results

• The mean THC content was 14.7% w/w and ranged from 3.37 – 27.6% w/w. • 90% samples contained THC contents greater than 10% w/w; 14% samples contained THC contents greater than 20% w/w. • The mean CBD content was 0.38% w/w and ranged from 0.06 – 1.50% w/w. • Only one sample contained a THC content greater than 1% w/w CBD. • The THC:CBD ratio in 49 of the 50 samples tested ranged from 24:1 – 65:1. • The mean THC:CBD ratio was 48:1, the median was 49:1. • Only one sample displayed a THC:CBD ratio of less than 24:1. This sample was an outlier, with a THC:CBD ratio of 7:1.

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The samples tested in our study are in agreement with the existing literature on the subject, and reinforce our knowledge that the THC content of street cannabis is high in the vast majority of cases, while the CBD content in almost all cases is negligible. 36– 39 While greater variation in THC and CBD contents and ratios may be more common among cannabis that is home-grown or ordered online by enthusiasts, it is evident that street cannabis shows very little variation, being almost exclusively high in THC and markedly low in CBD.

Caveats exist around the data. Only cannabis flower was analysed, with resin and cannabis extracts excluded. Samples were taken from the Greater Manchester area only so are not a perfect representation of the content of the street cannabis market nationally. Samples were the result of police seizures, which is not a perfectly representative sampling method. However, as an indication of the cannabis that is being consumed by the majority of people, the results are highly revealing. High THC, low CBD cannabis dominates the UK’s illicit market as it has a rapid growth period up to maturity and can be grown indoors. This enables those selling cannabis to make the greatest profit and presents the lowest risk. While popularity of this product is undoubtedly high, this may well be due to the fact that no other product is easily available and consumers have neither the access to nor the experience of any alternative. The result of the increasing potency and market dominance of street cannabis may be having a direct impact on the number of drug treatment presentations in the UK. 192

Increased Treatment Presentations In the past ten years, there has been a 64% increase in the number of individuals who have accessed drug treatment services for their cannabis consumption in the UK - with 31,129 adults seeking support in 2016. 40, 41 This increase in presentations is taking place at the same time as a steadily declining population of cannabis consumers in the UK. 42 Despite the reducing number of consumers, cannabis now accounts for 26% of all drug treatment 43 presentations, and is the fastest growing drug-consuming cohort in treatment. In young people’s drug treatment services, 87% of service users reported consuming cannabis. 44 Frontline treatment workers are noticing this increase in cannabis referrals and finding that those heavily dependent on the drug also experience mental health issues:

“A lot more cannabis users coming into treatment, mainly social services referrals e.g. parents. Lots of young people coming in for cannabis problems including addiction, saying it’s taking over their life, can’t do anything, smoke non-stop, agoraphobic, psychotic effects.” 46 “Big rise in cannabis users accessing services that are more usually accessed by opiate users. All for Skunk. Almost all presentations have mental health issues. They see our cannabis group, consultant psychiatrist, one-to-one key work for issues around dependence, exacerbating mental health problem, onset of anxiety.” 47 “Young people are now committing more serious crimes and more crime to buy cannabis. Before they would be stealing money off parents or doing a bit of social dealing on the side, now they are shoplifting and doing home burglaries. Why? Because there are a lot younger dependent cannabis users.” 48 “80% of our clients are here for Skunk problems. People sorting out their own grows in spare rooms, buying seeds and hydroponics over the web from Barney’s Farm online. Their favourite blend is Amnesia ‘Ammy’. Impact on their mental health, hearing voices and hallucinations. Cannabis sometimes used as way of getting kids involved in crime. One boy was given £3,000 worth of driving lessons he thought through kindness from a friend and the elder who then told him he owed money and threw him a bag of weed and said start selling that.” 49

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As our own study indicates, the vast majority of street cannabis now contains high THC levels and very little CBD to mitigate its problematic effects. This trend appears to be having a direct impact on the number of people who present for help in drug treatment, a subject examined in depth by McCulloch in ‘Why did cannabis presentations rise in England between 2004/5 and 2013/14?’ Despite this growing number of consumers accessing treatment, as our previous report ‘Black Sheep’ outlined, this is just the tip of the iceberg and accounts for 14.6% of those who show signs of cannabis dependence and problematic use. 50

Funding Cuts with No Clear Plan In the past few years, drug treatment services have experienced severe cuts to their budgets, with some areas set to lose up to 50% of their funding. 51 The Government’s latest drug strategy does not provide any clear guidance or solutions to this issue. There is an increased demand on services to meet the growing number of cannabis users accessing them, alongside other pressures - but no clear action plan or incentives are in place for such a need to be addressed. With budgets being stretched even further and targets still focused heavily on opiate users, vast numbers of problematic cannabis users are being missed. Treatment services not only need more funding, but they require the Government to recognise that street cannabis is an escalating problem in the UK. Regulation of cannabis would not only help provide this funding, but it would create opportunities where treatment services could work innovatively with licensed premises selling cannabis. “The main thing we are measured on in treatment are the number of opiate users who we successfully discharge. While users of other drugs are important the reality is that sometimes resources are tight as the opiate cohort are quite hard to deal with in terms of time, and they are the ones we need to get out to meet the targets.” — Anonymous drug treatment lead worker

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Increased Hospital Admissions for Drug-Related Ptsychosis Hospital psychiatric units have also experienced an increasing number of cannabis presentations over the past ten years. In 2015/16, there were 1606 admissions to hospital psychiatric units for cannabis-related mental health or behavioural problems - a 22% increase compared to 2014/15 and more than double the level since 2006/07. 52 Just like the increasing number of presentations at drug services, this is taking place at a time when there is: • An overall decrease in the number of drug consumers in the UK, including cannabis consumers • An increase in the level of THC found in street cannabis • A reduction in the level of CBD found in street cannabis

The reduction in overall consumption should, in theory, result in a decrease in admissions. However, this is clearly not taking place and street cannabis could be playing a significant role. Research carried out by Patel et al found that, in the UK, 46.3% of first episode psychosis admissions had documented consumption of cannabis and, in terms of their demographic, were mainly male, single and between the ages of 16-25. 53 Far more men were also admitted to hospital psychiatric units for drug-related mental health problems - 70% male compared to 30% female. 54 This data also matches the far higher percentage of male cannabis consumers, who are twice as likely to smoke cannabis than females. 55 This disparity could, however, be due to women avoiding treatment contact and having different needs. The report ‘Mapping the Maze’ highlights how many women avoid treatment services completely and that they are not suited to deal with their needs. 56 The study also found that patients who had documented consumption of cannabis had far higher rates of readmission, spent more time in hospital when admitted, and had increased likelihood of compulsory admission. 57 The research also concluded that there were poorer clinical outcomes within the cannabis-consuming cohort, which could indicate cannabis preventing the effectiveness of prescribed antipsychotic medication. 58 As with drug treatment, when speaking to frontline staff, this same increase is observed.

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“The majority of people being admitted for drug-related mental health problems in my experience have cannabis-induced psychosis… We see people who have been smoking cannabis on a regular basis for years, but who’ve been destabilised after going onto smoking Skunk. It’s like someone drinking four pints of lager a day and then suddenly switching to triple strength lager. It’s going to trip you up.” —D r Derek Tracy, consultant psychiatrist 59

Our research, along with other studies, shows a dramatic reduction in the CBD content of street cannabis, which could be contributing to the increase in hospital admission for psychosis. 60 Admissions for psychosis are the tip of the iceberg when it comes to problems related to cannabis. If we are seeing an increasing number at this tip, it is likely that increasing numbers of cannabis consumers are experiencing problems further down the spectrum. The increase of cannabis presentations in drug treatment suggests that this is the case, as do the statements from those who work in such services who see consumers presenting with mental health problems. As drug treatment services see only 14.6% of those who show signs of dependency on cannabis, most consumers who are experiencing a problematic relationship are not getting professional support and are relatively unknown when it comes to research or data. 61 With 31,819 cannabis consumers in treatment, this accounts for around 190,000 individuals who are consuming cannabis problematically but not accessing treatment. 62 With so many dependent consumers not seeking support, we can only speculate as to the number who experience problematic mental health conditions, but do not access services. With the majority of problematic consumers not getting support, the true scale of this problem is unknown.

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Young People Access Cannabis More Easily Than Alcohol We carried out a survey and a focus group with teenagers from London to find out how easy it is for young people to buy cannabis in the UK. Our findings suggest that young people felt it is far easier for them to access cannabis than alcohol. From our national survey of those aged 13-18, 44% of respondents said it was ‘extremely easy’ for them to get cannabis for free or to find a dealer or a friend who would sell it, while just 23% said the same was true for alcohol. This supports anecdotal comments from the frontline, although further research is required to substantiate.

The focus group also provided similar feedback and even laughed when asked how easy it was for them to buy cannabis: “When I asked how easy it was for them to get cannabis, they literally laughed in my face.” — workshop facilitator “When we’re walking to school, people come up and ask if we want to buy weed.” — Tereke, 16 “If you’ve got the money, you can get cannabis, no problem.” — Harry, 17 “Knock on a door.” — Tereke, 16 The young people also showed an awareness around the quality and type of weed they were buying. When asked in the focus group, respondents said that they smoked ‘Skunk’ not ‘weed’, and knew that it contained a lot of THC. The focus group felt that it was the only type of cannabis that they could buy and knew it was not the safest, but had little other choice: “We don’t smoke weed, we smoke skunk.” — Nubiyah, 16 “But skunk is more available.” — Billy, 16 “I don’t even think it’s that great, but it’s all you can get, there’s just bare THC in it.” — Harry, 17

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Our results suggest that cannabis is easier for young people to procure than alcohol and that, despite knowing street cannabis is typically high in THC and not a preferable experience, they would still rather buy it as nothing else is available. Although some studies have suggested that high potency cannabis is the preferred option 63 , this may be due to a lack of consumer choice and branding of products. With regards to the prevalence of use, data from the NHS shows that young people are more likely to take cannabis than any other drug, and that 26% of 15-year-olds have been offered it, with 10% going on to try it. 64 Out of those who had tried cannabis, 43% had done so in the last month and 20% of 15-year-olds thought it was okay for them to do so. 65 In total, 6.7% of pupils from the ages of 11-15 stated that they had taken cannabis in the last year, making it three times more popular than the entire category of stimulant drugs. 66 This data, alongside statistics from drug treatment and our own research, suggests that cannabis is the drug of choice among young people.

illegality, means higher strength strains, as any other tools for creating market advantages are unavailable. This does not take into consideration any of the product’s harmful effects. While an illegal market continues to exist, young people will remain exposed to street cannabis from an early age, which the existing research on brain development and growth suggests is highly problematic. A regulated market could effectively prevent this problem by reducing the ability of young people to procure cannabis. Even if young people managed to obtain cannabis in a regulated market, effective regulation could ensure high THC, low CBD strains were not commonplace or as readily available. The issues of access are also compounded by the way in which the police are inconsistently dealing with cannabis in the UK. This is creating a confusing message for young people, the implications of which we will now highlight.

Young people should not be able to access a Class B drug more easily than they do alcohol. However, despite the illegality of the market, it is impossible to effectively police and the availability of cannabis is exceptionally high. Street cannabis is typically grown indoors in a comparatively short space of time, which means that the market in the UK is saturated with high THC, low CBD cannabis, sold directly to young people up and down the UK. With the market in the hands of criminals, the priority is on making a profit, with no recourse to effective regulation. The strains that are grown are chosen to maximise profit, which due to the market’s

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Inconsistencies Breed Confusion Since 2010, cannabis arrests in the UK have fallen by almost 50%, cautions for possession by 48% and the total number of people charged by 33%. 67 These reductions have taken place alongside a vast increase in the number of presentations at psychiatric units for druginduced mental health problems and a rise in the number of people accessing drug treatment for cannabis. Our research showed that 76% of young people were worried about getting into trouble with the police when procuring cannabis. However, with police forces struggling to manage the issue, and many areas of the country relaxing their approach, young people should be less concerned about the criminal implications of procurement and consumption. The police are even less able to effectively tackle the illicit cannabis market in the face of severe budget cuts, with police spending having been reduced by 25% by the Government in the past decade. 68 Across the UK, police forces have taken contrasting approaches to managing cannabis. Between 2010-2015, Hampshire police charged or gave a court summons to 65% of those caught in possession of cannabis. During the same

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period, just 14% were charged in Cambridge, while Staffordshire, Hertfordshire, Cornwall and Devon all reported 16%. 69 The inconsistency continues in Durham, where its elected Police and Crime Commissioner Ron Hogg has announced that those growing cannabis for personal consumption are not a priority and that, in low-level cases, it is better to help the individual to recover than punish. 70 While the approach taken in Durham could be seen as both progressive and logical, it highlights the vast inconsistencies that exist across the UK. The result of this is that young people are not given a consistent message about cannabis and the chance of prosecution for possession is a postcode lottery. Police enforcement of cannabis is not working. Many young people are not deterred and the street cannabis market is making vast sums of money, most of which funds criminal gangs. As enforcement is no longer prioritised, police forces are creating their own models of decriminalisation. The Government needs to address this and create a system that provides regulation and control, so money can be diverted out of the hands of criminals and the police can focus on a much smaller illicit market.

Summary This chapter has highlighted the current state of street cannabis in the UK, both in terms of its content and the experiences of treatment services, which are experiencing an apparent increase in its problematic use. There are an estimated 190,000 problematic cannabis users who are not in treatment and there is growing evidence from hospital admissions that street cannabis is having a negative impact on the mental health of some consumers. While it is still a minority of consumers who experience a mental health issue that might warrant hospital admission, these people represent the tip of an iceberg of cannabis consumers who are experiencing low level problems further down the spectrum of these mental health conditions. Part of the problem when exploring cannabis and mental health is that the debate has become so focused on psychosis that we are losing sight of the bigger picture. This is something worth exploring in more detail and will help to further inform the debate.

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Chapter Four: Taking Control The illicit cannabis trade has created a market which is focused primarily on profit, not on the health and wellbeing of its consumers, with no regulation to keep this in check. Not just in the UK, but around the globe, governments have attempted to address this problem through police enforcement and punitive measures. While the focus of this report is not to assess or review these approaches, it must be recognised that change is taking place when it comes to drug policy. Alternative systems are being implemented which provide solutions to the problems highlighted in this report.

The difference between a criminal, unregulated market and a legal, regulated one is not in the incentive to create profit, but the way in which government can implement effective controls over the sale of its products. The illicit market is unmanageable and, regardless of the attempts to clamp down on it, it continues to flourish. A regulated market can be changed and controlled by government - and, in the UK, we have a track record of doing so with alcohol and tobacco. The cannabis market does not have to be in the grip of criminal gangs. It can be regulated, controlled and managed appropriately. The UK can provide a model where those who wish to use cannabis are given the information and support to do so safely. Money can be diverted away from crime and into the economy, where it can be used to support those who develop problematic use.

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Finding a Balance As we have explored, young people are at an increased risk of harm from consuming cannabis. Any proposals therefore need to have the interests of young people at their heart and work to best restrict access. At the same time, it is vital to move the market out of the hands of organised crime. Finding a solution with these two goals in mind creates some tension. A system seeking to prevent access to young people requires many safeguards and controls, such as age limits, pricing strategies to discourage consumption, limits on promotion and advertisement. On the other hand, a model focused on displacing the illicit cannabis market requires the creation of a legal market that can effectively eradicate it. Excessive restrictions could therefore easily lead to the formulation of another illicit market. The key is finding a balance where young people are adequately safeguarded with sensible restrictions on access and promotion, within a regulated market that can compete with the illicit trade. There should also be a balance when it comes to the choice of cannabis given to consumers. This report has raised concerns regarding strains high in THC and low in CBD, but many consumers may still wish to consume strains of such a nature, regardless of any risk. In a regulated market, health advice and information could be provided at the point of sale, allowing consumers to make informed choices. Should there be a demand for high THC cannabis, it may be that within a regulated model such strains are sold alongside adequate health warnings. This would ensure that the illicit market does not re-establish itself and that consumers act within a safer, monitored market that does not fund criminal enterprise.

Harm-Based Taxation There are many options available to tax cannabis and the most suitable method of doing so is likely to depend on the circumstances of the country in which regulation is being considered. One option would be that of a Pigouvian tax system, designed to cover the harms caused by the selling of cannabis through tax. To implement a Pigouvian tax system, the overall social cost of consuming cannabis would be calculated and then the product taxed to ensure that enough money is provided to mitigate against its harms. This method of taxation could be used to ensure cannabis with high levels of THC and low levels of CBD are taxed higher than more balanced strains. This would work in the same way as alcohol taxation does in the UK, where drinks containing a higher ethanol content are more heavily taxed. This kind of system would not only provide a means to fund treatment services, but also encourage manufacturers of cannabis to produce balanced strains. This in turn would encourage consumers to also try more balanced strains rather than sticking solely to high potency cannabis. It would also allow cannabis with higher levels of THC to continue to be produced, although it is likely that such a product would not exist in vast quantities due to the increased cost to the consumer through taxation.

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A Minimum Age of Purchase The evidence presented in this report shows how young people should be safeguarded against easy access to cannabis (particularly street cannabis) due to the associated health risks and current ease of access that exists. Protecting young people from the adverse effects of street cannabis is a priority and setting a minimum age for purchase is t herefore a crucial issue. It is important to acknowledge that age restrictions alone are unlikely to prevent young people from using cannabis and would need to be complemented with preventative measures such as improved access to drug education and restrictions on advertising in order to be effective. Making a decision about age restrictions would require a careful balance of considerations. Setting the minimum age too high might result in the criminal market for cannabis continuing to thrive, but setting it too low could mean that young people are permitted to consume cannabis before their neurological development has stabilised. However, marking out cannabis consumption as an activity that is only for adults, able to make informed, responsible decisions, would be a very positive step to reduce harm. In Canada, where a regulated cannabis marketis being established, the minimum age of purchase has been set at 18, although the task force advising the Government on regulation has recognised the importance of robust measures regarding both advertisement and education.

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“To mitigate harms between the ages of 18 and 25, a period of continued brain development, governments should do all that they can to discourage and delay cannabis use. Robust preventive measures, including advertising restrictions and public education... are seen as key to discouraging use by this age group” —A Framework for the legalisation and regulation of cannabis in Canada 71 The UK could follow the same guidance and ensure that preventative measures are in place to mitigate the harm to this group. The minimum age requirement could also be flexible, based upon the emergence of new evidence and understanding in the area of cannabis and its impact on young people’s brains.

Prevention and Education It is essential that preventative work is undertaken alongside a regulated market to educate and inform young people of the detrimental effects of cannabis use, particularly on brain development, mental health, social integration and educational achievement. The Government’s latest drug strategy recognises the importance of effective preventative work and calls for more evidence-based work to be undertaken in education. The key issue in meeting this call for action is one of funding and resource. However, with a regulated cannabis market in place, tax collected by the Government could easily support evidence-based education 72 programmes, to build resilience among young people and help to prevent problematic use. Regulation also increases the opportunity for treatment services to engage with consumers of cannabis. Our ‘Black Sheep’ report highlighted how most problematic cannabis users are not engaged with treatment services and that the challenges of doing so in an illicit market are complex. 73 If cannabis were to be sold in a regulated market, treatment services could develop relationships with shops selling the drug to establish referral pathways and promote non-problematic patterns of use in the community. Treatment services could facilitate drop-ins, provide promotional material and engage with the community far more easily than they do at present.

Strict Control on Promotion and Packaging It is important to recognise that promotional work and advertising could have a detrimental effect on the efforts of youth drug education and prevention. Irresponsible advertising and promotion could present a mixed message to young people and lead to an increased desire to use, as well as more problematic use in both young people and adults. To guard against this, advertisement restrictions similar to those outlined in the Tobacco Advertising and Promotion Act 2002 would ensure that promotion is only available at the point of sale, in places where under-18s are not permitted entry. There is a debate amongst regulators and the public health community around the extent to which branding should be permitted. A branded product certainly create healthy competition and a high quality of product, but could become irresponsible in its attraction of young people if not sufficiently restricted. The answer appears to lie in responsible and regulated branding, allowing the formulation of brands, but not to the point where branding is irresponsible.

Having additional funding through a Pigouvian tax system could also allow specific services to be established, aimed at engaging problematic cannabis users. At the moment, the majority of cannabis users are not accessing treatment, which suggests that more innovation is required from treatment services to effectively support this cohort.

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Reduced Demand While the demand to smoke cannabis by young people in the UK will no doubt still exist, regulation opens up the opportunity for more effective policy to reduce the number of young people consuming cannabis. With an effective, regulated market in place there will be little need for an illicit cannabis market, and the availability and ease of access for young people could therefore significantly diminish. With such a reduced illicit market in place, enforcement agencies would find the task of policing it far easier, saving time, resources and money. This in turn would reduce the ease by which young people could access street cannabis. As the illicit market reduces in favour of a regulated one, the type of cannabis that young people might be able to procure would change in nature. Street cannabis is grown to meet the needs of the illicit market and therefore contains exceptionally high THC and little CBD. As a regulated market with a variety of strains becomes available, those who do procure the drug illegally via the regulated market are far more likely to access less harmful strains of cannabis. Many of the young people we spoke to for this report said that they only consume strains with high levels of THC and low CBD because it is all that they can get. By removing the illicit market, even those who do manage to illegally access cannabis not only have a choice on the strain (as many young people do procuring alcohol illegally), but they would be in most cases consuming cannabis that has far fewer risks associated with it.

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Reform Provides Solutions Policy reform can address the issues highlighted in this report. We do not have to continue to allow the illicit market to make billions of pounds in profit for criminal gangs and fill the market with harmful strains of cannabis that are impacting negatively on the mental health of consumers. We can take control by eliminating the illicit market, prioritising public health and by giving consumers greater choice in the procurement of cannabis. By providing choice, regulation would cut down on the use of more problematic strains which evidence shows are more likely to lead to addiction. As the procurement of cannabis is currently a lottery and no evidence exists that enforcement can work, the only sensible solution is to follow other countries around the world and create a safer, regulated legal market.

The Cost of Doing Nothing There is a need for a new debate and dialogue around cannabis in this country. While the evidence on the impact of THC on consumersâ&#x20AC;&#x2122; mental health continues to emerge and be discussed, those who appear to be most at risk have ubiquitous access to highly potent cannabis. Rather than waiting for the debate to continue indefinitely and years of further academic research to come to light, we should take steps now to protect consumersâ&#x20AC;&#x2122; mental health and address the issues raised in this report as a priority.

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References: Tide Effect

1. Boycott, Rosie. “Why we believe it is time to decriminalise cannabis.” The Independent on Sunday. 27 Sep 1997. 2. Boycott, Rosie. “Why we believe it is time to decriminalise cannabis.” The Independent on Sunday. 27 Sep 1997. 3. Shukman, David. “Cannabis: Promise, risk and controversy.” BBC News. 18 Feb 2015 4. Shukman, David. “Cannabis: Promise, risk and controversy.” BBC News. 18 Feb 2015; Freeman, T & Winstock, A. “Examining the profile of high-potency cannabis and its association with severity of cannabis dependence.” NCBI. 2015. 45 (15). 5. Cockburn, Patrick. “Is this the ‘tobacco moment’ for cannabis?” The Independent. 26 November 2012. 6. Di Forti, Marta et al. “Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study.” Lancet Psychiatry. February 2015. 7. The study examined 1,000 people in Dunedin all born in 1972-73. They took IQ and other mental functioning tests aged 13 and again aged 38. Every few years they were also asked about their use of marijuana – though this of course meant researchers relied on subjective reports of marijuana use rather than actual chemical testing. ‘It is not possible to definitively prove causality — that the cognitive decline was specific to exposure to cannabis and not some other unmeasured confound,’ said Nadia Solowij of the University of Wollongong. 8. Reece, A.S. “Chronic toxicology of cannabis.” Clinical Toxicology 47. 2009. pp. 517-524. 9. Nutt, David. “David Nutt: my views on drugs classification.” The Guardian. 3 November 2009. 10. Rogeberg, Ole. “Correlations between cannabis use and IQ change in the Dunedin cohort are consistent with confounding from socioeconomic status.” Proceedings of the National Academy of Sciences 110.11 2013. 4251-4254. APA 11. Hickman, Matt, et al. “If cannabis caused schizophrenia—how many cannabis users may need to be prevented in order to prevent one case of schizophrenia? England and Wales calculations.” Addiction 104 (11). 2009. pp.1856-1861. 12. Hamilton, Ian, et al. “Effect of reclassification of cannabis on hospital admissions for cannabis psychosis: A time series analysis.” International Journal of Drug Policy 25.1. 2014. pp.151-156. 13. Advisory Council for The Misuse of Drugs report. March 2015. The exact figure quoted is 2.067m. The report estimates other user numbers as follows: cocaine 743,000; ecstasy 500,000; crack 47,000; heroin 33,000. (38.8m drink alcohol and 9.3m smoke tobacco). 14. Chalabi, Mona. “How many Britons have taken illegal drugs and who are they?” The Guardian. 25 July 2013; Home Office. “Drug Misuse: Findings from the 2012/2013 Crime Survey for England and Wales.” July 2013. Available online here: www.gov.uk/government/uploads/ system/uploads/attachment_data/file/225122/Drugs_Misuse201213.pdf 207

15. Davenport, S & Caulkins, J. “Evolution of the United States Marijuana Market In The Decade Of Liberalization Before Full Legalisation” Journal of Drug Issues. August 2016. 16. Back in the 1960s and 1970s, European consumers crumbled hashish into cigarettes while Americans rolled ‘pure’ joints with dried flower. The American joints were therefore smaller than European ones, though both contained roughly equal amounts of herb. The difference persists. 17. Melberg, H., Jones, A. & Bretteville-Jensen, A. “Is cannabis a gateway to hard drugs?” Empirical Economics. Vol. 38. 2010. 18. 18 Hall, WD., and Lynskey M. “Is cannabis a gateway drug? Testing hypotheses about the relationship between cannabis use and the use of other illicit drugs.” Drug and alcohol review 4.. 2005. pp.39-48. 19. The official figure is 19% of British adults – 20% of men and 17% of women. This means that smoking rates have more than halved since 1974, when 51% of men and 41% of women smoked. The correlation between consumption and social deprivation means that increasing prices are unlikely to be a major cause of this decline. Instead, it almost certainly owes more to (a) greater public health education of the consequences of smoking (b) the gradual phasing out of tobacco advertising (no television commercials from 1965, no still images of people smoking from 1986, and an almost total ban from 2005). 20. “Taking a New Line On Drugs.” Royal Society for Public Health. 2016. The 16 harm criteria are divided into three groups: the harm to users (drug-specific mortality, drug-related mortality, drug-specific damage, drug-related damage, psychological dependence, drug-specific mental impairment, drug-related mental impairment, loss of tangibles, loss of relationships); the physical and psychological harm to others; and the social harm (crime, environmental damage, family adversities, international damage, economic cost and community.) 21. There is also of course the libertarian argument that it is not for the state to tell adults of sound mind what they can and can’t put in their body, and that if an adult wishes to do him or herself harm up to the point of suicide then that is nobody’s business but theirs. 22. Alcohol Concern. “Alcohol statistics.” Alcohol Concern. 2016. 23.

Public Health England. “UK Focal Point On Drugs.” 2014.

24. Boffey, Daniel. “Sharp rise in babies born with foetal alcohol syndrome.” The Guardian, 21 June 2014. The apparent increase in cases of course may be down to improved diagnostic techniques as much as greater incidence of the syndrome in absolute terms. 25. Reminick, David. “Going the distance: On and off the road with Barack Obama.” The New Yorker. 27 Jan 2014. 26. Brownstein, Joe. “Marijuana vs. Alcohol: Which is Really Worse for Your Health?” Live Science. 21 Jan 2014.

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27. “Respiratory conditions linked with cannabis include reduced lung density, lung cysts, and chronic bronchitis. Cannabis has been linked in a dose-dependent manner with elevated rates of myocardial infarction and cardiac arrhythmias. It is known to affect bone metabolism and also has teratogenic effects on the developing brain following perinatal exposure. Cannabis has been linked to cancers at eight sites, including children after in utero maternal exposure, and multiple molecular pathways to oncogenesis exist.” Reece, A. S. “Chronic toxicology of cannabis.” Clinical Toxicology 47. 2009. pp. 517-524. 28. Class A includes heroin, cocaine, crack, methadone, ecstasy, LSD and magic mushrooms. Class B includes cannabis, amphetamines, barbiturates, codeine and mephedrone. Class C includes benzodiazapenes, ketamine and anabolic steroids. 29. Lazarus, Susanna. “Stoned Again: Jacqui Smith on the decision to re-classify cannabis.” Radio Times, 29 Nov 2012. 30. YouGov poll, June 2011. 31. ComRes. “UKDPC Drug Policy Survey.” Poll of 150 MPs, weighted to reflect Commons composition. 9 Sep 2012. Interestingly, there was no significant difference in opinion according to party allegiance. 32.

Bodkin, Henry. “’War on drugs has failed’: public health bodies call for drug use to be decriminalised.” The Telegraph. 16 June 2016.

33. Kirby, Jane. “Health Experts Call for Illegal Drug Use and Possession to be Decriminalised.” Independent. 15 June 2016. 34. Figures as at 30 June 2015, and include all offenders who have had their offence categorised as a ‘drug offence’ and in which cannabis is explicitly stated in their offence description. They do not include instances where cannabis may have been a contributing factor to the main offence committed. Information contained in May 2016 answer by Under-Secretary of State for Prisons and Probation Andrew Selous MP in response to a question by Jeff Smith MP. 35. Accountancy Age. 21 March 2016. 36. HMRC. “Tackling Illicit Tobacco: From Leaf To Light.” 24 March 2015. 37. Smyth, Jamie. “Security: Smoking out the smugglers.” Financial Times. 1 Sep 2013. 38. The RSPH and FPH campaigned for a sugar tax and public space smoking restrictions before they were introduced, so they have a proven track record of influencing government policy. 39. The Home Office would also clearly be involved, as it would assume responsibility for the consumer aspects of a regulated industry, as it is with alcohol licencing and regulation. 40. The issue was put to the electorates of five states in all: Arizona voted not to legalise. 41. McGreevy, Patrick. “Kennedy group puts $2 million into fight against pot-legalization measures.” Los Angeles Times. 1 Aug 2016. 42. The Times leading article. “Pot Luck.” 23 August 2016. 209

43. Rosenhall, Lauren. “California millennials surging: Huge generation could cast decisive votes—especially on marijuana.” The Mercury News. 30 July 2016. 44. Garofoli, Joe. “Newsom warns marijuana legalization in California no sure thing.” SFGate. 21 June 2016. 45. Cannabis is currently legal in four US states – Alaska, Colorado, Oregon and Washington – as well as the District of Columbia. 46. Figures from Rocky Mountain High Intensity Drug Trafficking Area (RMHIDTA) 2016 report and correct as at January 2016. Available online here: http://www.rmhidta.org/html/FINAL%20 Denver%20Post%20HKCS%20Response%20(3).pdf 47. Survey carried out by Quinnipiac University in November 2015. 48. Ingold, John. “Marijuana legalization unlikely to blame for Denver crime increase.” The Denver Post.17 Feb 2016. 49. The Times. August 2016. 50. UNODOC. “World Drug Report, 2012.” 2012. 51. World Health Organisation, Executive Board release 138/11, January 2016. 52. Interview. CTV News. August 2016. 53. Interview. Vancouver News. March 2016. 54. Berlinger, Joshua. “Germany to legalize medicinal marijuana by 2017.” CNN, 4 May 2016. 55. YouTube video, 2011, as part of the Direktzu programme allowing public questions to theChancellor’s office. 56. “Berlin likely to semi-legalize marijuana.” Deutsche Welle. 12 November 2016. 57. Cher, Ladan. “Uruguay’s Half-Baked Marijuana Experiment.” Foreign Policy. 21 Mar 2016. 58. Interview with AFP News. July 2014. Mujica also emphasized that this was a paternalistic attitude a long way from American-style notions of freedom and personal choice. “If I have to take a drug in order to be free, I’m screwed. You can’t buy freedom in little jars. That’s a brutal dependency. If I’m dependent, I’m not free.” 59. Cher, Ladan. “Uruguay’s Half-Baked Marijuana Experiment.” Foreign Policy. 21 Mar 2016. 60. Mike Power, “The Green Screen.” Volteface. March 2017. 61. Wee, Heesun. “California’s high on its billion dollar ‘green rush’”. CNBC. 12 July 2016. 62. Chowdrey, Nick. “How Legalising Weed Would Save Britain Billions.” Vice. 18 Mar 2014. 63. Bryan, M, del Bono, E. & Pudney, S. “Licensing and regulation of the cannabis market in England and Wales: towards a cost-benefit analysis.” ISER, 2011. 210

64.

Data from Washington’s Liquor and Cannabis Board, aggregated by Steve Davenport of the Pardee RAND Graduate School and Professor Jonathan Caulkins of Carnegie Mellon University. Quoted in the Washington Post, May 2016.

65.

I n September 2016, MTV launched the comedy show ‘Mary + Jane’, which follows the adventures of Jordan and Paige – ‘two best buds with the best bud’ - as they struggle to get their weed delivery business off the ground.

66.

Turner, Karen. “Microsoft to move into cannabis industry as partnership announced.” The Independent. 20 June 2016.

67.

I n one respect, Microsoft is better suited to such investment than other global tech galácticos. It is headquartered in Redmond, WA: i.e. in a state where cannabis is already legal. Apple and Google, on the other hand, are based in California.

68.

urner, Karen. “Microsoft to move into cannabis industry as partnership announced.” The T Independent. 20 June 2016. Perhaps ironically given Microsoft’s involvement, Bogue is married to Marissa Mayer, CEO of another tech giant – Yahoo!

69.

urner, Karen. “Microsoft to move into cannabis industry as partnership announced.” The T Independent. 20 June 2016.

70.

Barratt, Samuel. “A framework for a regulated market for cannabis in the UK: Liberal Democrat report.” Liberal Democrats. 8 Mar 2016.

71.

ow in its third iteration, Silk Road 3.0, following law enforcement shutdowns of Silk Road N and Silk Road 2.0

72.

This is of course also why drug dealers have been so attracted to skunk – higher concentrates mean less bulk, so they can carry/smuggle more in one go. A similar pattern could be seen during Prohibition in 1920s America, when the sale of spirits while beer sales fell: beer was too bulky for bootleggers and spirits offered greater profits.

73.

Thomas, Zoe. “Who’s funding the US cannabis industry?” BBC News. 23 June 2016.

74.

Dorris, Jennie. “Marijuana: Past, Present, Future.” Carnegie Mellon Today. 22 February 2016.

75.

sthana, Anushka. “Nick Clegg accuses Theresa May of tampering with drug report.” The A Guardian. 17 April 2016.

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I bid

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