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All Party Parliamentary Group Meeting (Cannabis and Children)

by CanSS, posted 06 05 2014

Charles Walker, MP, Chairman of the All Party Parliamentary Group (Cannabis and Children) opened the meeting and welcomed the speakers.

Professor John Kelly introduced himself and thanked the Parliamentary Group for inviting him to speak:

I have been working in the addiction field for some years.  I am a clinician and a clinical researcher and I have also become more involved in policy as I have gone on in my career.  I grew up not very far from here, about 30 miles south in Gillingham in Kent.  I went over for some training in 1990 and ended up staying in the states where I met my wife.

I am going to talk to you today about addiction of course, and more specifically about cannabis, and we know about how cannabis affects children and particularly adolescents.  So, why should we focus on cannabis?  Why should we spend time on cannabis?  Isn’t it a benign substance that we shouldn’t bother about?  At least, some people would have us believe that, including many of the adolescents that I treat who believe that, and tell me that, it is nothing to worry about and that it is actually good for you and helps your health.  So is that true, can it actually help or does it harm your health?  And it what way does it harm health?  Does it harm physical health, does it harm mental health?  What about your social standing, does your behaviour affect others with when you are taking marijuana?

So there are a couple of things to zoom out and think about as I talk to you today.  One thing that I would like to talk about is the life course perspective.  So why is the life course perspective important?  Life course is important because at different stages through our human development there are particular risks and protective factors which influence the development of certain conditions, diseases, disorders and so from a public health standpoint, it is very important to pay attention to not just the disease prevalence, but when do those diseases and disorders and their problems occur?  What is the impact of a certain risk factor at different stages in the life course?

That is very important to think about.  It turns out that there are very important things that we need to pay attention to when it comes to adolescents in particular, children up to age 18/19/20.

The other model that I want to talk about is the bio psycho social harms. What do I mean by that? I mean that there are biological aspects to illnesses.  There are psychological aspects and ramifications and there are social impacts.  So keeping those two things in mind, they might serve as a useful framework.  The other thing to think about with marijuana is the comparison with other drugs.  When you think about other drugs, how does it play out in in terms of direct impact and also comparatively speaking in terms of both licit drugs like alcohol, or illicit drugs like amphetamines, heroin etc., is it relatively more benign or relatively more harmful and what risks.  So when we think about any drug, whether it be alcohol, marijuana, opiates we can think about drugs doing harm in three different ways.  There are three different pathways in which drugs do harm.  One is through a path way of toxicity, one is through a pathway of intoxication, and the other is through a pathway of addiction.  So there are distinct but related pathways and related to those pathways is both the volume and pattern of use. So, using a lot in one day is more harmful than using the same amount spread over seven days. 

Does that make sense?  So the intensity of use and the volume and pattern of use also has an impact on the degree of harm caused by that substance.  So we think about cannabis.  Does it cause toxicity? Does it cause intoxication? Does it cause addiction?  It doesn’t matter where you are on the life course with regards to the harm caused by each of those pathways.  So what do we know about toxicity of marijuana?  Well, we don’t yet know a whole lot about the toxic effects, but what we do know, at least what is emerging now, is that especially during the period of development called adolescence, the brain is still developing of course.  The brain develops from inside out and from back to front.  The last part of the brain to develop is the frontal cortex.  We now know, and this is something that has become apparent within the last fifteen years, is that the front part of the brain which is associated with impulse control, judgement, abstract reasoning, decision making and putting the brakes on isn’t really fully developed until the mid-twenties. 

This is something that we have only really found out in the last ten years from neuroscience.  So there do seem to be toxicity effects related to marijuana use, particularly during adolescence.  It is adolescents and young adults who are actually using the most marijuana.  That is where we see a peak frequency of use proportionally to population.  So, is there any problem with that in terms of neurocognition, memory, impulse control, concentration?  Does it affect things like that?  We don’t have a lot of data. It is only relatively recently that this has been studied a lot more.  There is though once compelling study that one of my colleagues wrote.  Jodi Gilman’s study has just come out in the Journal of Neuroscience in April and it has just gone viral.  It was picked up in the media over here because it showed structural changes in the brain and the function of the brain after really minimal use.  These were adolescents, an adolescent group smoking moderately, irregularly, not very much and who were matched with those children who did not smoke at all.  What they found was that there were structural changes in the brain. Comparing the scans, the researchers found abnormalities in all 3 structural measures assessed (grey matter density, volume, and shape) in casual marijuana users relative to nonusers.  They found these changes in those who were really very minimal users of marijuana.  So in other words, it has the potential to alter the structure of the brain in ways that could affect things like motivation, aggression, impulse control, attention, emotional processes.  That was just one recent study.  It was a cross sectional study 20/20, so although a very small study, a very interesting one as it is really the first one that shows structural changes in the brain and its functions after low levels of marijuana use.  So what about neuro cognition? 

There are a few studies, short term studies that show a deficit for people who are using fairly heavily, using marijuana fairly heavily, showing again deficits in memory and attention specifically.  There are several short term studies that show this.  There is another study that shows the relation to this toxicity we are talking about.  Can it cause damage in the brain that can have long term implications?  This study was actually done on a New Zealand cohort over 25 years.  It involved kids from aged 13 until they were 38.  Now why did they do that?  There were 1300 13 year olds and they looked at all factors.  They looked at marijuana use, they looked at alcohol use, they looked at other drug use, all types of behaviours, and cigarette smoking and they looked at the influence of these factors on neurocognitive health.  What they found was that during this period of adolescence, up to age 18, if you were a heavy user of marijuana during that period, and only during that period, you had an 8 point drop in IQ at age 38. 

So what does that mean?  What is the main point?  Well that means that you drop from the 50th percentile to the 29th percentile.  So if you were of average IQ and you smoked marijuana heavily, you dropped down to 29 percentile.  That is a pretty significant drop.  In fact, what was also remarkable about this study was that other people (they also interviewed people in the close social network during this period of study) and they asked them, “Do you notice this person having any memory retentive problems?”  The people who smoked heavier as teenagers, it was noticed that it was observable by people in their close social networks.  So in other words, there were observable deficiencies that were attributed to the use of marijuana as teens.  Now this was also apparent even when people had stopped taking marijuana.  So even if they were not using in the past year or longer, they still showed this persistent neurocognitive decline.  This study systematically went through and ruled out every other possible compound, including alcohol use, other drug use, and any other factor that could account for changes in IQ.  They systematically ruled out all of these.  That is why this study is so remarkable.  We need more studies like this.  They are rare as we don’t yet have 25 year follow ups.  We have a lot of retrospective stuff but this is a valuable piece of evidence that suggests that marijuana can and does cause neurotoxic damage to developing brains.  Also that it can have long term ramifications in terms of neurocognitive functioning, memory and attention.  So much so in fact that other people can notice it. 

So, what do we know about toxicity?  It seems that there is some evidence to suggest both also from animal studies as well as with humans that shows that cannabis use can be neurotoxic.  Now, what about after the age of 18?  We don’t know.  Probably the other thing to remember about that piece of evidence is that those people were smoking marijuana that was actually less potent back then 25 years ago.  On average potency, and of course the availability of what people smoke, the potency is now about 103%  on average higher than what it was in terms of THC content.  So typically, what you find with all drugs, including alcohol is that the higher the availability and potency of a drug, the higher the risk of harm. Neurological harm as well as the risk for addiction.   You are more likely to be addicted if you are exposed to a high potency form of a drug the higher the risk of addiction. 

So what about intoxication?  I said there were three pathways – toxicity, intoxication and addiction of cannabis.  Intoxication – clearly marijuana, the smoking of marijuana causes acute intoxication.  That is why people do it.  They like the feeling of being intoxicated.  The active ingredient of marijuana, THC – delta 9, although there are many different cannabinoids within marijuana, produces the high although there are other potent cannabinols as well. It produces this feeling of euphoria, anxiety reduction, sedation, sometimes sleepiness and other effects as well.  Now these are the effects that people like and want repeated.  That experience is mediated, like with other drugs, through the dopamine reward pathway in the brain.  It comes from the brain stem, up through the mid brain, etc, through the brain neuro circuitry – a circuitry of reward.  Like other drugs, that is what causes addiction. All drugs work similarly through that pathway in the brain.   The mechanism by which it eventually gets to the dopamine pathway is a little bit different with marijuana.  It operates through cannabinoid receptors which are designed to be receptors for a naturally occurring ligand in the body called anandamide.  Anandamide is in fact a Sanskrit word for bliss!  So we have this general thing inside the body so like opiate which are a fit for opioid receptors, we have this natural fit too for marijuana. That then causes it to cascade mainly through the transmitters in the brain which eventually leads to the feelings of euphoria, pleasure, etc. which also causes intoxication.  

So what does that mean? Because it causes intoxication, it causes psychological damage, it means you are more likely to fall over, you are more likely to have an accident, you are more likely to have your judgement impaired, it means your visual and spatial awareness are impaired, attention and memory distortion in terms of time and space which can affect all kinds of perceptual orientation. So, does it cause intoxication? Yes!  There can’t be any argument that it does indeed cause acute intoxication.  The problem of course with the way things have moved in the United States with medical marijuana which is really back door legalisation, but I don’t want to go into that now.  It is very unclear; the evidence base for smoking marijuana is very thin and is highly variable.  There is evidence though of THC as a therapeutic agent and we have THC approved medications.  These have been approved by proper scientific process and have been shown to work in the ways that they were intended, but there is very little in evidence for smoked marijuana, except potentially  in spasticity in multiple sclerosis patients.  So it is known that THC has therapeutic value, like opiates do.  We use heroin in hospitals (morphine) and cocaine as pain killers because they are very effective.  We also use THC in hospitals because it is effective at treating certain conditions.  The question that remains is, that is medical marijuana is a good idea to recommend?  Can we recommend smoking marijuana when we don’t know what is in it and how much THC you are going to get etc and it has not really been thought through and yet it has been legalized in two states, Colorado and Washington?  That means a nineteen can smoke 24/7 legally without fear of being caught.  So we will see what happens there, but, for sure what will happen is that we will see more drug driving. Problem is, we don’t have good road side tests for testing people under the influence of marijuana like we do for alcohol.  But what we do know, is that we will see more people under the influence, and although we will be unable to see as clearly that they are intoxicated as we can with a breathalyser for alcohol, there will be more accidents and deaths because their ability to drive safely will be impaired. One question that arises though is whether people will use less alcohol as they use more marijuana.  That is something that we just do not know. 

So what about addiction? So people say to me, I was at a school in South Boston where I was talking to social workers.  I am doing a study right now, a free treatment study which is sponsored by the National Institute of Health in the United States, and they are giving me money to test out new treatments for adolescents with marijuana and addiction. So, I am down at the school after she said to me come on down as we have a lot of kids using marijuana and they are not doing much schooling.    She said to me, well, marijuana doesn’t cause addiction, does it?  We know that!  So here is a trained, qualified social worker, working in schools, who has this belief that marijuana doesn’t cause addiction.  Meanwhile, 70% of young people who come into treatment in the United States, their primary substance is marijuana and probably 90% of the kids that I am seeing right now in the study that am I running use marijuana as their primary substance.  And does it cause addiction?  Yeah, it causes the same syndrome of addiction as all the other drugs.  There is tolerance, there is a withdrawal.  Typically, the consistent findings are, there is withdrawal where there is a heightened anxiety, sleeplessness, anorexia or loss of appetite.  In other words, the withdrawal syndrome symptoms are always opposite of the acute effect of the drug.  If the drug makes you very sleepy, tired, mellow, hungry, the opposite will be true in withdrawal.  You will be agitated, anxious, have difficulty sleeping, you won’t want to eat. The other thing is that there will be strong cravings for the drug.  This is the idea of what happens when tolerance develops.  Because tolerance is a bunch of brain annotations. 

In other words, if you take too much of a drug, your brain will try to adjust and adapt to the presence of that drug.  It will try and regulate the receptor systems into which the chemical dopamine which gets released by the drug fits, and when the brain tries to compensate and turn the volume down, less of the natural substance is produced and available.  That means that you have to up the volume of the drug you are using to get the same effect that you are used to and so on, each time you use more of the substance, the brain releases less of the natural substance and more of the drug is needed to get the same effect, and so on!  That is what happens with drug addiction, you have to take more and more to get the same effect, and the same thing is true of marijuana addiction.  This continued use and needing to use more and more are all the classic symptoms associated with addiction syndrome.  These are also true of marijuana.  So, toxicity, intoxication and addiction all occur with marijuana.  Again one of the other things that is also true of marijuana as with alcohol and other drugs, the earlier the developing brains exposure to it, the higher the risk of addiction.  There is something about early exposure, independent of other factors, including genetics, it doesn’t matter if you have a genetic loading for addiction, independent of that, if you are exposing adolescents earlier to alcohol for example, you increase their risk of a lifetime addiction to it between 4 and 8 times.  The same seems to be true of marijuana, because the developing brain seems to be particularly vulnerable to the effects of neuro toxicity. So, so if you delay the initiation of marijuana use, you lower the chance of addiction.

So, what do we know about treatment?  I was shocked and disheartened earlier in this room when someone told me that there is no adolescent treatment centre in Great Britain.  That is so shocking and I can’t believe it. 

In the United States we have about 14,000 treatment centres specifically for adolescents, (about 25% of the total).  So why is that important?

From a public health standpoint what are you going to do as a society?  Are you going to, as a society, run away and wait until everyone is much more severely impaired and much more addicted?  That is, to my mind, a very backwards way of thinking let alone the suffering that those people endure.  What about the suffering of their families?  I am so shocked to hear this.

So what would treatment look like if it were possible and here?  In the States we have the same kind of intervention treatments that have shown to be effective for adults and we have adapted it and it has shown to be effective with adolescents.  These are things like community enforcement, cognitive behavioural approaches, contingency management, and assertive, continuing care.  They are shown to be innovative practices because young people are often not that motivated to seek help.  We find that they are often ambivalent.  They do recognise to varying degrees different problem behaviours associated with their drug use, such as getting into trouble at school, low grades, bullying, etc.  We do need different models which can be adapted again to different stages of their life course.  So let us not wait until it is critical.  It is far more expensive and the prognosis of recovery is not so great. The other thing that is coming into play is more recovery support services and that is what we are going to come on to next.  In the states we are starting more Recovery High Schools where not only do they receive treatment but we also have recovery focussed environments where young people can return to a very low risk environment to maximise their potential for succeeding.

Charles Walker then introduced the next speaker:

Dr. Jeff Brain, MA, CTS, CEP

I am the Dean of Admissions at Allynwood Academy.  I have a Masters degree in Clinical Psychology and I am a therapist and also a certified trauma specialist and a certified educational planner.  We are here to talk about what our other speaker was alluding to about a unique and successful school based intervention for adolescents that are struggling with cannabis use disorder.  Allynwood Academy is a private college preparatory twelve step orientated therapeutic boarding school for high school aged students who are struggling with substance abuse disorder and related emotional and behavioural issues.  So I would to first speak and have you identify with the type of student we most typically see in our school.  Our students are bright, high school aged students who become derailed in their functioning, both at home and at school due to any number of underlying emotional issues such as anxiety, depression, ADHD.  They typically turn to substance use to fit in, to self- medicate or to avoid the social, emotional or relationship challenges they are facing as teenagers.  Most are treatment resistant, more oppositional, more defined than is typical for an adolescent.  They have begun to under achieve academically or drop out of school completely and have lost interest in hobbies.  Many gravitate either towards negative peer groups or become increasingly isolated.  Many have history of trauma that have been precipitants or accelerators of their decline and some have gotten into trouble with the law, mostly on charges related to substance use, for example, possessing marijuana or cannabis whilst on school grounds.  The drug of choice for a significant proportion of students at Allynwood is cannabis, and it is in our experience, particularly challenging to address.  We see first-hand the wreckage cannabis creates for our students and their families. 

So, why is it so challenging?  First is the popular rhetoric that cannabis is benign and in fact medicinal.  As you likely know, and we talked about it earlier, several states in the US have legalised marijuana, even for recreational use.  So this cultural mind set and the advocacy that changed the laws which border on propaganda are eclipsing the very real damage that cannabis has on young people.  It is easier for people to agree that if you are putting a needle in your arm that you an addict and need treatment.  It is much harder for people to recognise the need for help with cannabis when our students think that everyone is doing it.  Of course, with increasing frequency, they are correct.  This is the first very real obstacle that we face as a school because the culture around the cannabis movement increases the adolescents resistance towards treatment.  This information gap has them believing, against the evidence of their lives that cannabis cannot hurt them.  It is in collusion with the disease, yet, as I said, we see first- hand the damage it is exerting on 13, 14, 15, 16, 17 year olds who are enrolled at the Allynwood Academy.  I would now like to introduce our Head of School, Richard Reeve, who oversees both the academic and therapeutic services at Allynwood.  He is a former teacher and principal.  Richard is now completing his training to become a certified Jungian Psychoanalyst at the C.G. Jung Institute of New York City and he will speak about the unique profile and challenges of cannabis use amongst the students we have.

Richard Reeve

Thank you for letting me speak on this issue.  I just want to bring into focus how the cannabis user presents us with specific challenges that are different from students who come to us whose main issues are alcohol or other addictive drugs of choice.  What we see is that in many ways, the cannabis addicted student is our most difficult student to work with.  Those students coming to us with heroin as their main drug of choice are much more available for treatments based on the chaos that they have experienced in their life journey.  The students that come in with cannabis use disorder tend to have a pattern of apathy that keeps them, often times we see it, six to nine months, just sort of waiting it out, not really engaging, before we might even begin to see a willingness open up for them to look at themselves, look at their lives and start to participate in the therapeutic process.  We also see a tendency, a very common tendency with these students for withdrawing and isolating patterns that continue even though there are no drugs and their clean time has been established.  So it is as if, if you can imagine, that they are continuing perhaps through internal reverie or imaginative processes or what is sometimes is called in the language of dissociative posture to maintain the brain functioning that they were indulging in, in their use, so their abilities to attend or to be present and to attend to their jobs or in being students.  It is a long slow process to get them back into the classroom and engaged in their studies.  Again, different from those students whose primary choice of drug is alcohol or opiates.  Our parents are seeking help for their sons and daughters with this issue because in their journey, most of these students have been doing well academically and when consistent use of cannabis kicks in, you can watch the transcript move along and there will be a sudden plunge and you can actually time when the use began by that significant pattern and so the students that are coming to us with this issue have holes in their transcripts and a drop in their GPA  and they are functioning academically at a much lower level than they were before their use of marijuana began.  Also their families; we do an initial seminar every month with the new families.  Every month I get to hear the stories of six or seven families and the journeys that they are going on, and unlike the students with the alcohol or the opiate issue, which are the other two primary drug use issues we face, the parents of the cannabis use children have a feeling of having lost their child.  The child is present, the child is part of the family system dynamic, but it is just as if that child is simply not there for them. We do not hear that as much, it is not part of the stories when we listen to the stories of other parents whose children’s drug of choice is not cannabis.  I think that is an interesting factor, the impact on the family itself.  I also want to focus in on an issue that is an important issue in adolescent development which has to do with the capacity to be attentive and the way in which a child recognises and understands time. 

What we find is that the students who come in with the primary diagnosis of cannabis use disorder; this issue is much more in array.  Their sense of being able to track time, their sense of being able to understand stretches of time; it is as if time itself has been lost.  They seem to have lost their capacity to be able to relate to time in what we would consider a psychologically mature way.  We do not see that with students who have other drugs of choice.  So in closing, I would just say that, and this is a very concerning thing as well, and there is a lot of research to back this up elsewhere, but in the past six months at our school, we have had experience of students being clean from their marijuana use for longer than a month, one for three months, who have started to have symptoms, psychiatric symptoms emerge,  which they experienced initially as flashbacks that they related to their drug use, but they continued in that experience until full blown psychiatric breaks and then had to be placed in psychiatric hospital to be stabilised and balanced out.  So again, in our experience of students coming from other different drugs of choice backgrounds, we do not experience that.  I think that is another important piece to keep in the mix is the danger that we are seeing in the students that are coming to us, primarily focussing on the cannabis use issue.  There is good news nonetheless, and that is that we work with these students and we are a long term programme and with the appropriate safety and them being put in an environment that is drug free, and given the time, we see that a long term recovery is possible for adolescents and even if they have been significant users for many years, but the journey and the progress, is in our experience, is significantly slower  to get for those with cannabis use disorder than for that of those students whose drug of choice is other than cannabis.

Dr Jeff Brain

Why it takes so much time is that all our students benefit and have to relearn; learn new coping mechanisms and have time to practise them.  The drug use has robbed them of that opportunity of learning and going through a maturation period where they are learning healthy, adaptive mechanisms and coping mechanisms.  Of course, we are doing the intervention and support through those critical teenage years of developmental maturation.  What is also important for us as a residential programme is the removal of triggers and the enabling dynamics of family systems, and it provides meaningful time away from the using environment to heal and get re-grounded.  Most importantly especially with our cannabis use disorder students is that they need time to clear, to re-engage and to address their denial.  In our experience, it typically takes six to nine months for students in a residential setting to begin to really re-engage and become available for learning academically, to become available for therapy work and for recovery work.  So to get to this point however, it takes a tremendous amount of resources.  For example a two year stay at Allynwood Academy costs upwards of about £80,000.  So why so expensive?  Well, at Allynwood, when you think about our model; this is what it looks like and what more we are charged to do.  So we are providing a drug free safe and nurturing environment for healing to occur, a private education that equips our students for college, we are providing extra-curricular activities such as athletics, music, art, drama to provide outlets for their talents and interests.  We are providing intensive therapeutic and recovery support which includes individual, group and family therapy and the opportunity to work with a twelve step sponsor and attend twelve step meetings.  We provide opportunities for real enjoyment and fun through the variety of the experiential and recreational activities and we also provide opportunities for our students to development or strengthen their work ethic and interpersonal relationships – essentially, to learn how to work and play with others, and we do this 365 days a year. 

Yet just providing the intervention and education and treatment is not enough for our students.  We also provide meaningful opportunities throughout our students stay to gradually but progressively experience new levels of freedom and responsibility.  This is a critical point for treatment for substance abuse and cannabis use disorder students.  The transitional work is crucial for sustaining the work and the change.  The fact that Allynwood students have the opportunity to come out from what I call the therapeutic umbrella and get rained on a bit by re-emerging back into the world means that some of our students are able to take High School and college courses at a nearby Community College whilst also having the opportunity of living at our college student housing and receiving therapeutic case management and recovery support as they make that initial transition into university life.  It is those transitional opportunities which really equip our students to handle life on life’s terms.  So we are really charged with carrying students through a long period of time and doing intervention, rebuilding, re-strengthening and then transitioning them into what lies ahead for them.  Thank you and we much appreciate being here.

Questions and Answers

Charles Walker: 

I am going to start off the questions with a question for John. Thank you for a very good presentation.  Why on earth did two states in the United States recently legalise the consumption of cannabis?  Surely, and I know you have advised the governments of the United States of America, surely your arguments had some cut through but clearly not enough.  Do you have any idea on why Colorado, for example, voted to legalise this poison?

John Kelly

I think the reason why is because the people who are strong advocates are very well mobilised and thus they are able to convince people that marijuana, and they make the same case that a lot make for legalisation, that you are better off legalising because of all the crimes associated with it.  They make the case that if you legalise it, you can tax it and gain revenue, it is benign and that there are no real discernable harms associated with it, it is much less harmful than alcohol which is already legal, etc.  They make these arguments and busy people buy what is on the electoral forms and voting forms.  It is uncool etc to stand against marijuana and generally people have gone along with it.

Richard Reeve

I would agree with that.  It is also that the campaign to legalise has been highly funded as well so there have been much more resources poured into the political argument to legalise than for arguments not.

Charles Walker

Right, I would just say that this and then I will throw it open to the floor.  Alcohol is legal and it is a disaster and we can’t protect our children from it. It has destroyed many young lives and the idea that somehow if we legalise cannabis we will protect our children is nonsense.

Nigel Price

In relation to the legalisation of cannabis in Washington and Colorado, are there any plans in place to review this or is that it, it is now legal and whatever, or, are there any plans in place by legislators to look in say 5 or 10 years to see the impact this legalisation has had across the social divide of the United States?

John Kelly

I think there are plans.  That is what has been talked about.  The problems is, there has been a clever move by the legalisers that the tax revenue from cannabis is tied to schools in Colorado.  Now, if you try and make it illegal again, it could be said that you are actually robbing our school system of much needed money.  It makes it harder and harder as time goes on to separate the revenues.

Nigel Price

They need to show many schools are being built from the revenue.

John Graham

Thank you for your erudite presentations.  They are very relevant to evidence of what this particular event is all about with regards to the effect of cannabis on children.  A relevant observation I would like to make myself is that recently, for the last several months, I have been working with a young offenders’ team at Camberwell magistrate’s court which is one of the hub magistrate’s courts in London.  I have doing what we call DRR assessments, that is drug rehabilitation requirement court orders which are an alternative to a custodial sentences where the individual is mandated to engage in a structured treatment programme.  Now the relevance is that I have been doing two or three assessments each day, some are by video for those that are in custody, that is in prisons, and some of the individuals, it is all acquisitive crime, some of it very serious, some of them have opiate or alcohol issues, but all of them, every single one and I am not exaggerating, marijuana/cannabis features in both their recreational activities and their offending behaviour and that is what comes out in their assessments.  I think that is very relevant in this context.

Jeff Brain

We have heard the same message from our students often, who will be willing to work in recovery on eliminating the heroin or alcohol or the something else but who still wish to maintain their cannabis use.

John Graham

I hear that all the time too, that they are not going to give up their marijuana use because they don’t see it as a problem.

Kathy Gyngell

Just a quick point to explain how complex the situation is here; we have had something that is called adolescent drug services but we have no adolescent rehabilitation services.  There are many more people here who are much more up to date than me, but we have a budget of something, it is not huge, but about 25 million a year, but the syndrome is, when I visited a lot of these services, the old social workers syndrome is that you can’t get them off cannabis and what we are worried about is if they move to class A drugs.  So it was a denial of our cannabis problem and then a defeat about whether you could do anything about it, even to the extent that I went to a conference of adolescent addiction psychiatrists and some of them there were working in semi secure units.  One of them said when they are out for the day (they are allowed out and to go and see family etc) can we drug test them when they come back?  So there was no punitive sanction going on even in secure units about anyone wanting even to challenge it.  They have gone out and used, and they are pretty sure that they have obviously used before they came back, so we have lacked any sort of determination in these services and confidence amongst the adults dealing with these kids.  We have given the kids the power really.  But amongst the professionals, who are as far as I understand it, I may be wrong and there are professionals here who may correct me, so in a way we have this terrible situation to what amounts to where addiction treatment services are colluding in a way with the problem.

Jeff Brain

We have seen that with parents too.  Parents fall victim to that feeling that somehow they have lost with cannabis and therefore they set the standard on some other behaviour of abuse and it is a real issue that we face when we try to intervene to help the families and bring the standard and thresholds down even that cannabis use is unacceptable and we then point to real evidence in their children’s lives where grades decline, sometimes they are using at aged 12 and 13 year old.  There is the evidence there for them to see that it is the cannabis that is the real problem. 

Kathy Gyngell

We certainly have nothing like your high school here, nothing, nothing, nothing!  We don’t even have a single residential teenage rehab centre!

Charles Walker

Your high schools you pay for?  This is a private school?

Richard Reeve

This is a private school, yes.  You pay for.  This is not a recovery based high school paid from public funds.  This is a private school.

Charles Walker

How many recovery based high schools are there in the United States?

John Kelly 

I think about 150.

Charles Walker

Which are funded by the state?

John Kelly

I think about 6.

Sarah Buckingham

I am on the Board of Trustees of a county based drugs/alcohol charity which is now one of the top charities in the country.  They are now taking on a large proportion of mental health in that county as well and the CEO of this charity is advocating the legalisation of cannabis.  Now how on earth, what stance can we as Trustees of this charity take to alleviate promoting this stance?  It is a really difficult one.

John Kelly

I think you have to look at rationalising this against the rational case for legalisation such as what would be the benefits of legalisation as against the harms associated with legalisation and I think there are good arguments on both sides.  On one side we have to look at public health and security and safety.  There are different arguments here.  On the one hand, do you tax it and regulate it and perhaps reduce crime.  Then on the public health side you could say that if you regulate it, you make it cheaper because it is now legal so the price should come down and it will become more available meaning that the public health harms will go up to the extent that equally it will cause harm.  The point that Richard raised which I forgot to mention is the point of psychiatric damage in terms of the onset particularly of psychosis.  There is a strong link with THC which is not present with alcohol or other drugs but it increases the risk of chronic psychosis including chronic psychosis like schizophrenia which does not occur with other drugs and which may not ever happen unless that person is exposed to marijuana.  That is a really severe life programme shift.  That will destroy the quality of your life.  If you get chronic psychosis or schizophrenia you don’t get rid of it and it stays with you for the rest of your life.

Charles Walker

Professor Kelly, I do a little bit in the mental health area and a diagnosis of schizophrenia/psychosis schizophrenia in this country shortens your life by 15 to 20 years.  In managing the patients, they manage the symptoms but they don’t manage the patients so they gain weight because of the drug therapies, they tend to smoke 60 – 80 cigarettes a day and no one cares, they make nuisances of themselves and hence your life expectancy is then reduced by 15 – 20 years so there is a huge public health issue around legalisation which needs to be more properly aired.

Graham Burford

Does cannabis affect co-ordination skills?  Does it affect driving?

John Kelly

Yes

Graham Burford

So with alcohol, you have a set limit above which you get fined and sent to court.  There is no limit for cannabis use though.  Is there some test that they say, that if you have a certain mistakes in a driving test you will get fined or you will be free.  Can they be taken to a police station and sat in front of a machine and if they pass that is ok, or if not they are taken to court?

John Kelly

We don’t have any such test right now.

Graham Burford

What will happen in Colorado?  They say in Colorado they might get more accidents, can they then statistically say this is due to cannabis or can they do tests like that?

John Kelly

They can try and infer that and there are ways, observational methods that you can use to rule out other factors that could be attributable causally as much as one can in the circumstances to the use of marijuana.  There will be people tracking exactly this.

Jeff Brain

Yes, I just wanted to say that if I am correct, it is going to be more of a case of a process of elimination.  For instance, no smell of alcohol, well then what are the reasons why you are driving impaired and then they will try to prove it is down to marijuana.

Graham Burford

There surely must be some level laid down?

Jeff Brain

They can’t test for that level.  The pee tests are highly unreliable so the only way we can get reliable drug test results is to send blood tests off to a laboratory.  That is expensive and it also takes time.

Deidre Boyd

We have a global toxicology expert at the back.

Expert

They use a salival based test as a roadside test outside of the United States.  Salival tests can give determination of whether you have used marijuana within the last four hours and prove intoxication.  Saliva tests outside of the United States, in Germany for example, will determine if you are intoxicated.  It has to be done recently otherwise it gets out of the saliva system too quickly and then you have to go to a lab.  Short term it can be tested in your saliva.

Charles Walker

So, why is it only used outside the United States?   Why not in the United States?

Expert

It is not yet approved in the United States.  My former employers are working with the State Department on this right now to get an approved saliva test in the States.

Dr Barry Twigg

It has been really inspiring to listen to you all tonight and what you are all doing in research and treatment. To what extent are your findings and experiences being communicated to young people in the United States and how effective is it?

John Kelly

There has been a shift in the overall perception of harm among young people.  There has been a climb in its use, partly because there has been a cultural shift and the perception that marijuana is less harmful.  The advocates of legalisation of course have pushed medical marijuana.  That sounds very good because if something has a medicinal value, therefore, what can be wrong with it?  It is therapeutic so people generalise that.  So what is happening is there is a downward turn of the perception of risk which has correlated with an increase of use.

Dr Barry Twigg

So what is going to counteract this?

John Kelly

It has been a struggle to try and counteract this.  There has been more of a push from Federal Agencies from the White House, with anti-drug policies and agencies working with drug abuse, particularly with people now rushing to do more research into what are the risks and harms associated with marijuana use.  Actually the Federal Government in some way only has itself to blame because it has disallowed a study of marijuana.  They would not allow a study of marijuana for a long time and so there has been very little research done into the harms associated with marijuana use and the smoking of marijuana.  Now there is a national anti-drug media campaign together with a national effort to try and educate young people of the risks involved with underage use of alcohol and the use of marijuana and the damage that it can cause to their brains.

Dr Barry Twigg

So there is a Federal educational procedural campaign and syllabus that is used in all American schools?

John Kelly

Yes

Jeff Brain

What is challenging is the effectiveness of it. The programmes in our schools are now starting at a very young age to educate children about the effects of drugs.  The challenge is that most often children will listen to peers rather than listen to adults and it is the adults are the ones who are reporting and challenging the abuse and all their friends are using.  The campaign is out there but until, and part of the work that we have done in other schools in recovery high schools, is really that kids talk to other kids to talk about their own experiences, like only one teenager can really talk to another teenager about the realities of what they went through and how they are handling the decision to speak about the dangers of it.

Dr Barry Twigg

Sorry to come back on this, but are there Federal or State programmes to ensure that this peer education takes place in all schools?

John Kelly

The question of effectiveness is a different question.  Whether they do it or not is one question.  How effective it is, is another question, because it is very hard to give an education on prevention.  It is an important distinction here.  We have an effective prevention programme or you educate the people about the risks of it.

Charles Walker

What is the prevalence of drug use amongst teenagers in the United States?

Richard Reeve

Gosh, I don’t have the numbers off the top of my head but I know that in terms of frequent use I think it is about 15 to 20%.

John Kelly

In terms of marijuana use among high school aged students 14 – 18 year olds I think it is about 30% and daily use is about 8%.

Anthony Bright

I find it really encouraging that there is a twelve step based recovery programme for kids but I find it very worrying that you are legalising skunk and cannabis and what I find really worrying is that everyone seems to be singing from a different song sheet.  Everyone has got an opinion.  My son had psychosis and his CPN worker said to him “don’t smoke strong strains of skunk, may be just smoke a weaker grade”, so it seems so bizarre that everyone is singing from a different song sheet.  Now, I started smoking marijuana and I ended up on heroin so it is a really dangerous road, even with the old marijuana.  So is there such a thing where you could all be singing off the same song sheet so the young kids do get a bit of rope and realise or given choices because kids haven’t got any hope and that is what is quite sad and all these experts are singing from different song sheets”

Charles Walker

Obviously, there is going to be a diversity of opinion in any argument or any debate, but it does seem as the health risks of skunk become more widely known and more appreciated, so the voices of the legalisers seem to become louder and the traction they have increases and that seems at odds with all the evidence that is coming out.  Perhaps you could frame a response to the gentleman with that addition to his question.  It seems that all the evidence that you have been suggesting is that people are becoming more and more aware of the dangers and yet still the band wagon of legalisers is gathering pace in the face of growing medical evidence that our children’s lives and prospects are  being put at risk by these drugs.

John Kelly

Yes, a big part of this getting everybody onto the same page is getting the facts out there, getting the consensus on the scientific facts.  Because we can’t randomise people, because they are human beings, we have got to get the proof through studies because we can’t randomly expose people to marijuana and not expose a control group. We couldn’t get approval to do those things, so we have to do is a naturalistic study which is always open to criticism and people can come along and say that things could always be caused by this and that even that involves the New Zealand study – people after the fact, even though we ruled those out – that this could be caused by this and that could be caused by that and how do you know that didn’t work negatively, they will poo poo and trash it just to fit their storyline.  So you are always going to get opinions.  What we have to do is the same as we try and do for other drugs like alcohol. We still have legal drinking. We know that it does do dramatic harm and we have to try and do the type of things that we do there and minimise the extent of harm.  We have to do the same with education, proper prevention, understanding the neuroscience of how alcohol enters the brain,  many people know that, putting warnings on cans and containers and we will have to do the same with marijuana, making sure that people know and understand what the risks are, but still people are going to do it. They still do it with alcohol and they still do it with tobacco.  The cancer report that came out with alcohol, the World Health Organisation put out a warning that alcohol is a class 1 carcinogen; it causes cancer, now not a lot of people know that it causes cancer.  It increases breast cancer risk between 7 and 12 per cent even with a very low dose.  We know that with alcohol, but we need to be there with all these substances really with multi-pronged efforts to reduce harm.  As a society if we have a will to do it we will reduce harms and improve public health.

Colin Hart

Here obviously there is a very strong movement against public smoking.  It is illegal basically.  I don’t think you have that in the United States.  I guess most people, kids taking drugs are smoking it aren’t they?  They are smoking cannabis and there is a very strong relationship with smoking.  It seems to me that we have had the argument from the medical establishment here that schizophrenia; there is a link that is not causal, now it is accepted that it is not causal.  You were saying Professor Kelly that you could have psychosis that you would not get in any other way.  Could you say a little more about the studies that are showing that you can get psychosis through taking cannabis and not get it in any other way?

John Kelly

Well, these are all naturalistic observational correlation studies that have been carefully controlled with other causal factors taken out.  It may be that with certain people they may have had a genetic predisposition to developing psychosis.

Colin Hart

But they might not have occurred?

John Kelly

That’s right, they might not have occurred.  So again, like most illnesses, the interaction between genes and environmental factors, the same seems to be true of schizophrenia, so all you have is time.  Identical clones will develop schizophrenia.  If the clone of someone, well half the time that person is going to develop schizophrenia, so even with an identical clone it is not guaranteed that both will develop schizophrenia.

Charles Walker

You mean a twin?

John Kelly

Yes, twins, that’s right.  In other words, it has to be some kind of maturational developmental/ environmental exposure that occurs for that to happen.  So you are absolutely right, here is an agent that we know has a much higher propensity of inducing psychosis that doesn’t seem to be apparent with other kinds of substances.  This psychosis would not happen in any other way without the exposure to THC.

Nigel Price

It seems to be that is a strong argument and I wonder whether that is the sort of argument that kids might consider that it could send you mad if you take cannabis once, and it might only be once. The medical statute here is that they say whatever the arguments are about cannabis, alcohol is worse.  It seems to me that you are not going to take alcohol once and become mentally ill but that is true of cannabis.

John Kelly

I don’t know about one time, but maybe in some cases that may be true, but again it is about the overall harms attributed to various behaviours.  Someone might say that bungee jumping is dangerous and someone might say that riding a bicycle on the street is dangerous also, so it is all about how we view public health and what we are willing to do about it as a society and how tolerant we are going to be with the casualties, because undoubtedly there are going to be casualties.  If we make something cheaper and more available that is going to do harm then there are going to be more casualties.  Now unless we as a society are going to say let’s absorb those casualties, and we going to pay for them as we are going to tax the revenue that arises from those sales of marijuana and we are going to provide what is needed from those taxes.  Now that sounds good but in reality it doesn’t happen.  Alcohol for example, the United States gets 15 billion dollars revenue for alcohol, but the burden to society now is 250 billion.  Who is paying the tab?  That is not the alcohol that is for sure.  It is the taxpayer. It is 2 dollars for every drink; that is what we pay.  So we have to able to have the will as a society to look at those figures and do something about it.  The other problem is what will happen with marijuana is what happens with alcohol, once it becomes main stream there will be lobbies and there will be lots of money to be made and there will be independent policies and the economics and that will happen with marijuana too.

Lesley Jakeman

I am here on behalf of a group of parents who have lost children to cannabis, heroin and cocaine. I would just like to say thank you gentlemen for coming to this country and speaking out and spreading this information and what good work you are involved in because if people like you had spent time here and been able to speak here publically; my son died nine years ago at the age of twenty, having started cannabis at fifteen and experienced all the things that you talked about in detail.  If this information had been known, perhaps he would not have died and the other people that I know who died might not have as well because perhaps what you are doing will save many lives in the future and parents like myself won’t go through what we have been through.  So, thank you, it means a lot to me, thank you.

John Graham

It is so important that it is communicated.

Lesley Jakeman

Indeed.

Ruti

I would just like to say that through the twelve step programme, I have talked to many, many people and I absolutely concur with what you say about the withdrawal period of people coming in through using skunk. Those using skunk take a huge amount of time.  I noticed that people coming in with crack, heroin, alcohol, cocaine, it is normally about two weeks and they are coherent again and they are bouncing back and people up to their seventies.  I had a young girl specifically and she was twenty three and coming off cannabis and it took her five months before she could engage with any written work and it was nearly a year before she really started engaging and I see that with people who have cannabis as their prime addiction.

Jeff Brain

Thank you for coming and I am sorry for your loss.  What is important not to lose sight of is that in my opinion, we can advocate and legislate about whether cannabis is legal or not, treatment and intervention for young people, because kids will be addicted whether it is legal or not and so changing the attitudes of parents and social workers and therapists and having sponsors that are available to young people to spread that message, getting the treatment available to students at the earliest possible opportunity is the way to save lives.

Estelle

Thank you. I am a parent and my son was smoking skunk, had a psychotic episode and ended up being sectioned under the mental health act and I think in terms of looking for casualties, go and look in psychiatric hospitals, because many of the young men there are there because of the link to cannabis.  Where I come from just over the river there is an epidemic of skunk in young men and I feel sad that my son and they are involved in the mental health system.  They are given drugs with horrific side effects and not once was it mentioned, have you thought about treatment.  It is only because we are quite knowledgeable and we come from a background of addiction.  His CPN, you know my partner mentioned, said to him, just smoke a weaker strain of cannabis.  This is a professional who is working with young people.  It would be nice to have awareness and training for the professionals.  We know what they are talking about.  We came to the last meeting and spoke to someone who pointed us in the right direction and a day at a time; my son is now in treatment. We really believe that cannabis is an addiction and we really believe that we need more treatment coming into Britain.  There really is an epidemic.  Go onto the psychiatric wards and speak to the nurses.  They say they see it all the time, particularly with young men and it is frightening and heart-breaking.  We lost our son; that is how we felt, we lost him; and now slowly, with treatment, he is coming back and he has a chance now.  It is like these young people here don’t know that they have a chance.

Jeff Brain

John, do you see addiction training in medical school now?  I know from years ago that the whole process of addiction was not covered.

John Kelly

No, it is still not anywhere that it needs to be.  There is only a very small section on alcohol and other drug use like cocaine and heroin, and I suspect it is the same in the UK.  It is responsible for a very large proportion of disease and we are nowhere where we need to be in terms of training medical practitioners in the nature of addiction of drugs, toxicity, intoxication and dependence and psychiatric illness.  There is a vague knowledge about those things but nothing really specific which is really remarkable when you think about the number of beds in general hospitals which are taken up with attributable alcohol and drug use.

Deidre Boyd

This is in answer to an earlier question about why there is not more concerted effort when the legalisers seem to have it.  When you read the news it seems to be that legalisation is everywhere but there is a question as to whether the journalists are reporting the views that people feel or whether they are creating something.  George Sorros and the company here will know him, spent 40 to 80 million dollars on legalisation but 52 million dollars on the media.  He gives journalistic scholarships and you can see that on the journalistic colleges websites taking in applications and on their websites will be advertisements for George Soros’s open society and we will fund you and then he also pays for journalists to go on these “jollies” abroad, staying in nice hotels for conferences, so that is a vast, a huge amount of money being spent on journalists to get them to be supportive of legalisation.  I am not making this up!

Mary Brett

How effective is NIDA in the United States?  They have scientists and researchers, they write leaflets for teenagers which are extremely good.  How effective is it?  I mean here, we have got FRANK which as you can here by the laughter from all around is hopeless.  Don’t get me started, FRANK lies. You have NIDA so is it not terribly effective?

Jon Kelly

Well the purpose of NIDA is an indirect Public Health role.  It is really the institution that is supposed to have funding for research that gets done on teenagers drug use.  Its role really is not prevention and dissemination of information directly, although if you go to its website it produces leaflets as you say which are summaries of the evidence put in way that people can understand it.  The truth is that the young people I believe will say that it is bullshit man and are against it.  I