A new approach to formulating and appraising drug policy: A multi-criterion decision analysis applied to alcohol and cannabis regulation

Decriminalization thresholds for drug possession: A multi-criteria policy analysis framework

BACKGROUND

Decriminalization of personal possession of drugs has been proposed as an approach to mitigate the harms of drug prohibition. Despite growing interest, particularly in Canadian settings, analyses of approaches to defining the parameters of what constitutes personal possession within decriminalization models are lacking. Using the Province of British Columbia, Canada, as a case study, we undertook an evidence-based multi-criteria policy analysis of three models for defining personal possession: 1) a model that defines personal possession as the absence of evidence of drug trafficking; 2) a cumulative threshold of 15 grams; and 3) a cumulative threshold of 2.5 grams.

METHODS

We utilized data from four sources: qualitative interviews with 16 experts, including representatives from government and law enforcement; Vancouver Police drug seizure data; self-reported drug consumption data from longitudinal cohorts of people who use drugs in Vancouver; and publicly available government documents (e.g., the Government of BC's submission for decriminalization). Data was used to identify and define evaluation criteria which reflect the stated policy objectives of decriminalization alongside other policy considerations. This framework was used to conduct a multi-criteria policy analysis of the three different models.

RESULTS

The seven evaluation criteria included: 1) reduction in interactions with police; 2) reduction of police drug seizures; 3) coverage for those with high consumption; 4) impact on equity-deserving groups; and acceptance on the part key stakeholders, including: 5) people who use drugs; 6) law enforcement; and 7) the public. The model that performed the best was the cumulative threshold model of 15 grams.

CONCLUSION

Findings highlight that different threshold models advance and constrain the stated policy objectives of drug decriminalization to varying degrees. This analysis provides a framework that other jurisdictions considering decriminalization could use to help inform determinations of threshold levels based on stated policy objectives.

Conflicting forces in the implementation of medicinal cannabis regulation in Uruguay

BACKGROUND

Uruguay is widely known as a pioneer country regarding cannabis regulation policies, as it was the first state to regulate the cannabis market for both recreational and medicinal purposes in 2013. However, not all aspects of the regulation have moved forward at the same speed. Medicinal uses keep facing several challenges that undermine patients' effective access to treatments and products. What are those persistent challenges for the medicinal cannabis policy in Uruguay? This paper aims to describe and understand the current state of medicinal cannabis in the country and identify the most critical challenges and conflicting forces for its proper implementation.

METHODS

To do so, we conduct twelve in-depth interviews with key informants, including governments officials, activists, entrepreneurs, researchers, and doctors. These interviews are complemented with information from the congressional committees' public records and other documentary sources.

RESULTS

This research shows that the legal framework was thought to assure quality products over access. The main challenges of medicinal cannabis in Uruguay are related to three issues: (i) the timid development of the industry, (ii) a limited and expensive supply, and (iii) the emergence of an informal productive sector.

CONCLUSIONS

The political decisions regarding medicinal cannabis made in the last seven years have derived from a halfway policy that fails to guarantee patient access or promote the growth of a vibrant national industry. Positively, the several actors involved are aware of the extent of these challenges and new decisions have been made to overcome them, meaning that monitoring the future of the policy is very much needed.

Head shops and new psychoactive substances: a public health perspective

In 2010, Ireland found itself at the eye of an international storm as a network of head shops emerged selling new psychoactive substances (NPS) and Irish youth rapidly became the heaviest users of NPS in Europe. Within months, the Irish government enacted novel legislation, which has since been copied by other countries, which effectively stopped the head shops selling NPS. Critics of this policy argued that it could cause harms to escalate. A number of separate studies indicate that a range of drug-related harms increased amongst Irish youth during the period of head shop expansion. Within months of their closure, health harms began to decline. NPS-related addiction treatment episodes reduced and admissions to both psychiatric and general hospitals related to any drug problem began to fall. Population use underwent sustained decline. Consequently, the closure of head shops can be viewed as a success in terms of public health.

Developing a new national MDMA policy: Results of a multi-decision multi-criterion decision analysis

BACKGROUND

Ecstasy (3,4-methylenedioxymethamphetamine (MDMA)) has a relatively low harm and low dependence liability but is scheduled on List I of the Dutch Opium Act ('hard drugs'). Concerns surrounding increasing MDMA-related criminality coupled with the possibly inappropriate scheduling of MDMA initiated a debate to revise the current Dutch ecstasy policy.

METHODS

An interdisciplinary group of 18 experts on health, social harms and drug criminality and law enforcement reformulated the science-based Dutch MDMA policy using multi-decision multi-criterion decision analysis (MD-MCDA). The experts collectively formulated policy instruments and rated their effects on 25 outcome criteria, including health, criminality, law enforcement and financial issues, thematically grouped in six clusters.

RESULTS

The experts scored the effect of 22 policy instruments, each with between two and seven different mutually exclusive options, on 25 outcome criteria. The optimal policy model was defined by the set of 22 policy instrument options which gave the highest overall score on the 25 outcome criteria. Implementation of the optimal policy model, including regulated MDMA sales, decreases health harms, MDMA-related organised crime and environmental damage, as well as increases state revenues and quality of MDMA products and user information. This model was slightly modified to increase its political feasibility. Sensitivity analyses showed that the outcomes of the current MD-MCDA are robust and independent of variability in weight values.

CONCLUSION

The present results provide a feasible and realistic set of policy instrument options to revise the legislation towards a rational MDMA policy that is likely to reduce both adverse (public) health risks and MDMA-related criminal burden.

A multi criteria decision analysis (MCDA) for evaluating and appraising government policy responses to non medical heroin use

BACKGROUND

Globally, non-medical heroin use is generating significant public health and social harms, and drug policy about heroin is a controversial field that encompasses many complex issues. Policy responses to illegal heroin markets have varied from militarized eradication of the opium poppy and harsh punishment of users, to more tolerant harm reduction approaches with decriminalized possession and use.

METHODS

This paper reports the outcomes of a multi-criteria decision analysis (MCDA) on four generic regulatory regimes of heroin: prohibition, decriminalisation, state control and free market. Invited experts on drug harms, addiction, criminology and drug policy developed a comprehensive set of 27 policy outcome criteria against which these drug policy regimes were assessed.

RESULTS

State control of heroin was identified as the preferred policy option although other policy regimes scored better on specific outcome criteria. The free market model scored better than decriminalisation, with absolute prohibition scoring worst on every criterium. The ranking of the regimes was robust to variations in the criterion-specific weights.

CONCLUSION

The implications of these findings for the development of future policy responses to heroin and opioids generally are discussed in detail. Despite increasing overdose deaths and an opioid epidemic in North America, prohibition remains the predominant policy approach to heroin regulation at present. It is hoped that the current paper adds to the discussion of finding a valid regulatory alternative.

A framework for identifying and mitigating the equity harms of COVID-19 policy interventions

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a global pandemic. Governments have implemented combinations of "lockdown" measures of various stringencies, including school and workplace closures, cancellations of public events, and restrictions on internal and external movements. These policy interventions are an attempt to shield high-risk individuals and to prevent overwhelming countries' healthcare systems, or, colloquially, "flatten the curve." However, these policy interventions may come with physical and psychological health harms, group and social harms, and opportunity costs. These policies may particularly affect vulnerable populations and not only exacerbate pre-existing inequities but also generate new ones.

METHODS

We developed a conceptual framework to identify and categorize adverse effects of COVID-19 lockdown measures. We based our framework on Lorenc and Oliver's framework for the adverse effects of public health interventions and the PROGRESS-Plus equity framework. To test its application, we purposively sampled COVID-19 policy examples from around the world and evaluated them for the potential physical, psychological, and social harms, as well as opportunity costs, in each of the PROGRESS-Plus equity domains: Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, and disability).

RESULTS

We found examples of inequitably distributed adverse effects for each COVID-19 lockdown policy example, stratified by a low- or middle-income country and high-income country, in every PROGRESS-Plus equity domain. We identified the known policy interventions intended to mitigate some of these adverse effects. The same harms (anxiety, depression, food insecurity, loneliness, stigma, violence) appear to be repeated across many groups and are exacerbated by several COVID-19 policy interventions.

CONCLUSION

Our conceptual framework highlights the fact that COVID-19 policy interventions can generate or exacerbate interactive and multiplicative equity harms. Applying this framework can help in three ways: (1) identifying the areas where a policy intervention may generate inequitable adverse effects; (2) mitigating the policy and practice interventions by facilitating the systematic examination of relevant evidence; and (3) planning for lifting COVID-19 lockdowns and policy interventions around the world.

Impact evaluations of drug decriminalisation and legal regulation on drug use, health and social harms: a systematic review

OBJECTIVES

To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally.

DESIGN

Systematic review with narrative synthesis.

DATA SOURCES

We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018.

INCLUSION CRITERIA

Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest.

RESULTS

We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use.

CONCLUSIONS

Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.

Assessing the European impact of alcohol misuse and illicit drug dependence research: clinical practice guidelines and evidence-base policy

BACKGROUND

Despite alcohol and illicit drug dependence being one of the most common diagnoses in Europe, there is heterogeneity of research evidence used in policy and practice.

OBJECTIVE

We sought to (1) evaluate European research outputs on alcohol misuse and drug addiction in 2002-2018 in the Web of Science, (2) compare these with their burden of disease and (3) determine their impact in several ways.

METHODS

A bibliometric research was undertaken including an assessment of the citation counts, the influence of research on members of national health advisory committees, and their contribution to the evidence base of clinical practice guidelines (CPGs).

FINDINGS

There were 3201 analysed references cited in 28 CPGs across 11 European Countries on alcohol misuse and illicit drug abuse. Research conducted in the USA dominated both sets of CPGs, while many European countries were overcited relative to their research presence. The illicit drug research appeared to be adequate relative to the evidence of harm in Europe. However, alcohol misuse research appeared grossly inadequate to the harm it causes by a factor of 20.

CONCLUSIONS

The volume of research on illicit drug addiction is commensurate to the European burden, whereas alcohol misuse is far below what is needed to curb a significant source of harm.

CLINICAL IMPLICATIONS

The research asymmetries call for attention to the causes of the problem. Development of research-based solutions to a serious social harm is needed, including minimum pricing and collaborative work to harmonise efforts on disease management and treatment practices across European countries.

Problems with defining cannabis dependence

PURPOSE OF REVIEW

Cannabis enjoys a unique social status, widely perceived as a relatively harmless drug, with several benefits reported by the people who use it. Several jurisdictions have opened up access to cannabis to their populations for medicinal and/or recreational reasons. Given this changing regulatory environment, this article is intended to prompt debate about what is known about cannabis dependence and what has still to be revealed.

RECENT FINDINGS

Evidence suggests that 1 in 10 cannabis users are at risk of developing dependence. However, investigation of the way risk is estimated and the diagnosis of cannabis use disorder is constructed highlight some methodological problems, which call into question the incidence and prevalence of this diagnosis.

SUMMARY

There is scope to improve the way cannabis dependence is defined and counted in at-risk populations. Improving our understanding of this risk could lead to identifying who might be at risk of developing dependence prior to exposure to the drug.

Early-Stage Cannabis Regulatory Policy Planning Across Canada's Four Largest Provinces: A Descriptive Overview

Background: Observing and documenting major shifts in drug policy in a given jurisdiction offer important lessons for other settings worldwide. After nearly a century of prohibition of non-medical use and sale of cannabis, Canada federally legalized the drug in October 2018. Across this geographically large and diverse country, there is a patchwork of cannabis policies as the provinces and territories have developed their own regulatory frameworks. Objectives: As drug policy transitions are often studied well after implementation, we document early stage cannabis regulatory policy planning in the four most populous provinces of Québec, Ontario, Alberta, and British Columbia. Methods: In June 2018, we systematically searched peer-reviewed and gray literature (such as web content, reports, and policy documents authored by varied authorities and organizations) to identify key aspects of the evolving provincial cannabis legalization frameworks. In the absence of peer-reviewed studies, we reviewed primarily gray literature. Results: For each of the four provinces examined, we provide a succinct overview of early-stage public consultation, plans for cannabis distribution and retail, other key regulatory features, endorsements of a public health approach to legalization, general alignment with alcohol policy, and contentious or standout issues. Conclusions/Importance: Our review clearly illustrates that cannabis legalization in Canada is not unfolding as monolithic policy, despite a federal framework, but with divergent approaches. The public health outcomes that will result from the different provincial/territorial regulatory systems remain to be measured and will be closely monitored.

Toward an Improved Multi-Criteria Drug Harm Assessment Process and Evidence-Based Drug Policies

Drug scheduling within the international system of drug control and national legislation has been recently criticized as having insufficient footing in scientific evidence. The legal harms related to non-medical uses of certain drugs (e.g., cannabis) have arguably exceeded their physiological and social harmfulness compared to legally available substances (e.g., tobacco), which prompted some states to explore alternative regulation policies, similar to the drug regime in the Netherlands. Other legally prescribed drugs (e.g., stimulants) created a surge of interest for "better than well" uses, while yet others (e.g., opioids) caused an epidemic of dramatic proportions in North America. The evidence-based multi-criteria drug harm scale (MCDHS) has been proposed as a way of grounding policy in the actual degree of harmfulness of drugs. Indeed, the scale has had great ramifications in several areas of policy, and it has been used extensively in distinct lines of interdisciplinary research. However, some aspects of MCDHS remain disputed. For example, the way the data has been generated has been criticized as suffering from "expert bias." This article reviews strengths and weaknesses of evidence provided with the use of MCDHS. Furthermore, the author argues that the shortcomings of MCDHS can be resolved by offering methodological improvements. These include (1) dissociating the harms of use from harms of abuse, (2) adding the perspectives of people who use drugs, pharmacists, and general medical practitioners along with the expert assessments, and (3) focusing on subsets of drugs to allow for comparison without mixing different social contexts of drug use. The paper concludes with outlines of substance subset-specific extensions of the MCDHS and related policy proposals in the four areas identified as generating the most controversy: non-medical use of opioids, "study aid" uses of stimulants, shifting trends in nicotine containing products, and regulation of medical and recreational uses of cannabis.