Consideration of use opportunities, novel products, and user modes in cannabis monitoring, research, and policy: a response to the commentary.

Abstract

In his commentary, Fink extends our argument on the importance of use opportunities 1—a basic physical requirement for actual use 2-8—in examining cannabis use phenomena. We very much agree that ‘specific questions about cannabis use opportunities are needed to clarify the mechanisms that… link MMLs [medical marijuana laws] and RMLs [recreational marijuana laws] to population changes in cannabis use’ 1. Studies accounting for these fundamental questions remain scarce. National surveys—the key sources of information for population-level estimates and national drug strategies—often lack easily obtainable items capturing use opportunities. They also lack a clearer account of novel cannabis products and consumption modes. The increasing complexity of cannabis use phenomena cannot be fully understood without closer consideration of these critical issues. The importance of exposure to cannabis-use opportunities is embedded in current policies restricting access to cannabis. However, the effectiveness of such policies is essentially unknown, because use opportunity rates remain unknown. Our surveys, by and large, seldom collect such straightforward information, let alone richer contextual details about the nature, timing or frequency of such opportunities 1, 9. To the best of our knowledge, systematic and specific queries about use opportunities are included only in the European School Survey Project on Alcohol and Other Drugs (ESPAD) 10. Curiously, multiple surveys and studies inquire about the perceived cannabis availability. Why inquiry about conjectures and hypothetical situations at the expense of the real ones remains puzzling. Furthermore, limited knowledge is available about novel cannabis products and the associated consumption modes 11. Non-traditional products include synthetic cannabinoids, liquids for e-cigarettes, and cannabis-infused edibles ranging from chocolates to red wine. New routes of administration vary from the ingestion, electronic-device inhalation, and skin-care application. The effects of these products and intake modes—be it general or specific, long- or short-term—are virtually unknown, even as they appear to be far from uncommon 12-15. Our current surveys do not fully reflect these developments classes, amounts, quality and potency of the available cannabis products are not being captured systematically. Questions on synthetic cannabinoids are included in some national surveys, whereas the Global Drug Survey 2017 and some US jurisdictions affected by cannabis legalization have modified their local surveys to include the use-mode information. Nevertheless, these cannot be considered as comprehensive and coordinated (inter)national surveillance efforts. Capturing realistic cannabis use opportunities is of utmost importance in the current deregulation climate. Knowing how many individuals (and youth, in particular) experience use opportunities would provide a basic epidemiological gauge of the actual at-risk population and the more informative use rates 2. Further, traditional examination of cannabis use through the enumeration of pot smokers does not capture the new realities of emerging cannabis markets and use cultures. More nuanced examination of (1) use opportunities and (2) product type/intake mode is critical in understanding diverse pathways to cannabis use and corresponding preventive and treatment strategies 1. Consequently, we call for a comprehensive and coordinated integration of these two key questions into cannabis surveillance systems, research, and policy. None.