Viewpoint

Uruguay’s middle-ground approach to cannabis legalization

There is ongoing debate about what policy approaches to cannabis use might best address health and social related harm. Profit-driven, adult-use cannabis markets have been introduced in the United States and Canada, where legalization reform has had mixed effects to date in terms of public health and has made limited progress in achieving social justice aims. Meanwhile, several jurisdictions have seen an organic evolution of alternative cannabis-supply regimes. Cannabis social clubs (CSCs), the focus of this commentary, are nonprofit cooperatives that supply cannabis to consumers with the goal of harm reduction. The peer and participatory aspects of CSCs may have positive effects on health-related outcomes of cannabis use, such as through encouraging the use of safer products and responsible use practices. The nonprofit objectives of CSCs may diminish the risk for increasing cannabis consumption in wider society. CSCs have recently made an important transition from grassroots organizations in Spain and elsewhere. In particular, they have become key players in top-down cannabis legalization reform in Uruguay and, most recently, Malta. The history of CSCs in reducing harm from cannabis use is an important advantage, but there might be concerns around the grassroots origins, low taxation opportunities, and capacity to sustain social objectives. Also, the CSC model might not seem unique, as contemporary cannabis entrepreneurs have absorbed some features of their community-based predecessors. CSCs can play an important role in future cannabis legalization reform due to their unique strengths as cannabis-consumption sites and can be effective in advancing social justice by giving people affected by cannabis prohibition agency and direct access to resources.

Since the Dutch tolerance policy, allowing the purchase of cannabis in ‘coffeeshops’, is associated with problems of public order and safety as well as health risks, there has been a long debate about legalisation of cannabis production and supply. It was therefore decided to conduct an experiment with a controlled legal (‘closed’) cannabis supply chain for recreational use. This is of international relevance in view of the current illegal cannabis exports from the Netherlands, the importance of sharing knowledge about the effectiveness of cannabis policies, and the accumulation of evidence needed to evaluate and update international treaties. Here we describe and discuss the background, general approach and design of the experiment.

An independent expert committee elaborated how the closed chain will operate and be evaluated, based on the experience with the medicinal cannabis chain, and round table discussions with stakeholders (mayors, coffeeshop owners, cannabis consumers, growers, regulators, scientists, and addiction experts).

Ten trusted cannabis growers are contracted to produce and supply cannabis to the coffeeshops in intervention municipalities, with product quality control, law enforcement against criminal interference, and preventive efforts to reduce health risks being implemented. No changes will be made in the cannabis supply to the coffeeshops in participating control municipalities. A process evaluation will assess whether the chain from production to sale in the intervention municipalities was really closed. In a quasi-experimental study comparing intervention and control municipalities, the chain's effects on public health, cannabis-related crime, safety and public nuisance will be estimated.

The fieldwork period is expected to start early 2024 and will take four years, including reporting to the government and parliament. These will then decide whether and what further steps towards legalisation of the production and supply of cannabis will be taken.

In the context of changing cannabis and other drug policy and regulation, concerns may arise regarding drug treatment access and use. We assessed cannabis/cocaine-related dependence and treatment in Argentina, Chile, and Uruguay.

Nationally representative cross-sectional household surveys of people ages 15-64 in Argentina (4 surveys, 2006-2017), Chile (7 surveys, 2006-2018), and Uruguay (4 surveys, 2006-2018) were harmonized. We estimated weighted prevalences of cannabis or cocaine-related (cocaine or cocaine paste) dependence, based on meeting 3+ past-year ICD-10 dependence criteria. We estimated weighted prevalences of past-year alcohol/drug treatment use (Argentina, Chile) or use/seeking (Uruguay) among people with past-year cannabis/cocaine-related dependence. We tested model-based prevalence trends over time and described individual-level treatment correlates by country.

Cannabis/cocaine dependence prevalence increased in the region starting in 2010-2011, driven by cannabis dependence. Adjusted cannabis dependence prevalence increased from 0.7% in 2010 to 1.5% in 2017 in Argentina (aPD=0.8, 95% CI= 0.3, 1.2), from 0.8% in 2010 to 2.8% in 2018 in Chile (aPD=2.0, 95% CI= 1.4, 2.6), and from 1.4% in 2011 to 2.4% in 2018 in Uruguay (aPD=0.9, 95% CI= 0.2, 1.6). Cocaine-related dependence increased in Uruguay, decreased in Argentina, and remained stable in Chile. Among people with past-year cannabis/cocaine dependence, average alcohol/drug treatment use prevalence was 15.3% in Argentina and 6.0% in Chile, while treatment use/seeking was 14.7% in Uruguay. Alcohol/drug treatment prevalence was lower among people with cannabis dependence than cocaine-related dependence. Treatment correlates included older ages in all countries and male sex in Argentina only.

Alcohol/drug treatment use among people with cannabis/cocaine-related dependence remained low, signaling an ongoing treatment gap in the context of growing cannabis dependence prevalence in the region. Additional resources may be needed to increase treatment access and uptake. Future studies should assess contributors of low treatment use, including perceived need, stigma, and service availability.

A number of jurisdictions are considering or implementing different options for cannabis law reform, including New Zealand. Multi-Criteria Decision Analysis (MCDA) helps facilitate the resolution of complex policy decisions by breaking them down into key criteria and drawing on the combined knowledge of experts from various backgrounds.

To rank cannabis law reform options by facilitating expert stakeholders to express preferences for projected reform outcomes using MCDA.

A group of cannabis policy experts projected the outcomes of eight cannabis policy options (i.e., prohibition, decriminalization, social clubs, government monopoly, not-for-profit trusts, strict regulation, light regulation, and unrestricted market) based on five criteria (i.e., health and social harm, illegal market size, arrests, tax income, treatment services). A facilitated workshop of 42 key national stakeholders expressed preferences for different reform outcomes and doing so generated relative weights for each criterion and level. The resulting weights were then used to rank the eight policy options.

The relative weighting of the criteria were: “reducing health and social harm” (46%), “reducing arrests” (31%), “reducing the illegal market” (13%), “expanding treatment” (8%) and “earning tax” (2%). The top ranked reform options were: “government monopoly” (81%), “not-for-profit” (73%) and “strict market regulation” (65%). These three received higher scores due to their projected lower impact on health and social harm, medium reduction in arrests, and medium reduction in the illegal market. The “lightly regulated market” option scored lower largely due its projected greater increase in health and social harm. “Prohibition” ranked lowest due to its lack of impact on reducing the number of arrests or size of the illegal market.

Strictly regulated legal market options were ranked higher than both the current prohibition, and alternatively, more lightly regulated legal market options, as they were projected to minimize health and social harms while substantially reducing arrests and the illegal market.

Variation in drug policies, norms, and substance use over time and across countries may affect the normative sequences of adolescent substance use initiation. We estimated relative and absolute time-varying associations between prior alcohol and tobacco use and adolescent marijuana initiation in Argentina and Chile. Relative measures quantify the magnitude of the associations, whereas absolute measures quantify excess risk.

We analyzed repeated, cross-sectional survey data from the National Surveys on Drug Use Among Secondary School Students in Argentina (2001–2014) and Chile (2001–2017). Participants included 8th, 10th, and 12th grade students (N = 680,156). Linear regression models described trends over time in the average age of first use of alcohol, tobacco, and marijuana. Logistic regression models were used to estimate time-varying risk ratios and risk differences of the associations between prior alcohol and tobacco use and current-year marijuana initiation.

Average age of marijuana initiation increased and then decreased in Argentina and declined in Chile. In both countries, the relative associations between prior tobacco use and marijuana initiation weakened amid declining rates of tobacco use; e.g., in Argentina, the risk ratio was 19.9 (95% CI: 9.0–30.8) in 2001 and 11.6 (95% CI: 9.0–13.2) in 2014. The relative association between prior alcohol use and marijuana initiation weakened Chile, but not in Argentina. On the contrary, risk differences (RD) increased substantially across both relationships and countries, e.g., in Argentina, the RD for tobacco was 3% (95% CI: 0.02–0.03) in 2001 and 12% (95% CI: 0.11–0.13) in 2014.

Diverging trends in risk ratios and risk differences highlight the utility of examining multiple measures of association. Variation in the strength of the associations over time and place suggests the influence of environmental factors. Increasing risk differences indicate alcohol and tobacco use may be important targets for interventions to reduce adolescent marijuana use.

The use of person-centred language is well accepted regarding substance use and infectious disease healthcare and research, and appropriate acronyms have become commonplace, e.g., “people who inject drugs (PWID)” has mostly replaced phrases like “injecting drugs users”. However, the use of the term's ‘prisoner’ or ‘prisoners’ remains common. Although less common, terms such as ‘offenders’ and ‘inmates’ are also still used on occasion. This persists despite calls from people with lived experience of incarceration, and fellow academics, to stop using these terms. Given the considerable overlap between substance use, infectious diseases, and incarceration, in this commentary we discuss how they interact, including the stigma that is common to each. We propose that using person-centred language (i.e., people in prison or people formerly in prison) needs to become the default language used when presenting research related to people in prison or people formerly in prison. This is a much-needed step in efforts to overcome the continued stigma that people in prison face while incarcerated from prison officers and other employees, including healthcare providers. Likewise, overcoming stigma, including legalised discrimination, that follows people who were formerly in prison upon gaining their freedom is critical, as this impacts their health and related social determinants, including employment and housing.