Inquiry into the Mental Health Effects of Cannabis
I. 6A
Inquiry into the mental health effects of cannabis
Report of the Health Committee
Forty-Fifth Parliament
(Brian Neeson, Chairperson)
1998
Presented to the House of Representatives
Price Code: D
CONTENTS
Page
Summary of recommendations 4
Introduction 6
Inquiry methodology 6
Terms of reference 7
Abbreviations used in this report 8
Glossary 9
Background information 10
Rates of cannabis use 10
The nature of cannabis 10
Methods of use 10
Cannabis intoxication 11
Recreational effects 11
Legal status of cannabis 12
National Drug Policy 12
Difficulties associated with cannabis research 13
Issue One: the effect of cannabis on people's
development 14
Cognitive development 14
Cannabis use by adolescents and children 14
Cannabis and suicide 15
Effects on educational achievement 15
Effects on foetal development 15
Issue Two: the role of cannabis as a trigger for
mental illness 17
Cannabis dependence 17
Cannabis psychosis 17
Cannabis and schizophrenia 18
Cannabis use by those with a mental illness 18
Therapeutic cannabis use by those with a
mental illness 19
Impact of illegality on mental health 19
Issue Three: the effects of cannabis on Maori
mental health 21
Rates of cannabis use amongst Maori 21
Drug-related hospital admissions 21
Socio-economic factors in cannabis use 22
Further research needed 23
Issue Four: the adequacy of services for those
with drug-related mental illnesses 25
Mental Health Blueprint 25
Services for those with a dual diagnosis 25
Lack of integrated dual diagnosis services 26
Need for integrated care 27
Need for more residential care facilities 27
Mental health service development targets
established 28
Need for workforce development 28
HFA management of services 29
Lack of services for children and young
persons 30
Inadequacy of services for rural communities 31
Treatment services for Maori 32
Need for community-based programmes 33
Drug education 33
Other issues 36
Cannabis and violence 36
Potency of cannabis 36
Conclusions 38
Future action 39
Appendix A - Committee procedure 41
Terms of reference 41
Approach to inquiry 41
Appendix B - Committee personnel 42
Committee members 42
Committee staff 42
Appendix C - Excerpts from ``Committee exchange with Australia,
Report of the Health Committee'', I. 6b 43
The mental health effects of cannabis 43
Appendix D - Bibliography 44
Appendix E - List of Submissions 45
Inquiry into the mental health effects of cannabis
Summary of recommendations
We recommend that:
the Government fund research on the prevalence and patterns of cannabis use
by Maori;
the Government fund research on the ways in which cannabis-related mental
health problems are experienced by Maori;
the Government fund research into the effects of cannabis on Maori
communities and the adequacy of drug treatment services for Maori;
the Government encourage the provision of a greater number of residential
care facilities throughout New Zealand;
the Government provide funding for dual diagnosis patients to the level
recommended in the Mental Health Commission's Blueprint for Mental Health
Services in New Zealand, November 1998;
the Government develop a policy to encourage greater co-ordination and
co-operation between alcohol and drug services and mental health services;
the Government adopt a specific plan for the provision of child and
adolescent mental health and drug and alcohol services incorporating the needs
of Maori;
the Government dedicate funds to the training of child and adolescent mental
health professionals (including professionals with expertise in treating dual
diagnosis);
the Government ensure that funds allocated to the training of child and
adolescent mental health professionals make specific provision for the training
of Maori workers;
the Government include people living in rural communities, particularly in
areas with high levels of cannabis use, as one of the `at-risk populations' to
receive better services under the National Drug Policy;
the Government extend the provision of regional mental health services to
ensure equitable coverage for New Zealanders living in rural areas, as
recommended in the Mental Health Commission's Blueprint for Mental
Health Services in New Zealand, November 1998;
the Government fund training for GPs in diagnosing and treating mental health
disorders and/or substance abuse;
the Government examine strategies to counter professional isolation for
health providers in rural communities;
the Government treat as a matter of priority the funding of further
community-based interventions (including counselling) which aim to address
community problems as a way of combating drug abuse;
the Government continue to advocate and support strategies (including
counselling) through which Maori can identify and meet their own needs in
relation to drug treatment;
the Government examine the practicalities and likely outcomes of the
provision of ongoing school-based drug education, as part of alcohol and
tobacco education;
the Government promote drug education programmes tailored to meet the needs
of the target groups; and
based on the evidence received, the Government review the appropriateness of
existing policy on cannabis and its use and reconsider the legal status of
cannabis.
Introduction
In recent years there have been numerous claims that cannabis consumption has
led to mental illness and violent offending. Indeed, this view has gained
widespread currency in New Zealand, though a considerable body of research
refutes such claims. At the same time, figures show that a large number of New
Zealanders use, or have used cannabis, and recent reports have shown that
cannabis represents an important cash crop in some areas of New Zealand. The
effects of cannabis and means of controlling its use have become increasingly
significant issues for debate in this country.
In 1998 the Government released its National Drug Policy which brings together
policies dealing with tobacco and alcohol (Part 1) and illicit and other drugs
(Part 2). In the policy, the Government states its intention to reduce the
harmful effects of cannabis use which it identifies as including possible
cognitive impairment, and other mental health effects.
[Ministry of Health, National Drug Policy, 1998, iii. ]
This last statement emphasises the lack of conclusive evidence about
the mental health effects of cannabis. It was this apparent lack of strong
evidence and the current level of public interest in the cannabis issue that
led us to initiate the inquiry. Our intention was to gain as much information
as possible about the effects of cannabis on mental health. The committee
members unanimously supported undertaking the inquiry.
This report provides some background information on the nature, effects and
legal status of cannabis and comments on the difficulties inherent in
conducting research on an illegal drug. It addresses the four areas of interest
set out in the inquiry's terms of reference and discusses some related issues
that arose in the consideration of the inquiry.
We would like to thank all of the individuals and organisations that made
submissions on the inquiry. We hope that this report sheds some light on issues
surrounding the mental health effects of cannabis and contributes to informed
debate on the issue.
Inquiry methodology
The inquiry was initiated as an information gathering exercise, with a view to
gaining a better understanding of the relationship between cannabis and mental
health. It was not undertaken to gather evidence in support of any particular
viewpoint or agenda. We have relied on evidence submitted to us from a wide
variety of sources and on our questioning of witnesses as our primary methods
of gathering information on the subject. While this is the usual method of
gathering evidence for a select committee inquiry and is a good way of
collecting a wide range of information, it is not an exhaustive approach. We
have not received all relevant information on the mental health effects of
cannabis. We did receive a significant study regarding the
physiological effects of cannabis on the brain from Professor Faull of Auckland
University. Social research is seldom an exact procedure and judgements are
frequently made based on available information. We have considered all material
provided to us and have drawn conclusions accordingly, noting issues about
which information is scarce.
We recognise that, despite the efforts of law enforcement and education
agencies, large numbers of New Zealanders use cannabis. While cannabis is
illegal, we must face the fact that 43 percent of the sample of one recent
study admitted to having used the drug. Given the high rate of use and the fact
that the abuse of any drug can cause harm, we see no use in distinguishing
between drugs on the basis of their legal status. It is important to analyse
the health effects of cannabis separately from the legal status of the drug.
Failure to do so can mean that views about the legal status of cannabis can
cloud views of its effects on health. The distinction between legal and illegal
drugs may be an artificial one when considering health effects because most
indicators would show that legal drugs are, at present, the more serious
problem.
[Ministry of Health, Cannabis: The Public Health Issues 1995-96,p. 3. ]
Furthermore, differentiating between legal and illegal drugs
ignores polydrug use; the concurrent use of more than one drug. Cannabis is
commonly used with alcohol and tobacco. While the abuse of any drug is
undesirable, we accept that people will continue to use drugs. Therefore,
this inquiry has not focused on the legality of cannabis use but has
concentrated on its mental health effects.
Terms of reference
In accordance with our desire to focus specifically on the mental health
effects of cannabis, we set narrow terms of reference for the inquiry. The
terms of reference set the task of inquiring into the mental health effects of
cannabis, with specific reference to four issues:
1. the effect of cannabis on people's development;
2. the role of cannabis as a trigger for mental illness;
3. the effects of cannabis on Maori mental health; and
4. the adequacy of services for those with drug-related mental illnesses.
These issues are addressed in the main body of this report in the order they
appear above. More information about our approach to the inquiry is contained
in Appendix A.
Abbreviations used in this report
Alcohol Advisory Council of New Zealand ALAC
Alcohol and Drug Service at Capital Coast Health ADS
Aotearoa Legalise Cannabis Party ALCP
Blueprint for Mental Health Services in New Zealand,
Mental Health Commission, November 1998. the Blueprint
Caring Communities Incorporated CCI
Christchurch Health and Development Study CHDS
Department of Psychological Medicine, Dunedin Medical School DPM
Drug Policy Forum Trust DPFT
Dunedin Multidisciplinary Health and
Research Development Unit DMHDRU
Effective Drug Education Trust EDET
Health Funding Authority HFA
Health Research Council HRC
Institute of Environmental Science and Research ESR
Life Education Trust LET
Mental Health Commission MHC
Ministry of Health the Ministry
New Way Trust NWT
New Zealand Drug Foundation DF
New Zealand Police the Police
PRYDE New Zealand PRYDE
Queen Mary Hospital QMH
Schizophrenia Fellowship SF
Te Puni Kokiri TPK
Te Runanga O Te Rarawa TROTR
Glossary
Polydrug use: The use of two or more drugs, including, but not limited to
cannabis, alcohol and prescribed drugs such as anti-psychotic
medications.
Dual diagnosis: In the context of this report dual diagnosis refers to
the diagnosis of both a mental health disorder and a drug
dependency problem.
Harm minimisation: `Harm minimisation' is an approach that aims to
minimise the adverse health, social and economic consequences
of drug use, without necessarily ending such use for people
who cannot be expected to stop their drug using immediately.
The primary goal of this approach is a net reduction in
drug-related harm. Harm minimisation strategies often lead to a
reduced number of people using drugs over time. A harm
minimisation strategy will include education for schoolchildren
about drug-related harm, how it can be prevented and how it
can be reduced.
Background information
Cannabis is the most widely used illicit drug in New Zealand and the third most
popular recreational drug overall, after alcohol and tobacco. Cannabis use in
New Zealand has many similarities with use in Australia. However, cannabis is
very easily grown in New Zealand, making it difficult to control supply.
Rates of cannabis use
A 1990 study by S Black and S Casswell of the Auckland-based Alcohol and Public
Health Research Unit found that 43 percent of those surveyed reported having
experimented with cannabis on at least one occasion. Regular use is highest
amongst young men aged 20-24 (65 percent of whom have tried cannabis) and
Maori. The study showed that a large number of people try cannabis but the
majority do not appear to use it regularly and only a small proportion use it
frequently.
[S. Black and S. Casswell, Drugs in New Zealand: A Survey, 1990,
1993. ]
The Dunedin Multidisciplinary Health and
Development Research Unit (DMHDRU) longitudinal study of 1000 people born in
Dunedin in 1972 and 1973 found that 61.9 percent of the 21 year olds surveyed
had smoked cannabis on at least one occasion. Of those surveyed 58.6 percent of
the males and 46.1 percent of the females reported having experimented. Males
also reported more frequent use.
The nature of cannabis
Cannabis is the generic name given to several different preparations of the
plant species cannabis sativa and cannabis indica. Its primary psychoactive
constituent is delta-9-tetrahydrocannabinol (THC). There are three common forms
of cannabis:
Marijuana - the dried leaves, flowering tops and small stalks of the cannabis
plant. It is usually greyish-green to greenish-brown in colour,
and can be fine or coarse. The THC content varies between
0.1 and 10 percent (and is generally 0.5 to five percent).
Hashish - dried resin and compressed flowers of the cannabis plant. It is
concentrated and pressed into small slabs or blocks. These vary in
colour from light brown to very dark green. The THC content varies
between two and 20 percent (and is generally two to eight percent).
Hash oil - a viscous oil derived from cannabis by solvent extraction. It
ranges in colour from golden brown to black. This is the strongest
preparation, with between five and 50 percent THC content (but
generally between 10 and 20 percent in New Zealand).
Methods of use
The most common method of using cannabis is inhalation (smoking a marijuana
joint or a pipe containing marijuana or hashish). A water pipe or `bong' is a
popular implement for smoking cannabis preparations as it cools the smoke
before it is inhaled and limits the loss of the drug through side stream smoke.
Hash oil is used sparingly because of its high potency; a few drops may be
added to a joint or tobacco cigarette, to the contents of a cannabis pipe, or
the oil may be heated and the vapour inhaled. Cannabis smokers inhale deeply
and hold their breath for several seconds to ensure maximum absorption of THC
by the lungs. Cannabis is also eaten in foods.
Cannabis intoxication
Cannabis acts upon specific receptors in the brain, as do opioid drugs. In this
respect it differs from alcohol, cocaine and other illicit drugs which act by
disrupting brain processes.
Upon inhalation, THC is absorbed from the lungs into the bloodstream within
minutes. However, after ingesting cannabis, absorption is much slower, taking
between one and three hours for THC to enter the bloodstream and delaying the
onset of psychoactive effects. When cannabis is smoked, the initial metabolism
takes place in the lungs, followed by more extensive metabolism by liver
enzymes, with the transformation of THC to a number of metabolites.
Peak levels of THC in blood are usually reached within 10 minutes of smoking
and decline rapidly to about five to 10 percent of their initial level within
the first hour. This initial rapid decline reflects rapid conversion to
metabolites as well as the distribution of unchanged THC to lipid-rich tissues.
THC and its metabolites are highly fat soluble and may remain for long periods
in fatty tissue from which they are slowly released back into the bloodstream.
Because of the slow release of THC and its metabolites, repeated use of
cannabis results in an accumulation of THC and its metabolites in the body. As
a result THC and its metabolites may be detectable in the blood for several
weeks while the period of intoxication lasts only a matter of hours.
[National Drug and Alcohol Research Centre, The Health and Psychological
Consequences of Cannabis Use, Australia, 1995, pp. 4-6.]
Recreational effects
Although THC is essentially a sedative, the user experiences a temporary
`high'. Cannabis typically produces an altered state of consciousness in
users, characterised by mild euphoria, relaxation and perceptual alterations,
including time distortion and intensification of ordinary sensory experiences.
In a social setting, cannabis frequently produces talkativeness and infectious
laughter. The drug also creates a loosening of associations which allow the
user to become lost in a pleasant daze.
The psychoactive and other effects of cannabis on a user are determined by a
variety of factors such as:
the THC content of the drug;
the method of administration;
the circumstances in which the drug is taken;
the mental state of the person using the drug;
the user's history of drug taking;
whether other psychoactive drugs are also used; and
individual physiology.
[Drugs Advisory Committee,
New Zealand Drug Foundation, Public Health Commission, Cannabis and
Health in New Zealand, 1995, p. 4, cited in Ministry of Health,
Cannabis: The Public Health Issues 1995-1996, p. 6.]
Legal status of cannabis
The use of drugs is controlled by the Misuse of Drugs Act 1975. This statute
differentiates between types of drugs on the basis of the purported harm that
could be caused by their misuse, dividing restricted drugs into three
categories:
Class A - includes heroin and LSD
(lysergic acid diethylamide), drugs regarded as having the
greatest potential to cause harm;
Class B - includes morphine, opium,
amphetamines, cannabis oil (hash oil) and cannabis resin (hashish),
drugs regarded as having a high abuse potential; and
Class C - includes cannabis plant, leaf or
fruit, drugs regarded as being the least potent or harmful.
The Misuse of Drugs Act 1975 prescribes penalties for dealing, possessing,
using, cultivating or stealing controlled drugs. The Act is administered by the
Ministry of Health (the Ministry) but is enforced by the Police and Customs Service.
National Drug Policy
The government released its National Drug Policy for 1998 to 2003 during the
course of the inquiry. The policy achieves one of the five major directions of
the 1994 National Mental Health Strategy. It aims to improve the health and
well-being of all New Zealanders by setting out the government's determination
to prevent and reduce drug-related harm. The policy emphasises strong law
enforcement (to control the supply of drugs), credible messages about
drug-related harm (to reduce demand for drugs), and effective health services
(to manage drug problems which do still occur). The policy sets out three
priorities and a number of desired outcomes for each priority. These outcomes
include:
increased involvement of the community, and particular
subgroups of the community, in reducing drug-related harm;
more effective school policies and education in the school
setting about the harms and hazards of drug use;
improved range, quality and accessibility of effective
treatment options for people with drug problems;
improved expertise of health workers in the drug field; and
reduction in the prevalence of cannabis use in the
population.
Difficulties associated with cannabis research
The illegal status of cannabis makes reliable data identifying its
effects difficult to obtain. The Drug Policy Forum Trust (DPFT) argued that users coming to the attention
of the health system represent a biased sample. Experts whose interactions are
limited to users who have developed mental health problems may ascribe
causality to cannabis and overlook the users whose consumption has not
adversely affected their mental health because they do not have professional
contact with such users.
Many submissioners emphasised the difficulties inherent in attempting to
establish a definitive causal relationship between cannabis use and mental
illness. The interactions between a multitude of social, genetic and
environmental factors cannot be discounted to illustrate that cannabis alone is
the causative factor. The evaluation of the health hazards of any drug is
difficult. Causal inferences about the effects of drugs on human health are
difficult to make, especially when the interval between use and alleged ill
effects is a long one.
[W. Hall, et al. The Health and
Psychological Consequences of Cannabis Use,
Canberra, Australian Government Printing Service, 1994.]
In addition, appraisals of the hazards of drug use are affected by the social
approval of the drug in question.
Submissioners from the Department of Psychological Medicine, Dunedin Medical
School (DPM) outlined the various methods of research into the effects
of cannabis, including:
Case Controlled Studies - in which a
history of cannabis use is compared in people with and without mental illness,
based on a set of matching characteristics such as age, sex and educational
levels. If cannabis use is higher in those with a mental illness, a
relationship is inferred.
Cross Sectional Studies - in which samples
of people are simultaneously assessed as to whether they use cannabis, and
whether they have a mental illness. If cannabis users are over-represented in
the group who have mental illness, and under-represented in the group that do
not, a relationship is inferred.
Cohort Studies - in which a population
sample is followed over time. Invariably some use cannabis and some do not.
If the two groups differ in the incidence of mental illness a relationship is
inferred.
The DPM favoured the use of cohort studies because data is collected from
birth, thereby allowing researchers to create a clearer picture and better
identify cause and effect relationships. However, it warned that the list of
variables that potentially contribute to mental illness is lengthy, and that
the most exhaustive studies may miss crucial factors. The impossibility of
standardising the amount of cannabis used further undermines the outcome.
Issue One: the effect of cannabis on people's development
Cognitive development
The Life Education Trust (LET) stated that cannabis causes severe
damage to cognitive functions. The most serious impairments, it believes, are
reduced short-term memory, locomotion disorders, altered time sense, paranoia,
fragmentation of thought and lethargy.
[Steinherz, K. & Vissing, T.
``The medical effects of marijuana on the brain'', 21st
Century., Winter 1997-1998. Cited in the submission of the Life
Education Trust.]
The Ministry was unable to locate authoritative scientific evidence to
demonstrate cannabis-related brain damage. The Ministry cited research
documenting cognitive impairment of information processing and short-term
memory through the use of cannabis. This may affect the user's ability to
recall new information, thereby disrupting the learning process. However, the
Ministry noted that the preponderance of current scientific evidence suggests
that cannabis does not significantly impair these cognitive functions. Wayne
Hall of the Australian National Drug and Alcohol Research Centre who was
recently commissioned to provide a comprehensive report on scientific research
in this area summarised current knowledge about the effects of cannabis on
cognition.
[Hall, W., et al. The Health and Psychological
Consequences of Cannabis Use., Canberra, Australian Government Printing
Service, 1994. ]
He found that long-term use of cannabis may cause subtle impairment in the
higher cognitive functions of memory, attention and the organisation and
integration of complex information. We heard that the longer and heavier the
use, the more pronounced the impairment. Current studies are unable to
determine whether any residual effects remain after cannabis use is
discontinued.
[House of Lords Select Committee on Science and Technology, Ninth
Report.]
Hall and the HFA pointed out that cannabis should be viewed as a lesser threat
to cognitive functioning than alcohol. We concur with the findings of Hall, the
Ministry, the New Zealand Drug Foundation (DF) and the Health Funding Authority
(HFA) that although long-term heavy use of cannabis does not produce severe
deterioration of cognitive function, it may cause subtle impairment.
Cannabis use by adolescents and children
The causal relationship between deviancy and cannabis use in youth was explored
by several submissioners. PRYDE stated that cannabis use caused changes in the
behaviour of adolescents. PRYDE attributed lying, educational failure, slowed
physical and emotional development, and emotional withdrawal from the family to
cannabis use. However, the DPFT, the HFA and the
Christchurch Health and Development Study (CHDS) argued that youth who
are prepared to break the law to use cannabis exhibit a predisposition towards
deviancy. The CHDS study of a young cohort found that cannabis users are an
``at risk population that, independently of cannabis use, would have been at
greater risk of adjustment problems in early adulthood''.
[Fergusson, D.M., Horwood, L.J., ``Early onset cannabis use and psychosocial
adjustment in young adults'', Addiction, 1997; 92: 279-296.]
Cannabis using youth were characterised by early conduct
difficulties, health problems, academic problems and dysfunctional families.
The DMHDRU longitudinal study of 1000 people born in Dunedin in 1972 to 1973 reinforced these
findings. It found that cannabis use amongst male participants at age 15 was
predicted by earlier depression and antisocial behaviours during the
pre-adolescent years. Further evidence of this predisposition to antisocial
behaviours leading to drug use was given in the Police submission. The Police
noted that only 9.55 percent of adolescents appearing on drug offence charges
had been convicted previously on drug offence charges. Significantly, 46.3
percent had been convicted of prior non-drug related offences. The Police added
that although conduct disorders such as truancy, persistent lying and
non-confrontational stealing were associated with adolescent cannabis use, they
believed cannabis use was not the cause of these behaviours. Evidence before us
suggests that cannabis use does not cause behavioural difficulties, instead it
is frequently used by youth who are pre-disposed to deviant behaviours.
Cannabis and suicide
Data collected by the Canterbury Suicide Project found that rates of cannabis
abuse were higher amongst those making serious suicide attempts. However,
further analysis suggested that again the involvement of cannabis was by
association, as opposed to causation. Individuals who were predisposed towards
a suicide attempt through a disadvantaged socio-demographic background or
mental illness were also more likely to use cannabis. Evidence suggests that
cannabis use is not a causal factor in suicide.
Effects on educational achievement
The DPFT stated that research into the impact of cannabis use upon youth is
scarce due to ethical constraints. It categorised the impact of cannabis
intoxication as similar to that of alcohol intoxication in its impairment of
the learning ability of school children. Intoxication caused by use of either
substance disrupts short-term memory for the period of time spent under its
influence. The school years are an important period of development and we are
concerned at the potential for cannabis use to interfere with learning. This is
of further concern in light of evidence that subtle cognitive impairment can
result from cannabis use.
Effects on foetal development
No conclusive evidence exists to demonstrate deleterious effects of cannabis
use upon foetal mental development. However, some scientific publications have
reported that cannabis use during pregnancy is associated with
neuro-behavioural alterations such as increased tremors and decreased visual
responses in babies.
[Fried, P.A. (1985) ``Postnatal consequences of
maternal marijuana use'', National Institute of Drug Abuse Research
Monograph Series, Vol 59, pp. 61-72. Cited in the submission of the
Ministry of Health.]
Studies exploring the relationship between
prenatal exposure to cannabis and postnatal intelligence quotients have had
contrasting outcomes, and are undermined by the difficulty in attributing
causality. The most recent review of literature on the effects of cannabis use
on the foetus found that cannabis has no reliable impact on birth size, length
of gestation, neurological development, or the occurrence of physical
abnormalities.
[Zimmer, L., and Morgan, J.P. (1997). Marijuana
Myths, Marijuana Facts - A Review of the Scientific Evidence. New
York: Lindesmith Center.]
However, longer range studies found that the
neuro-behavioural consequences of maternal cannabis use were not evident until
children reached the age of four. At that stage the offspring of regular
cannabis users showed reduced verbal ability, increased impulsiveness and
memory loss.
[Day, N.L., et al. (1994) ``Alcohol, marijuana and
tobacco: effects of prenatal exposure on offspring growth and morphology at age
six''. Alcoholism: Clinical and Experimental Research, vol
18(4), pp. 786-794. Fried, P.A. (1995). ``Prenatal exposure to tobacco and
marijuana during infancy, early and middle childhood: Effects and an attempt at
synthesis''. Archives of Toxicology Supplement, vol 17,
pp.233-260. Cited in the submission of the Ministry of Health.]
We note an important caveat to these results; that separating in
utero effects from post-natal effects becomes increasingly difficult as
the children age.
Professor Faull of the Anatomy Department of the University of Auckland
informed us of the results of his recent studies of cannabinoid receptors in
the human brain. His research found that foetal and neonatal brains contain
higher levels of cannabinoid receptors than the adult brain. He suggested that,
as a result, cannabis had the potential to have a greater effect on the brain
of the foetus and child than on the brain of the adult. While the study focused
on the distribution of cannabinoid receptors in the brain rather than the
effects of cannabis specifically, the findings suggest a cautious approach to
the effects of cannabis on the foetus and young child.
[Glass, M., Dragunow, M., and Faull, R. ``Cannabinoid receptors in the human
brain: A detailed anatomical and quantitative autoradiographic study in the
fetal, neonatal and adult human brain'', Neuroscience, Vol. 77,
No. 2, pp. 299-318, 1997.]
Overall, we have concluded that the residual effects of maternal cannabis use
on foetal mental development are subtle and difficult to extract from other
causal factors such as socio-economic status and other drug use. We recommend
that women be advised to refrain from using cannabis while pregnant.
Issue Two: the role of cannabis as a trigger for mental illness
Cannabis dependence
We note that regular cannabis use can lead to cannabis dependence, a recognised
form of mental disorder. Cannabis dependence is characterised by an increased
tolerance of the drug's effects and an inability to control use even where
there are adverse consequences from use.
[Ministry of Health, Cannabis: The Public Health Issues, p. 11.]
The nature
of the dependency is controversial. Many experts note the lack of physical
withdrawal symptoms and suggest that the dependency is psychological, as
opposed to physical. The Ministry and the Alcohol and Drug Service at Capital
Coast Health (ADS) estimate that approximately 10 percent of regular cannabis
users will progressively lose control over their use. The ADS have observed
that cannabis dependency is more common in males, possibly as a reflection of
greater use rates by males, as noted by survey data.
[See earlier section on Rates of cannabis use]
The DMHDRU added that while females
tend to internalise mental health disorders through depression and anxiety,
males tend to externalise through acting out, aggression, and substance abuse.
The DMHDRU longitudinal study found 9.6 percent of those participating met the
criteria for dependence at age 21.
[9.8 percent met the criteria for alcohol dependency.]
The HFA added that cannabis dependency differed
significantly from nicotine dependency, with rates declining as users
aged.
[New Scientist, 21 February 1998, p.27. Cited in
the submission of the Health Funding Authority.]
The Police commented on the mental health problems suffered by a group of
former undercover police officers who were exposed to cannabis use during the
course of their operations. The officers reported symptoms associated with
cannabis dependence:
general fatigue;
lack of sleep;
depression;
mood changes;
paranoia;
disorientation; and
inability to reduce or stop use.
The extent to which cannabis was a contributing factor, as opposed to other
issues relating to the stressful nature of their work environment has yet to be
evaluated.
Cannabis psychosis
We heard strong evidence from the Ministry, the DPM and the HFA that high doses
of cannabis can evoke acute psychosis in vulnerable individuals. We accept that
this is a rare occurrence. The symptoms of cannabis psychosis can include
confusion, amnesia, delusions, hallucinations, anxiety and agitation. These
symptoms typically last only as long as the period of cannabis intoxication.
Cannabis and schizophrenia
Aside from cannabis-induced psychosis we are reluctant to draw any causal
relationship between cannabis and mental illness. Instead, we accept that
cannabis use may be associated with forms of mental illness. The purported
linkage between cannabis and schizophrenia was cited as a good example. We
heard that cannabis use may accelerate the onset of schizophrenia in
predisposed individuals, and cannabis use by people with schizophrenia may
complicate the management of their symptoms. These conclusions support the work
of Wayne Hall of the Australian National Drug and Alcohol Research
Centre.
[Hall, W., et al. The Health and Psychological Consequences of Cannabis Use.,
Canberra, Australian Government Printing Service, 1994.]
The Schizophrenia Fellowship (SF) did not challenge these findings.
Interestingly, the HFA added that the incidence of schizophrenia has declined
during the period in which cannabis use has increased among young adults.
[The submission of the Health Funding Authority cited Hall et al. as
the source of this statement.]
Currently our understanding of the interplay between cannabis and
illnesses such as schizophrenia is limited. We note that Wayne Hall has called
for more research into the following areas;
the prevalence of cannabis use amongst persons with
schizophrenia, reasons for their use and the typical effects they experience;
the relationship between past and current cannabis
use and the course of schizophrenic disorders in affected individuals; and
the impact of the cessation of cannabis use on the outcome
of the schizophrenic disorder.
The Health Research Council (HRC) advised us that no projects in the area of
cannabis and mental health were currently proceeding under the auspices of that
organisation. However, the HRC are assisting with a fellowship to develop
research into the area of cannabis use.
Cannabis use by those with a mental illness
The SF and Caring Communities Incorporated (CCI) are deeply concerned
that cannabis is readily accessible to those with a mental illness. Both groups
believe cannabis use contributes to a downwards spiral into homelessness, debt,
crime and suicide. Furthermore, SF advised that substance abuse can be
associated with unpredictability and violence in those with a mental illness.
This is based on its assertion that cannabis can trigger psychotic episodes in
vulnerable individuals. The SF believed that although factors such as
non-compliance with medication and polydrug abuse are frequently present,
cannabis use is often the causal trigger for a psychotic episode. This is based
solely on anecdotal evidence.
The DF confirmed the suggestion that polydrug use complicates the causal
relationship between cannabis and mental illness. It quoted the Ministry of
Health: ``the most serious drug related harms are often suffered or caused by
polydrug users, for example people who drink alcohol and smoke cannabis'' and
``research evidence suggests that the prevalence of co-existing drug use and
mental disorders is extremely high''.
[Ministry of Health, December 1997, Working Papers on the National Drug Policy,
Part 2: Illicit and Other Drugs. Cited in the submission of the New
Zealand Drug Foundation.]
We view polydrug use as a dangerous practise, particularly among people taking
prescribed medication for an existing mental illness.
The SF is concerned that many people with a mental illness use cannabis
therapeutically as a temporary respite from agitation and anxiety. These
symptoms return as the period of intoxication ends, and the SF believes that
this cycle exacerbates psychotic symptoms such as delusions and hallucinations.
The termination of a compulsory treatment order, under the Mental Health
(Compulsory Assessment and Treatment) Act 1992 is often followed by
self-medication with cannabis. Unpleasant side effects such as dribbling,
restlessness, stiffness and shaking have also discouraged some mentally ill
people from taking anti-psychotic medication. We are concerned that patients
may compromise the management of their illness by discontinuing the use of
prescribed medicine in favour of using cannabis. We note that newer types of
anti-psychotic medication have fewer negative side effects.
Therapeutic cannabis use by those with a mental illness
Several submissioners including the DPFT and the Effective Drug Education Trust
(EDET) suggested that some schizophrenics are able to successfully
self-medicate with cannabis. The EDET added that it is cruel to deny these
individuals access to their medication of choice.
We note that the House of Lords Select Committee on Science and Technology has
recently released its report on the therapeutic use of cannabis. The House of
Lords committee recommended that the Government transfer cannabis use from
Schedule 1 to Schedule 2 of the Misuse of Drugs Regulations. This would
sanction the prescribing of cannabis to specific groups of patients for whom
cannabis-medicines are appropriate. We note that the House of Lords committee
stated that a number of groups, including sufferers of schizophrenia should not
be prescribed cannabis-based medicines.
Impact of illegality on mental health
The DPFT, EDET, the Aotearoa Legalise Cannabis Party (ALCP) and other
submissioners believe that the mental health of cannabis users is jeopardised
more by prohibitionist laws than by the drug itself. They stated that the
climate of criminality generates paranoia and anxiety. Those who develop
problems are less likely to seek help because they use an illegal substance and
may spiral into alienation, anti-social behaviour, criminality, mental illness
or violence.
The Police have acknowledged the concern that a minor drug conviction may have
an excessively negative impact on the life of a young person. In response, the
Police have implemented a range of alternatives to a court appearance,
including the diversion scheme. Furthermore, we received an assurance from the
Police that they do not intend to prosecute those who publically address the
legal status of cannabis, and are willing to enter into discussions with
pro-cannabis groups on these grounds. We welcome the stance taken by the Police
which aims to address drug issues in a practical way.
Issue Three: the effects of cannabis on Maori mental health
Currently, some Maori communities have the highest rates of use of
alcohol, tobacco and cannabis in New Zealand. However, it is important to
stress that such a generalisation cannot be made of all Maori communities
and such problems are also experienced in non-Maori communities. It is
important to recognise the relationship between low socio-economic status and
drug abuse when considering the effects of cannabis on Maori. It is also
important to recognise that there is a lack of robust research evidence about
Maori drug use.
Rate of cannabis use amongst Maori
The Mental Health Commission (MHC) has described mental health disorders,
including drug-related problems, as the most significant threat to Maori
health. Preliminary studies suggest that up to half of all Maori have
experimented with cannabis, and that cannabis use has reached epidemic
proportions in some Maori communities in the far north of New
Zealand.
[Dacey, T. Te Ao Taru Kino. Unpublished paper by Whariki Research Group.
Auckland: Alcohol and Drug Public Health Research Unit, 1998. Cited in the
submission of the Ministry of Health.]
However, individual submissioners noted that the enforcement of the drug laws
often disproportionately targeted Maori users. Statistics from the Ministry of
Justice indicate that Maori have a higher conviction rate for drug
offences than non-Maori.
A study undertaken by Te Runanga O Te Rarawa (TROTR) into cannabis use by
members of the Te Rarawa iwi living within the tribal rohe of Hokianga provides
important information on cannabis use by Maori. The data was obtained
through surveys, interviews, court statistics and talk back on iwi radio. Many
of the smaller Maori communities in the area suffer from a high rate of
unemployment and poverty. Of the 125 people surveyed, 49 were current cannabis
users and a further 31 had previously used cannabis. The vast majority stated
that they used cannabis for pleasure and leisure. Some of those surveyed stated
that they would not smoke cannabis if they had greater employment
opportunities. Others added that the cannabis industry provided a much needed
supplementary income in a depressed economy. Many raised concerns about
children growing up in homes where cannabis use is considered a normal
behaviour. Others raised concerns that cannabis use impacted strongly on
communities, creating divisions between those who use cannabis and those who do
not.
Drug-related hospital admissions
In its document Trends in Maori Mental Health, 1984-1993,
Te Puni Kokiri stated that drug and alcohol abuse and psychosis are
responsible for the majority of Maori first admissions to psychiatric
hospitals. In 1993, 56 percent of Maori admissions were for specifically
drug-related reasons, compared with 28 percent for Pakeha. However,
TPK and the Ministry questioned whether an attribution bias operated in the
diagnosis process. The clinicians may have incorrectly diagnosed Maori
patients as suffering from drug abuse to fulfil a prevalent racial stereotype,
when the patient was actually suffering from a non-drug related form of
psychosis. Such an attribution bias has been noted in the United Kingdom, in
relation to West Indian patients.
[Glover, G., ``Differences in psychiatric admission patterns between Caribbeans
from different Islands'', Social Psychiatry and Psychiatric Epidemiology,
vol 24, 1989, cited in the submission of the Ministry of Health.]
While there is no evidence that such a bias does exist in New Zealand, it
warns against relying too heavily on disproportionate Maori admission rates as
the sole indicator of the effects of cannabis on Maori.
The possibility that Maori are being treated differently by the health
system was recently raised by the Ministry. The Ministry noted that,
when Maori are first admitted to an institution for substance abuse, this
is frequently seen as the `major problem' rather than being a symptom of a
broader mental health problem. Furthermore, the way in which some Maori
communicate and behave may differ from behaviour that clinicians regard as
`normal' leading to possible inappropriate diagnosis.
[Dyall, L., ``Maori'', in Ellis, P. and Collins, S. (eds.), Mental Health in New
Zealand From a Public Health Perspective, Ministry of Health Public
Health Report No. 3, Wellington, 1997 cited in Ministry of Health submission;
Te Puni Kokiri, Nga Ia O Te Oranga Hinengaro Maori, Trends in
Maori Mental Health, Wellington, 1996.]
Although Maori admission rates for alcohol and drug disorders have
historically been higher for males, the female rate has increased by an
alarming 49 percent over the period 1984 to 1993. In 1993, the male Maori
admission rate stabilised at 33 percent higher than Pakeha
males, while the female Maori admission rate climbed to 67 percent higher
than the female Pakeha rate. Pacific Islanders have a very low rate
of first admissions for alcohol and drug disorders.
The Alcohol and Drug Service operated by Tairawhiti Health Limited, a Hospital
and Health Service (HHS), reported that 90 percent of its clients with cannabis
abuse or dependence problems were Maori. Of the patients admitted to the
Inpatient Psychiatric Unit, drug use (not specifically cannabis use) played a
major role in 11 percent of cases. The proportion of Maori admitted was
double the proportion of non-Maori. The Community Mental Health Team
identified 53 percent of its clients as having a dual diagnosis of mental
illness and cannabis usage.
Socio-economic factors in cannabis use
Many Maori live in areas in which the growth and use of cannabis is
commonplace and unemployment is high. Cannabis has become an important cash
crop in some of these regions.
[Submission of the Alcohol and Public Health Research Unit.]
We consider that the high rate of cannabis usage amongst Maori is a symptom of
underlying social problems, including low educational achievement and high
unemployment rates. Tairawhiti Healthcare Limited identified a number of
reasons for the high rate of cannabis usage in its community, including
factors such as poor housing standards and large numbers of people receiving
social welfare benefits. It will be difficult to reduce the rate of cannabis
use unless these underlying causes are first addressed. Many people leaving
drug treatment programmes simply return to the environment from which they
came. Often the problems that may have led to drug use remain and abstinence
from drugs may be challenged by peers.
[Submission of Tairawhiti Healthcare Limited.]
It is beyond the terms of reference of this inquiry to address the underlying
causes of high cannabis use rates in these communities. However, we support
actions to reduce unemployment, improve standards of living and provide greater
opportunities to New Zealanders, particularly those living in low
socio-economic areas. We draw the attention of the Government to the MHC's
recommendation in its submission:
``We suggest that the emphasis of any interventions is on the underlying
factors (such as issues of poverty, hopelessness and low self esteem)
rather than solely on drug use.''
Further research needed
We are concerned at the lack of research into the effects of cannabis on
Maori. The HFA and other submissioners agreed that such information and
research is currently inadequate. While some useful research has been conducted
and anecdotal evidence exists, we consider that priority areas for research
include:
the effects of a higher rate of cannabis use amongst, Maori;
the reasons for cannabis use by Maori;
the effectiveness of cannabis education strategies for Maori;
the adequacy of drug treatment services for Maori; and
the effects of the legal status of cannabis on Maori communities.
Very little drug research is carried out in New Zealand. However, there are
drug issues specific to this country which require urgent examination. We
consider the effects of drug use on Maori to be one such issue. Such
research can be conducted effectively by non-government organisations as well
as by the Crown. However, we believe that it is primarily the responsibility of
the Government to evaluate the adequacy of treatment services.
Recommendations:
We recommend that:
the Government fund research on the prevalence and patterns of cannabis use
by Maori;
the Government fund research on the ways in which cannabis-related mental
health problems are experienced by Maori; and
the Government fund research into the effects of cannabis
on Maori communities and the adequacy of drug treatment services for Maori.
Issue Four: the adequacy of services for those with drug-related
mental illnesses
Drug abuse is a major exacerbating factor for people with acute and semi-acute
mental disorders and over 50 percent of forensic psychiatric patients have drug
abuse as a contributor to their risk management. Although there is no hard
evidence as to the number of patients with a mental health disorder and a drug
abuse problem, the problem is substantial. Estimates are that between 35
percent and 85 percent of psychiatric patients have such a problem.
[Inquiry Under Section 47 of the Health and Disability Services Act 1993
in Respect of Certain Mental Health Services (the `Mason report'), May
1996, p. 70.]
While moderate cannabis use may prove relatively harmless
to most people, as discussed earlier, it clearly has a detrimental effect upon
a minority of people with pre-existing mental illnesses. We agree with the
MHC that the best solution to mental health problems
in which cannabis is a factor is to ensure good access to integrated treatment
services as well as reducing access to drugs. This section of the report
examines the adequacy of mental health services for those people who use
cannabis and have a mental illness.
Drug-related mental illness, in relation to cannabis, usually refers to those
people:
experiencing problems with polydrug abuse including cannabis;
who are cannabis dependence;
with a dual diagnosis of a mental health disorder and a cannabis abuse
problem; and
with mental health disorders exacerbated by cannabis.
Mental Health Blueprint
The MHC's Blueprint for Mental Health Services in
New Zealand (the Blueprint) was launched in November
1997 as a discussion document. A revised version of the
Blueprint was launched in November 1998. It provided a ten year
guide to improving the mental health system in New Zealand. The implementation
of all of the recommendations contained in the Blueprint has
the potential to create a large funding gap for mental health services.
Currently, there is a significant gap between the services provided for those
with drug-related mental illnesses and the services required by those people.
Services for those with a dual diagnosis
In many parts of New Zealand, mental health services and drug and alcohol
services have developed separately and have not been well co-ordinated. As a
result, these services often failed to meet the needs of those with a dual
diagnosis of a mental health disorder and a drug abuse problem. This partially
reflected conflict between the underlying philosophies of mental health
services and drug and alcohol services. Historically, alcohol and drug services
have emphasised personal empowerment and responsibility, while the mental
health services have, as part of their duties, been charged with providing
compulsory assessment and treatment. We support the view of the MHC, as
expressed in its Blueprint, that this conflict be urgently
addressed due to the high rate of co-morbidity between drug disorders and
mental illness.
A review of international research indicates that approximately 50 percent of
those suffering from a severe form of mental illness have co-existing alcohol
or drug use disorders. In New Zealand 48 percent of those admitted to acute and
intensive psychiatric care units have a substance use problem. A co-existing
alcohol or drug abuse problem worsens the treatment outcomes of those suffering
from mental illness. They are admitted for longer periods following psychotic
episodes, exhibit higher psychotic symptom scores at discharge and are more
frequently admitted than those without substance abuse problems.
Lack of integrated dual diagnosis services
Despite the seemingly high incidence and serious nature of dual diagnosis the
SF was critical of the fact that it is not treated
as a medical disorder in its own right. The SF recommended that this be
rectified, and that targeted funding be directed to the development of a
variety of modified treatment programmes. Current substance abuse services do
not address the needs of the people with a dual diagnosis because traditional
methods of treatment are too confrontational for thought disordered people
with paranoid ideation and low self esteem and large group work has been
proven ineffective with mentally ill substance users.
People with high treatment needs, such as those with substance abuse and mental
health diagnoses, have been turned away from mental health services because
they have a concomitant substance abuse problem which was not seen as the
responsibility of mental health services. Others have been turned away from
drug and alcohol services because they have symptoms of serious mental illness
that the service has not seen as its responsibility to address. Both types of
service have also had to consider whether treating dual diagnosis patients was
within their resources or clinical ability.
[Submission of the Mental Health Commission.]
The Mason report identified the need for better co-ordination between the drug
and alcohol treatment sector and the mental health sector. Greater integration
of the two sectors and more co-operation in terms of assessment for those with
dual diagnosis is essential. Blame for the current lack of co-ordination cannot
be laid solely at the feet of the treatment providers. Discrete, non-integrated
funding for the two types of service have reinforced their separate
development. In addition, the diagnosis and management of dual diagnosis
patients requires a high level of expertise and training which has not been
widely available to treatment providers.
[Inquiry Under Section 47 of the Health and Disability Services Act 1993 in
Respect of Certain Mental Health Services (the `Mason report'), May 1996,
pp. 71-73.]
Need for integrated care
The MHC promoted the development of pathways of integrated care between alcohol
and drug services, primary and secondary services and early intervention
practitioners such as teachers, school councillors and social workers.
Interventions designed for and by local communities have the best potential
long-term outcomes for lessening the misuse of drugs. This is primarily because
the community is best placed to appraise the underlying causes of drug use,
raise collective responsibility for the problem, and improve self esteem. The
MHC viewed the treatment of dual diagnosis as a holistic task, with stabilising
factors such as good housing, quality care giving and rewarding employment
opportunities crucial to the success of the treatment. Services have
increasingly recognised the benefits of involving friends and family in this
process. The interaction of these factors will discourage substance abuse and
motivate mental health patients to take responsibility for dealing with their
condition.
Need for more residential care facilities
We are concerned that many mentally ill people with substance abuse problems
are required to leave some mental institutions, and are evicted from flats and
family homes for their disruptive behaviour, and that responsibility for their
care often falls to the Police. The SF and CCI stressed the importance of residential care facilities, such as Odyssey
House in Auckland, one of the few providers of a therapeutic community
environment for people with a dual diagnosis. We heard evidence from the family
of a person who had been treated at Odyssey House and who praised the treatment
provided there but was critical of the lack of similar services throughout the
rest of the country.
We consider the provision of good quality, specialist treatment centres for
dual diagnosis to be essential and urge the Government to adequately fund such
programmes. However, we are aware that the HFA can only purchase such services
where they are available. The HFA has underspent the additional money made
available to implement the recommendations of the Mason report.
Approximately one third of the `Mason money' (additional funding made available
by the Government to implement the findings of the Mason report) was unspent in
1996/97, largely because of a lack of new services to purchase.
[Health Committee, Report on the 1996/97 financial review of the Transitional
Health Authority, I.20a.]
We encourage health providers and the HFA to work
together to ensure better provision of services in the area of residential care.
Recommendations
We recommend that:
the Government encourage the provision of a greater number
of residential care facilities throughout New Zealand;
the Government provide funding for dual diagnosis patients
to the level recommended in the Mental Health Commission's Blueprint
for Mental Health Services in New Zealand, November 1998; and
the Government develop a policy to encourage greater
co-ordination and co-operation between alcohol and drug services and mental
health services.
Mental health service development targets established
We are pleased to note that, with the publication of the draft National
Mental Health Funding Plan 1998-2002, the HFA has established targets
for service development over the next four years. These include a commitment to
the co-ordination of services for people with co-existing disorders and the
development of specialist teams whose responsibilities include:
training in dual diagnosis service provision for those
working in mental health and drug and alcohol services;
the development of centres of expertise to provide examples
of best practise; and
the provision of advisory and liaison services for other providers.
These teams are to provide a focus for developing services for dual diagnosis
clients. We hope that this initiative assists generic services to gain
expertise in treating dual diagnosis patients, so that such services are better
able to meet all the treatment needs of their clients.
Need for workforce development
Submissioners, including the New Way Trust (NWT), stated that New Zealand
suffers from a shortage of trained health professionals with a knowledge of
mental illness and substance abuse problems. Workforce development is an
essential part of the strategy to enhance services for dual diagnosis patients
and others suffering from drug-related mental illness. Mental health services
should be able to meet the mental illness and drug and alcohol disorder needs
of most patients while drug and alcohol services must be able to meet the needs
of clients with mental illnesses. The staff of both kinds of treatment
providers need training to develop skills in assessing and managing mental
illnesses and substance abuse problems.
[Mental Health Commission, Blueprint for Mental Health Services in New Zealand,
1998, pp. 34 and 39.]
Maori are under-represented in all areas of the mental health workforce.
The MHC has identified an urgent need to facilitate entry into programmes of
study by Maori so that they are able to enter the full range of mental
health occupations. If appropriate services are to be provided to Maori
then a substantial Maori presence is required throughout the mental health
workforce.
The HFA considers the lack of appropriately skilled mental health workers to be
a significant obstacle to the successful implementation of the MHC's
Blueprint. One of the major problems is the small size of the
mental health workforce. The MHC has identified that an additional 352 full
time equivalent clinical staff are required in the area of alcohol and drug
treatment.
[Mental Health Commission, The Funding Needed for Mental Health Services in
New Zealand, December 1998, p. 14.]
We have previously heard that the Ministry has provided for the
training of more clinical leaders in the mental health area. Furthermore, it
has allocated additional funding to the Clinical Training Agency to increase
the total number of psychiatrists and to provide training programmes on mental
health for newly-registered nurses. However, the payoffs from these initiatives
will not be seen immediately. The Ministry has reported that the
benefits of training programmes for nurses will be evident within three years
while the gains from training more psychiatrists will be achieved in 10 to 15
years.
[Health Committee, Report on the 1995/96 financial review of the Ministry of
Health, I. 20A.]
The Clinical Training Agency, a unit of the HFA responsible for co-ordinating
the planning and purchasing of post entry clinical training for health
professionals in New Zealand, is using `Mason money' to develop mental health
training programmes including:
Maori mental health training;
training for non-clinical mental health support workers;
providing internship years or advanced training in mental
health for nurses; and
increasing the coverage of training in mental health.
The MHC plans to work with the Ministry and the HFA to develop a mental health
workforce strategy to provide plans and programmes to improve knowledge and
skills in areas including assessment and management of drug and alcohol
disorders. The strategy will also provide for increases in the total mental
health workforce necessary to achieve the resource guidelines set out in the
MHC's Blueprint.
HFA management of services
In the course of our hearings of evidence, several criticisms were directed
towards the HFA's current management of services for those with dual diagnosis.
The DF was critical that the HFA had not appointed a manager to be directly
responsible for the delivery of dual diagnosis services. Furthermore, the LET
raised concerns that the four former Regional Health Authorities (RHAs)
subscribed to different sets of rules concerning referrals to the Queen Mary
Hospital facility in Hanmer Springs. The LET are hopeful that the merger of the
four RHAs into a single HFA will address this issue and provide greater equity
in referrals for those with a dual diagnosis, regardless of their geographic
location. However, the LET had seen no evidence of this to date.
We hope that the HFA's commitment to the co-ordination of services for people
with co-existing disorders, expressed in the draft National Mental
Health Funding Plan 1998-2002, and the initiatives it has taken to
develop specialist teams more appropriately address the needs of those with
drug-related mental illness.
Lack of services for children and young persons
The MHC has identified children and young persons mental health services as the
most inadequately funded area. Other submissioners, including the Commissioner
for Children, expressed grave concern at the dearth of adequate treatment
facilities aimed at treating adolescent cannabis abusers. The Commissioner
described this area as underfunded and undervalued by health service purchasers
and providers. A particular deficiency has been noted in the area of
residential treatment for adolescent cannabis users. The Mason report commented
that it is alarming that mental health services for children and adolescents
still lag far behind those for adults.
[Inquiry Under Section 47 of the Health and Disability Services Act 1993 in
Respect of Certain Mental Health Services (the `Mason report'), May
1996, pp. 132-135.]
We note that the MHC has recently identified that 347 child and youth beds and
care places are required but that only 24 are currently funded. In addition, the
MHC has recommended an increase of 780 full time equivalent clinical staff in
the child and youth mental health area.
[Mental Health Commission, The Funding Needed for Mental Health Services in
New Zealand, December 1998, p. 14.]
Cannabis use is highest amongst men and women in their late teens and early
twenties and a considerable proportion of younger people also report having
used it. The Government has also identified youth as a group at risk from
cannabis use [Ministry of Health, Cannabis: The Public Health Issues 1995-1996,
pp. 16-20; National Drug Policy, 1998, p. 40.] and it is essential that the
Government adopt a specific plan for the provision of child and adolescent
services.
Recommendations
We recommend that:
the Government adopt a specific plan for the provision of
child and adolescent mental health and drug and alcohol services, incorporating
the needs of Maori;
the Government dedicate funds to the training of child and
adolescent mental health professionals (including professionals with expertise
in treating dual diagnosis); and
the Government ensure that funds allocated to the training
of child and adolescent mental health professionals make specific provision for
the training of Maori workers.
We note that the Government, in its National Drug Policy, undertakes to focus
on better addressing the needs of children and young people and on providing
training for service providers. We look forward to the implementation of these
promises over the next five years and wish to underscore the urgency of such
initiatives.
Inadequacy of services for rural communities
The demography of New Zealand, with many small rural communities distant from
the major urban centres, creates complex problems in the provision of mental
health services. Rural communities and lower socio-economic groups have also
been identified as requiring more comprehensive mental health service coverage.
The DF stated that those with dual diagnosis living in isolated rural
communities have particular difficulties accessing treatment. While the
benefits of involving friends and family in the treatment process have been
increasingly recognised, people from rural communities are often required to
leave their local area to receive treatment. The geographical areas that are
frequently most adversely affected by cannabis abuse are those isolated from
appropriate services. The MHC has recommended that such services be provided on
a regional basis and, while this has occurred in some areas, it must be
developed further to create equity of access.
[Mental Health Commission, Blueprint for Mental Health Services in New
Zealand, 1998, pp. 73-74.]
The Government must address the issue of how to provide holistic, integrated
services to people outside urban centres though the provision of regional
specialist services.
Health professionals in rural communities face additional difficulties. In some
areas where cannabis usage is high, primary health care providers are often the
only providers. However, funding streams do not target the delivery of substance
abuse or mental health services by primary care services. An early diagnosis is
more likely to result in improved health outcomes for the patient. However,
most primary providers are not currently equipped with knowledge or skills in
mental health and substance abuse diagnosis. Furthermore, professional contact
and knowledge sharing opportunities are considerably diminished for health
professionals in rural communities and smaller provincial centres. There is a
clear need for ongoing training and education in this area, supported by the
Government, rather than funded by individual practitioners.
[Submission of the Royal New Zealand College of General
Practitioners.]
Recommendations:
We recommend that:
the Government include people living in rural communities,
particularly in areas with high levels of cannabis use, as one of the `at-risk
populations' to receive better services under the National Drug Policy;
the Government extend the provision of regional mental
health services to ensure equitable coverage for New Zealanders living in rural
areas, as recommended in the Mental Health Commission's Blueprint for Mental
Health Services in New Zealand, November 1998;
the Government fund training for GPs in diagnosing and
treating mental health disorders and/or substance abuse; and
the Government examine strategies to counter professional
isolation for health providers in rural communities.
Treatment services for Maori
Under the Treaty of Waitangi, the Government has a responsibility to address
issues of Maori health status to ensure that Maori enjoy the same
wlevel of health as non-Maori. The National Drug Policy recognises that
Maori are suffering disproportionate harm from legal and illegal drugs and
that strategies designed for the general population only have limited effects
when applied to Maori.
Participants at a series of hui conducted by the MHC in
1998 reported that the major mental health service concern for Maori is
access to drug treatment services, particularly for cannabis abuse. The hui
reflected views that:
there is an urgent need to develop appropriate treatment
services for Maori affected by drug problems and other mental illness;
health promotion and treatment programmes tend to be
heavily focused on alcohol but there is a pressing need for strategies to
address problems arising from cannabis use; and
effective mental health promotion programmes are needed to
address the reasons for individual and community drug abuse problems.
Clearly, specific treatment and prevention strategies are needed for
Maori. There is a need to develop the Maori health workforce to
provide these services. The MHC is currently developing a
method for identifying what proportion of services to Maori should be
provided by Maori providers and what proportion should be provided by
mainstream providers.
Need for community-based programmes
In their submissions to us, members of the Opotiki Safer Communities Council,
TROTR and Te Whanau O Waipareira Trust emphasised the need for community-based
initiatives. They felt that in particular, rural areas in the Northland region
seek community ownership of the decision-making process. In their communities
many former and current drug users were working to prevent their children
abusing cannabis. Unless the community was prepared to share the problem the
submissioners felt the problem would be perpetuated.
We agree that an important aspect of any initiatives to address drug problems
is for communities to be involved in the development, implementation and
operation of drug programmes. Such an approach seems to have the greatest
potential to bring about sustainable change rather than to merely shift the
abuse to another substance or create another social problem. There is greater
potential for a community involved in such a scheme to address the underlying
causes of its problems, to take collective responsibility for them and to
improve self esteem. We endorse the National Drug Policy's acknowledgement that
problems in Maori communities may be best addressed when solutions are
developed by and for Maori.
We are encouraged to note that the Ministry of Education has recently funded a
trial of community-based drug education programmes, facilitated by the Alcohol
and Public Health Research Unit. The initiatives are in response to concern
over the increasing rates of cannabis-related school suspensions. The
programmes are being run in Nelson, Opotiki, West Auckland, Hokianga and
Whangaruru and aim to assist schools and communities to address cannabis issues
and develop strategies that are appropriate to the needs of each community in
reducing drug-related harm.
Recommendations
We recommend that:
the Government treat as a matter of priority the funding of
further community-based interventions (including counselling) which aim to
address community problems as a way of combating drug abuse; and
the Government continue to advocate and support strategies
(including counselling) through which Maori can identify and meet their
own needs in relation to drug treatment.
Drug education
The Government has stated that one of the desired outcomes of its National Drug
Policy is more effective education in the school setting about the harms and
hazards of drug use. It identifies the school environment as a major setting
for developing skills to make healthy choices about drugs. The effectiveness of
drug education was raised frequently during discussions of the adequacy of
treatment services, in the course of the inquiry.
The Police acknowledged that the current enforcement response has not reduced
cannabis usage rates. It favours the development of a multi-disciplinary
approach by health, law enforcement and educational institutions to promote a
reduction in cannabis use and the minimisation of harm to users. The Police
have demonstrated their commitment to this type of approach through their
involvement in youth education programmes such as DARE.
We have heard evidence that anti-drug education has served to promote cannabis
use, instead of discouraging it. The Police acknowledge that this may have been
the case in the past but challenge any suggestion that current in-school
programmes introduce children to drug use. An American study of the
effectiveness of anti-drug education programmes in schools found that most
programmes were based on the assumption that knowledge about drugs would
preclude use. However, programmes that focused on the provision of factual
information had virtually no effect on rates of drug use.
[Goodstadt, M., ``Drug education: The prevention issues''., Drug Education.,
19 (3): 197-208. Cited in the submission of the Ministry of Health.]
Helen Shaw, a consultant who has worked for the Ministry of Education and was
the author of the 1993 Ministry of Education publication Cannabis in
Context, was critical of current drug education programmes in schools.
She quoted American research stating that although the uptake rate of drug
education programmes has increased dramatically, drug use has also escalated in
the same period.
[Brown, J.H. & Kreft, I.G.G., ``Zero effects of drug prevention programmes;
Issues and solutions'', Evaluation Review, 22 (1), 3-14. Cited in
the submission of Helen Shaw.]
She stated that the ``Say No'' programmes which advocate abstinence from drugs
were effective only for those students who had not tried drugs. For pupils
already involved in experimentation, these programmes tended to increase their
sense of alienation by labelling them as deviant. Recognising that pupils
experimenting with drugs frequently exhibited pre-existing behavioural
problems, she suggested that alienation could increase the likelihood of
negative outcomes such as dropping out of school or suicide. There is a need to
ensure that chronic users of drugs remained within a supportive matrix of
school and family. The tendency of schools to sanction students caught using
cannabis through suspensions and expulsions may be counterproductive in this
respect.
We consider that there is value in the provision of ongoing, school-based drug
education. This should adopt a holistic approach, educating students on
cannabis in combination with alcohol and tobacco education. It also appears
practical to tailor drug education programmes to meet the needs of all pupils.
This would involve:
affirming abstinence for students who have not experimented
with cannabis;
implementing harm minimisation programmes for moderate
users of cannabis; and
providing support and advice on treatment options for
students who are heavy users of cannabis.
The Ministry has recommended that effective drug education in New
Zealand should consider the following points:
legal and illegal drugs should be scrutinised equally;
the target audience may determine whether the approach
favours abstinence or responsible use;
supply reduction efforts should be combined with demand
reduction efforts;
drug education should target adults as well as children;
all drug harm minimisation programmes should support, and
be consistent with, the curriculum being taught in the school;
educational programmes targeting Maori are more
effective if conducted by Maori, using their own networks and
communication systems; and
a holistic, community-based strategy utilising iwi,
education, health and justice linkages to confront cannabis use at every level
in the community will encourage Maori people to make informed choices.
To date, no systematic public education campaign has been launched to
discourage cannabis use. However, we note that such health promotion objectives
are contemplated in the Government's National Drug Policy. We welcome any steps
that enable people to make informed choices about the use of legal and illegal
drugs.
Recommendations
We recommend that:
the Government examine the practicalities and likely
outcomes of the provision of ongoing school-based drug education, as part of
alcohol and tobacco education; and
the Government promote drug education programmes tailored
to meet the needs of the target groups.
Other issues
Several issues arose during the course of the inquiry that were related to
cannabis use but which were not contemplated when we set the terms of reference
for the inquiry. These are discussed below.
Cannabis and violence
A popularly-held view internationally is that cannabis use can cause crime and
violence.
[Zimmer, L. and Morgan, J., Marijuana Myths Marijuana Facts, A Review of the
Scientific Evidence, New York, 1997, p. 89.]
Statistics supplied by the Police show that, between 1994 and
1997, 30 homicides have been committed by offenders who reported being under
the influence of cannabis at the time of the offence. We also heard anecdotal
evidence that a combination of cannabis and alcohol can result in aggressive
behaviour. In neither instance is there proof of a causal relationship between
cannabis use and violence. We received no scientific evidence regarding the
interplay between alcohol and cannabis, but note that alcohol on its own can
stimulate aggressive behaviour. The Police stated that criminal involvement by
organised gangs in the production and sale of cannabis generated a climate of
intimidation and fear. The Police have uncovered firearms used to protect
cannabis crops and associate a number of homicides with disputes between
growers, dealers and users.
Research, including that conducted by the 1972 Shafer Commission in the United
States, has shown that cannabis itself does not induce violent behaviour.
Recent studies using experimental controls to exclude pre-existing social
factors have confirmed that cannabis does not stimulate violence. Instead
cannabis was found to induce a sedative effect during the period of
intoxication.
The DMHDRU longitudinal study found a correlation between time spent
unemployed, violent behaviour and high levels of cannabis use. This
relationship survived a re-analysis of the data to control for excessive
alcohol use. The submissioners were quick to note that this association did not
imply a cause and effect relationship between these factors. The question of
whether excessive cannabis problems leads to social problems or social problems
lead to excessive cannabis use has not yet been resolved.
Potency of cannabis
We wished to clarify whether the level of the psychoactive chemical
delta-9-tetrahydrocannabinol (THC) had been artificially increased over time
by growers, as had been as asserted in some submissions. The DPFT, the Police
and the Ministry stated that the potency of cannabis had not increased
significantly over time.
[Poulsen, H., Personal communication, 1998. Cited in the submission of the
Ministry of Health.]
The Institute of Environmental Science and Research (ESR) provided information
showing that the THC levels in New Zealand grown cannabis are not high by
international standards. The average level of THC is three to four percent in
the buds, while some strains cultivated in the Netherlands have contained THC
levels of over 20 percent. New Zealand hash oil has been found to contain THC
levels of 20 percent on average, while oil produced overseas can contain up to
50 percent THC. Indeed, it appears that an increase in the production of hash
oil in New Zealand, using relatively crude techniques, has actually served to
reduce THC levels in most New Zealand hash oil. As previously noted, the
intensity of cannabis intoxication is determined by the dose of THC received
in addition to personal and environmental factors.
Conclusions
Based on the evidence we have heard in the course of this inquiry, the negative
mental health impact of cannabis appears to have been overstated, particularly
in relation to occasional adult users of the drug. There are still significant
issues surrounding the effects of cannabis that are unclear. However, we have
considered all the evidence provided to us and drawn the following conclusions.
There is evidence that cannabis use may exacerbate schizophrenia in vulnerable
individuals. However, little is understood of the relationship between cannabis
and schizophrenia and it is too early to attribute causation to cannabis use.
This is an issue which requires further research.
For a small percentage of people, cannabis has adverse psychological effects
including feelings of anxiety, panic or depression. We also accept that
psychotic symptoms can be experienced during cannabis intoxication. Long-term
cannabis use may lead to cannabis dependency in some individuals.
Evidence received by this committee suggests that occasional cannabis use
presents few risks to the mental health of most adult users. We heard a number
of submissions that made the point that the risks posed by cannabis are
currently less than those posed by alcohol. The weight of available evidence
suggests that long-term heavy use of cannabis does not produce severe or gross
impairment of cognitive function. Evidence received during the inquiry supports
the view that there can be subtle cognitive impairment in cannabis users.
Some Maori communities have very high rates of cannabis use and it appears
that Maori have disproportionately high admission rates for drug-related
mental illnesses. There is an urgent need to address the underlying factors in
high rates of drug use such as issues of poverty, lack of opportunity and
feelings of hopelessness rather than to focus solely on reducing drug use,
exclusive of these factors. There is also a need for a considerable body of
robust research on the effects of cannabis on Maori and the reasons for
cannabis use in Maori communities. The Government must support services by
Maori for Maori and must support the development of mainstream
services able to provide services appropriate to Maori. In addition, there
is a need for an increased number of Maori workers in all mental health
professions.
We have identified deficiencies in current mental health services for those
with drug-related mental illnesses. This has been the subject of earlier work
by the Mental Health Commission and the Mason inquiry team. Drug and alcohol
services and mental health services suffer from fragmentation and a better
integrated approach is required. Services better able to meet the needs of
those with dual diagnosis are essential as is an increase in the number of
residential programmes. We have identified services for youth and adolescents
as one area requiring urgent attention. Rural communities require improved access to
a wide range of mental health services which may need to be provided on a
regional basis. Workforce development is the key to better meeting many mental
health needs.
We are concerned that polydrug use may be a confounding factor in the
relationship between cannabis use and mental illness. We are particularly
concerned that patients diagnosed with a mental illness may compromise the
management of their illness by using a number of drugs in tandem with their
medication.
We consider that community-based drug intervention and education programmes
have the greatest potential to bring about sustainable change in communities
and commend this approach to the Government.
There is value in schools providing drug education themselves, in combination
with alcohol and tobacco education. Drug education programmes should be
designed to meet the needs of all pupils. This involves providing appropriate
education, advice and support to non-users, occasional users and heavy users of
cannabis. It is important that people are assisted to make informed choices
about the use of drugs.
We view the double standard which sometimes surround the cannabis issue as an
impediment to effective anti-drug education. Attempts by users of legal drugs
to deter the use of illegal drugs often affects the credibility of the message.
The younger generation perceive a double standard in the social acceptance of
alcohol and tobacco despite their obvious negative health and social
repercussions, while cannabis is clearly prohibited and its harms are less
apparent.
We have identified a number of areas which require further research. Cannabis
use is a matter of considerable public concern and the Government and
Parliament have recently taken steps to address the issue in the form of the
National Drug Policy and the Misuse of Drugs Amendment Act 1998. However, we
consider that it is vital that legislative and policy decisions are made on the
basis of sound evidence. There are too many serious `gaps' in the knowledge of
the effects of cannabis to make these decisions at present.
Future action
Evidence received in the course of this inquiry has raised serious doubts about
commonly held beliefs about cannabis. Moderate use of the drug does not seem to
harm the majority of people though we do not deny the serious impact cannabis
use may have on certain individuals, particularly those with schizophrenia or
those with a vulnerability to psychotic illness. It is clear that current
policies do not deter cannabis use to any great extent. If cannabis does cause
harm to a small proportion of users then it is preferable that those people
have good access to treatment without fear of stigmatisation or
criminalisation. A harm minimisation approach aimed at reducing the incidence
and severity of drug problems appears to be a realistic approach to cannabis
use in New Zealand. Such a policy is already employed in operating needle and
syringe exchange programmes for injecting drug users to prevent the use and
sharing of dirty needles.
It is acknowledged that cannabis prohibition enforced by traditional crime
control methods has not been successful in reducing the apparent number of
cannabis users in New Zealand. That the Police are open minded on the issue of
the decriminalisation of cannabis is an indication that thinking on the subject
is changing.
[Submission of the New Zealand Police, 4 August 1998.]
While it is not the role of the Police to determine policy, we
believe that, as the organisation in most frequent contact with cannabis use,
Police views are important. Methods other than prohibition certainly deserve
consideration.
In light of the evidence we have heard on the effects of cannabis and the high
rate of cannabis use in New Zealand, the effectiveness of the current policy on
cannabis requires examination. These are important policy issues, the
consideration of which was beyond the scope of this inquiry. However, based on
the evidence received, we recommend that the Government review the
appropriateness of existing policy on cannabis and its use and reconsider the
legal status of cannabis.
Recommendations
We recommend that:
based on the evidence received, the Government review the
appropriateness of existing policy on cannabis and its use and reconsider the
legal status of cannabis.
APPENDIX A
Committee procedure
Terms of reference
The Health Committee resolved to conduct an inquiry into the mental health
effects of cannabis on 1 April 1998, with the following terms of reference:
To inquire into the mental health effects of cannabis, with specific reference
to:
the effect of cannabis on people's development;
the role of cannabis as a trigger for mental illness;
the effects of cannabis on Maori mental health; and
the adequacy of services for those with drug-related mental illnesses.
To report to the House and make recommendations to the Government accordingly.
Approach to inquiry
We advertised in the major daily newspapers for submissions on the inquiry. We
also invited government departments, universities, hospitals and some interest
groups to make submissions. The closing date for submissions was 15 May 1998.
We received 70 submissions and numerous supplementary submissions from the
organisations and individuals listed below and we heard 38 of the submissions
orally. We heard evidence at meetings in Wellington, Dunedin, Christchurch and
Auckland.
In addition to hearing submissions in New Zealand, we heard evidence during our
committee exchange with the Parliament of Australia in June 1998. We met with
Dr David Copolov, Director of the Mental Health Research Institute of Victoria
and Mr John McGrath MP, Chairman of the Cannabis and Psychosis Research
Reference Group, when we were in Melbourne. Their views were enlightening and
provided a valuable international context for our inquiry. A discussion of the
evidence heard in Australia on the mental health effects of cannabis was
contained in our recent report to the House on the committee exchange. This
discussion is reprinted as Appendix C to this report.
We met between 1 April and 16 December 1998 to consider the inquiry. Hearing
evidence took 33 hours and we spent a further nine hours in consideration.
APPENDIX B
Committee personnel
Committee members
Brian Neeson (Chairperson)
Shane Ardern
Phillida Bunkle
Judy Keall
Hon Annette King
Hon Roger FH Maxwell
Tukoroirangi Morgan
Hon Katherine O'Regan
Jill Pettis
Hon Ken Shirley
Tariana Turia attended several committee meetings as a replacement for Labour
Party members of the committee.
Committee staff
David Wilson, Clerk of the Committee
Jane Morgan, Parliamentary Officer (Select Committees)
APPENDIX C
Excerpt from ``Committee exchange with Australia, Report of the Health
Committee'', I. 6b
On 22 June we had a very informative meeting with Dr David Copolov,
Director of the Mental Health Research Institute of Victoria and Mr John
McGrath MP, Chairman of the Cannabis and Psychosis Research Reference Group.
Inquiries by the Victorian state government into decriminalisation of cannabis
had been hindered by the lack of quantitative data examining the mental health
implications of cannabis use. The Victorian Premier has deferred the decision
on decriminalisation subject to the provision of data by the Institute.
The mental health effects of cannabis
We were particularly eager to gather information on the mental health effects
of cannabis prior to the commencement of our inquiry into this issue. A
briefing from representatives of the Mental Health Research Institute of
Victoria proved valuable. We were interested to hear that the linkages between
cannabis use and mental illness are not yet clearly defined. We heard that
cannabis may contribute to the early onset of psychosis amongst those who are
already predisposed to schizophrenia. No scientific evidence has been gathered
to demonstrate permanent brain damage or the development of an amotivational
syndrome amongst users. Experts at the Institute appear to favour a harm
minimisation strategy, stating that ``it is a relatively safe drug''. The harm
minimisation strategy recognises that 41 percent of youth aged 14 to 19 have
used cannabis, and that decriminalisation in other countries has not inflated
consumption rates. Harm minimisation would focus on anti-drug education
strategies, while ensuring that current users were not further punished through
legal sanctions. The opposing viewpoint was also expressed; that the
liberalization of cannabis laws would send a message to youth that cannabis use
is acceptable.
APPENDIX D
Bibliography
We considered the following evidence during our inquiry:
Bedford, Dr K., letter from Institute of Environmental Science and
Research Limited, dated 9 September 1998.
Black, S. and Casswell, S. Drugs in New Zealand
(revised edition), Auckland 1993.
Learning Media, Ministry of Education, Cannabis in
Context, Wellington, 1993.
Mental Health Commission, Blueprint for Mental Health
Services in New Zealand, Working Document, November 1997.
Mental Health Commission, Blueprint for Mental Health
Services in New Zealand, 1998.
Mental Health Commission, The Funding Needed for Mental
Health Services in New Zealand, Wellington, 1998.
Ministry of Health, Cannabis The Public Health Issues
1995-96, Wellington, 1996.
Ministry of Health, National Drug Policy, Wellington, 1998.
National Drug and Alcohol Research Centre, The Health and
Psychological Consequences of Cannabis Use, Canberra, 1995.
Select Committee on HIV, Illegal Drugs and Prostitution, Third
Interim Report, Marijuana and Other Illegal Drugs, Legislative
Assembly for the Australian Capital Territory, Canberra, 1991.
Select Committee on Science and Technology, Ninth Report,
Cannabis: The Scientific and Medical Evidence, House of Lords,
London, 1998.
Te Puni Kokiri, Nga Ia O Te Oranga Hinengaro Maori,
Trends in Maori Mental Health, Wellington, 1996.
World Health Organisation, Cannabis: A Health Perspective and
Research Agenda, Geneva, 1997.
Zimmer, L. and Morgan, J., Exposing Marijuana Myths: A Review
of the Scientific Evidence, New York, 1995.
APPENDIX E
List of submissions
We received the following submissions during the course of the inquiry. We wish
to extend our thanks to all those who made written and oral submissions to the
committee.
1W Private
2 National Organisation for the Reform of Marijuana Laws, New Zealand Inc
3 David Currie
4 Department of Psychological Medicine, Dunedin Medical School
5 Schizophrenia Fellowship NZ Inc, Christchurch
6W Fran Lowe
7W Helen O'Shea
8 Life Education Trust
9W Department of Human Services, Melbourne
10W National Drug & Alcohol Research, Australia
11W Alcohol & Drug Services, Nelson Hospital
12W Dr B Scobie
13W H J Cording
14W Whangarei Mental Health Caregivers Support Group
15W Sally-Anne Lambert
16 Faculty of Medicine, University of Auckland
17 Christchurch School of Medicine
18 Ministry of Health
19W Mrs Glidden
20W Private
21W Tairawhiti Healthcare Ltd
22W Private
23W Judy Matangi
24W Arana Pearson
25W Private
26W Allan Webb
27 Dave Evans
28W David Flaws
29W Community Action on Youth and Drugs Project
30 PRYDE in New Zealand
31W Mrs C W Stockman
32W Private
33W MidCentral Health
34 New Way Trust
35W Department of Psychological Medicine, Wellington School of Medicine
36 National Organisation for the Reform of Marijuana Laws, New Zealand, Inc
37 The Royal New Zealand College of General Practitioners
38 Schizophrenia Fellowship, Wellington
39 Drug Policy Forum Trust
40 Alcohol and Public Health Research Unit, University of Auckland
41W Anonymous
42W Judy Jack
43 Dunedin Multidisciplinary Health and Development Research Unit,
University of Otago
44 I P Britnell
45 Effective Drug Education Trust
46W Lakeland Health
47 Susan G Berry
48 Health Funding Authority
49W Ben Knight
50 Dr A S Gardner
51 Blair Anderson
52 New Zealand Police
53 Jonathan Sewell on behalf of Tim Barnett MP
54 NZ Drug Foundation
55 Wellington Alcohol and Drug Service, Capital Coast Health
56 Mental Health Commission
57 Aotearoa Legalise Cannabis Party
58 Opotiki Safer Communities Council
59 National Management Committee, Aotearoa Legalise Cannabis Party
60 Caring Communities Incorporated
61 Private
62 Phillip Marau Russell
63 Queen Mary Hospital
64 Alan and Dale Withy
65W District Coroner, Christchurch
66W Adrienne Dale
67 Canterbury Suicide Project
68 The Commissioner for Children
69W Te Runanga O Te Rarawa
70 Helen Shaw