Assessing options for cannabis law reform: A Multi-Criteria Decision Analysis (MCDA) with stakeholders in New Zealand.

BACKGROUND: A number of jurisdictions are considering or implementing different options for cannabis law reform, including New Zealand. Multi-Criteria Decision Analysis (MCDA) helps facilitate the resolution of complex policy decisions by breaking them down into key criteria and drawing on the combined knowledge of experts from various backgrounds. AIMS: To rank cannabis law reform options by facilitating expert stakeholders to express preferences for projected reform outcomes using MCDA. METHODS: A group of cannabis policy experts projected the outcomes of eight cannabis policy options (i.e., prohibition, decriminalization, social clubs, government monopoly, not-for-profit trusts, strict regulation, light regulation, and unrestricted market) based on five criteria (i.e., health and social harm, illegal market size, arrests, tax income, treatment services). A facilitated workshop of 42 key national stakeholders expressed preferences for different reform outcomes and doing so generated relative weights for each criterion and level. The resulting weights were then used to rank the eight policy options. RESULTS: The relative weighting of the criteria were: "reducing health and social harm" (46%), "reducing arrests" (31%), "reducing the illegal market" (13%), "expanding treatment" (8%) and "earning tax" (2%). The top ranked reform options were: "government monopoly" (81%), "not-for-profit" (73%) and "strict market regulation" (65%). These three received higher scores due to their projected lower impact on health and social harm, medium reduction in arrests, and medium reduction in the illegal market. The "lightly regulated market" option scored lower largely due its projected greater increase in health and social harm. "Prohibition" ranked lowest due to its lack of impact on reducing the number of arrests or size of the illegal market. CONCLUSION: Strictly regulated legal market options were ranked higher than both the current prohibition, and alternatively, more lightly regulated legal market options, as they were projected to minimize health and social harms while substantially reducing arrests and the illegal market.

The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study.

BACKGROUND AND AIMS: Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids. DESIGN: Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME). SETTING: Australia. PARTICIPANTS: People who are prescribed opioids. MEASUREMENTS: Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up. FINDINGS: Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400). CONCLUSION: In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

The burgeoning recognition and accommodation of the social supply of drugs in international criminal justice systems: An eleven-nation comparative overview.

BACKGROUND: It is now commonly accepted that there exists a form of drug supply, that involves the non-commercial supply of drugs to friends and acquaintances for little or no profit, which is qualitatively different from profit motivated 'drug dealing proper'. 'Social supply', as it has become known, has a strong conceptual footprint in the United Kingdom, shaped by empirical research, policy discussion and its accommodation in legal frameworks. Though scholarship has emerged in a number of contexts outside the UK, the extent to which social supply has developed as an internationally recognised concept in criminal justice contexts is still unclear. METHODS: Drawing on an established international social supply research network across eleven nations, this paper provides the first assessment of social supply as an internationally relevant concept. Data derives from individual and team research stemming from Australia, Belgium, Canada, Czech Republic, Finland, Germany, Hong Kong, the Netherlands, England and Wales, and the United States, supported by expert reflection on research evidence and analysis of sentencing and media reporting in each context. In situ social supply experts addressed a common set of questions regarding the nature of social supply for their particular context including: an overview of social supply research activity, reflection on the extent that differentiation is accommodated in drug supply sentencing frameworks; evaluating the extent to which social supply is recognised in legal discourse and in sentencing practices and more broadly by e.g. criminal justice professionals in the public sphere. A thematic analysis of these scripts was undertaken and emergent themes were developed. Whilst having an absence of local research, New Zealand is also included in the analysis as there exists a genuine discursive presence of social supply in the drug control and sentencing policy contexts in that country. RESULTS: Findings suggest that while social supply has been found to exist as a real and distinct behaviour, its acceptance and application in criminal justice systems ranges from explicit through to implicit. In the absence of dedicated guiding frameworks, strong use is made of discretion and mitigating circumstances in attempts to acknowledge supply differentiation. In some jurisdictions, there is no accommodation of social supply, and while aggravating factors can be applied to differentiate more serious offences, social suppliers remain subject to arbitrary deterrent sentencing apparatus. CONCLUSION: Due to the shifting sands of politics, mood, or geographical disparity, reliance on judicial discretion and the use of mitigating circumstances to implement commensurate sentences for social suppliers is no longer sufficient. Further research is required to strengthen the conceptual presence of social supply in policy and practice as a behaviour that extends beyond cannabis and is relevant to users of all drugs. Research informed guidelines and/or specific sentencing provisions for social suppliers would provide fewer possibilities for inconsistency and promote more proportionate outcomes for this fast-growing group.

Child Health Systems in the United Kingdom (England).

Child health in the United Kingdom has improved markedly over recent decades but has failed to match health gains and reductions in mortality achieved by other European countries. Child poverty and inequalities are rising in the United Kingdom. The National Health Service (NHS) is a universally accessible health service, funded by taxation and is free at the point of use. The NHS is undergoing substantial reform, aiming to improve care quality and experience, meet rising demands, and contain costs. The NHS is struggling to balance access with expertise for urgent and unscheduled care. There is increasing use of urgent and emergency care, and there are unexplained variations in outcomes. Quality of care for children and young people with chronic and long-term conditions, including transition services, is variable and sometimes poor. Many determinants of noncommunicable conditions are worsening. Key achievements include a universal service free at the point of use, providing generally accessible, and equitable care. Key challenges include increasing fragmentation of services, insufficient emphasis on preventive care, achieving an effective balance between access and expertise of care for children, and improving child health and well-being outcomes despite generally high quality inputs and high levels of spending.

'What if you live on top of a bakery and you like cakes?'-Drug use and harm trajectories before, during and after the emergence of Silk Road.

BACKGROUND: Cryptomarkets are digital platforms that use anonymising software (e.g. Tor) and cryptocurrencies (e.g. Bitcoin) to facilitate peer-to-peer (P2P) trade of goods and services. Their emergence has facilitated access to a wide range of high-quality psychoactive substances, according to surveys of users. In this paper, we ask the question 'How does changing access to drugs through cryptomarkets affect the drug use and harm trajectories of their users?' METHODS: We conducted a digital ethnography spanning 2012-2014, a period that included the seizure of the original Silk Road marketplace and forum by law enforcement. Using encrypted online chat, we interviewed 17 people who reported using Silk Road to purchase illicit drugs. The interviews were in-depth and unstructured, and also involved the use of life history timelines to trace trajectories. Transcripts were analysed thematically using NVivo. RESULTS: For some, Silk Road facilitated initiation into drug use or a return to drug use after cessation. Typically, participants reported experiencing a glut of drug consumption in their first months using Silk Road, described by one participant as akin to 'kids in a candy store'. There was evidence that very high availability reduced the need for drug hoarding which helped some respondents to moderate use and feel more in control of purchases made online. Cryptomarket access also appeared to affect solitary and social drug users differently. Most participants described using other cryptomarkets after the closure of Silk Road, albeit with less confidence. CONCLUSION: In the context of high levels of drug access, supply and diversity occurring within a community regulated environment online, the impacts of cryptomarkets upon drug use trajectories are complex, often posing new challenges for self-control, yet not always leading to harmful outcomes. A major policy challenge is how to provide support for harm reduction in these highly volatile settings.

Characterising dark net marketplace purchasers in a sample of regular psychostimulant users.

BACKGROUND: The past five years has seen a proliferation in marketplaces operating on the 'dark net' selling licit and illicit substances. While monitoring systems have investigated the specific substances for sale on these marketplaces, less is known about consumer motivations for accessing these marketplaces and factors associated with their use. METHODS: An Australian national sample (n=800) recruited on the basis of regular psychostimulant use was recruited and asked about purchasing substances from dark net marketplaces and the reasons for doing so. Respondents who had purchased any drug from a dark net marketplace in the preceding year were compared to those who had not in terms of demographic information and factors including drug use, criminal activity, and sexual and mental health. RESULTS: Nine percent (n=68) of the sample had purchased from dark net markets in the past year. MDMA, LSD and cannabis were the three most commonly purchased substances, and the main benefits cited for purchasing online were the better quality and lower cost of drugs available. Controlling for other factors, participants who purchased from dark net marketplaces in the past year tended to be younger, more likely to be involved in recent property crime and to have used more classes of drugs in the preceding six months, specifically psychedelics and 'new psychoactive drugs'. CONCLUSIONS: Though a small minority of participants reported having purchased drugs online in the preceding six months, these appeared to be a more 'entrenched' group of consumers, with more diverse substance use and rates of criminal activity. For consumers in the current sample reporting recent dark net usage, country borders are now less of a significant barrier to purchase and there is a wider range of substances available than ever before.

Alcohol policy impact on young risky drinkers and their support for proposed measures.

OBJECTIVE: To explore the impacts of existing policies on young Australian risky drinkers' access to alcohol and to gauge their support for proposed alcohol measures. METHODS: The 16-19 year old participants were recruited from three Australian states using non-random convenience sampling, for either a face-to-face or online quantitative survey (N=958). The sample was deliberately selected to represent drinkers whose consumption placed them in the riskiest drinking 20-25% of their age bracket. RESULTS: Half (49%) the sample who were younger than the Australian legal purchase age reported it was 'easy' to buy alcohol from bottle stores, and 75% of those who had tried to purchase alcohol, said it was 'easy' the last time they tried. Half of those under 18, who had attempted to enter a licensed venue, reported they did not have their identification checked last time they gained access. Ninety per cent of all respondents drank within a private location at their last risky drinking session. Sixty-five per cent supported 'increasing the price of [alcohol by 20¢] a standard drink if the extra 20¢ was used to support prevention and treatment of alcohol problems'. CONCLUSIONS: Age- or intoxication-based restrictions to alcohol were commonly bypassed. IMPLICATIONS: Point-of-sale alcohol controls require improvement to prevent under age access. Given that a significant proportion of drinking occasions for those under 18 were in private premises, prevention strategies need to target these locations. There were diverse levels of support for strategies to reduce harm, including potential community backing for an evidence-based proposed price policy.

Lessons from conducting trans-national Internet-mediated participatory research with hidden populations of cannabis cultivators.

BACKGROUND: Internet-mediated research methods are increasingly used to access hidden populations. The International Cannabis Cultivation Questionnaire (ICCQ) is an online survey designed to facilitate international comparisons into the relatively under-researched but increasingly significant phenomenon of domestic cannabis cultivation. The Global Cannabis Cultivation Research Consortium has used the ICCQ to survey over 6000 cannabis cultivators across 11 countries. In this paper, we describe and reflect upon our methodological approach, focusing on the digital and traditional recruitment methods used to access this hidden population and the challenges of working across multiple countries, cultures and languages. METHODS: Descriptive statistics showing eligibility and completion rates and recruitment source by country of residence. RESULTS: Over three quarters of eligible respondents who were presented with the survey were included in the final sample of n=6528. English-speaking countries expended more effort to recruit participants than non-English-speaking countries. The most effective recruitment modes were cannabis websites/groups (33%), Facebook (14%) and news articles (11%). While respondents recruited through news articles were older, growing practice variables were strikingly similar between these main recruitment modes. CONCLUSION: Through this process, we learnt that there are trade-offs between hosting multiple surveys in each country vs. using one integrated database. We also found that although perceived anonymity is routinely assumed to be a benefit of using digital research methodologies, there are significant limits to research participant anonymity in the current era of mass digital surveillance, especially when the target group is particularly concerned about evading law enforcement. Finally, we list a number of specific recommendations for future researchers utilising Internet-mediated approaches to researching hidden populations.

Global patterns of domestic cannabis cultivation: sample characteristics and patterns of growing across eleven countries.

BACKGROUND: This article aims to provide an overview of: demographic characteristics; experiences with growing cannabis; methods and scale of growing operations; reasons for growing; personal use of cannabis and other drugs; participation in cannabis and other drug markets; contacts with the criminal justice system for respondents to an online survey about cannabis cultivation drawn from eleven countries (N=6530). Important similarities and differences between the national samples recruited will be discussed. METHODS: This paper utilizes data from the online web survey of predominantly 'small-scale' cannabis cultivators in eleven countries conducted by the Global Cannabis Cultivation Research Consortium (GCCRC). Here we focus primarily on descriptive statistics to highlight key similarities and differences across the different national samples. RESULTS: Overall there was a great deal of similarity across countries in terms of: demographic characteristics; experiences with growing cannabis; methods and scale of growing operations; reasons for growing; use of cannabis and other drugs; participation in cannabis and other drug markets, and; contacts with the criminal justice system. In particular, we can recognise that a clear majority of those small-scale cannabis cultivators who responded to our survey are primarily motivated for reasons other than making money from cannabis supply and have minimal involvement in drug dealing or other criminal activities. CONCLUSIONS: These growers generally come from 'normal' rather than 'deviant' backgrounds. Some differences do exist between the samples drawn from different countries suggesting that local factors (political, geographical, cultural, etc.) may have some influence on how small-scale cultivators operate, although differences in recruitment strategies in different countries may also account for some differences observed.

Growing medicine: small-scale cannabis cultivation for medical purposes in six different countries.

BACKGROUND: The production and consumption of cannabis for the treatment of medical conditions is of increasing importance internationally; however, research on different aspects of the phenomenon is still scarce. In this article, we report findings from a cross-cultural study of small-scale cannabis cultivation for medical purposes. This kind of comparative study has not been done previously. METHODS: The data were gathered with a help of web surveys conducted by the Global Cannabis Cultivation Research Consortium (GCCRC) in Australia, Belgium, Denmark, Finland, Germany and the UK (N=5313). In the analysis we compare reports of medical motives, for what conditions cannabis is used, whether users have diagnoses for these conditions and whether the use of cannabis been recommended as a treatment of those conditions by a medical doctor. Descriptive statistics are used to show the main commonalities and noteworthy disparities across different countries. RESULTS: Findings from countries were quite similar, even though several national differences in details were found. Growing cannabis for medical purposes was widespread. The majority of medical growers reported cultivating cannabis for serious conditions. Most of them did have a formal diagnosis. One fifth had got a recommendation from their doctor, but in most cases cannabis use was self-medication which was not discussed with their doctors. CONCLUSION: There is a wider demand for licit access for medical cannabis than currently available in these countries. Ideologically, medical growers can be seen distancing themselves from both the legal and illicit drug markets. From a harm reduction perspective, it is worrying that, in the context of present health and control policies in these countries, many medical growers are using cannabis to treat serious medical conditions without proper medical advice and doctor's guidance.

Attitudes of cannabis growers to regulation of cannabis cultivation under a non-prohibition cannabis model.

BACKGROUND: How cannabis cultivation is dealt with under various examples of cannabis legalization or regulation is an important consideration in design of such schemes. This study aimed to (i) investigate support among current or recent cannabis growers, for various potential policy options for cannabis cultivation if prohibition were repealed, and (ii) explore the support for these options across countries, scale of growing operations, demographics, drug use and cannabis supply involvement variables. METHODS: This study utilized data from the online web survey of largely 'small-scale' cannabis cultivators, aged 18yrs and over, in eleven countries conducted by the Global Cannabis Cultivation Research Consortium (GCCRC). Data from 1722 current and recent cannabis growers in Australia, Denmark and the UK, who were all asked about policy, were included in the analysis. It investigated support for various frameworks for cultivation: (no regulation (free market); adult only; growing licenses; restrictions on plant numbers; licensed business-only sale; approved commercial growing; etc.). Among current growers, support for these options were compared across countries, across scale of growing operations, and by demographics, drug use and crime variables. RESULTS: Although there were some between country differences in support for the various policy options, what was striking was the similarity of the proportions for each of the eight most popular policy options. Among current growers, many of these positions were predicted by demographic, drug use and cannabis growing variables which were conceptually congruent with these positions. CONCLUSION: The results have relevance for the provisions regarding cannabis cultivation in the design of new non-prohibitionist models of cannabis which are increasingly under consideration. It should be of interest to policy makers, drug policy researchers, law enforcement and cannabis cultivators.

Improving the practice of child death overview panels: a paediatric perspective.

OBJECTIVE: In England, every death in childhood is reviewed by a local multidisciplinary Child Death Overview Panel (CDOP) with the intention of understanding causation and implementing interventions to reduce future deaths. This study aimed to establish how well panels work from the perspective of the paediatricians involved and to ascertain whether they deliver good value and identify areas for improvement. DESIGN: A questionnaire was sent to every CDOP paediatrician in the country (n=93). Questions focused on the quality of CDOP case discussions as well as examples of effective and significant recommendations. Responses were analysed using simple quantitative and qualitative methods. RESULTS: 84/93 (90%) of the paediatricians responded. Among the respondents, 60 (71%) believe that investment in CDOPs is offering good value, 73 (87%) feel that case discussions are rigorous and consistent and over 90% believe that the correct issues are emerging from discussions. However, responders noted many areas for improvement: 40 (48%) suggested devolving the discussion of specialist deaths (eg, neonates) to hospital-based review meetings or holding themed meetings with invited specialists, 11 (13%) suggested filtering out cases where learning is unlikely before full CDOP meetings and 13 (15%) called for national integration and analysis of data. CONCLUSIONS: In this time of economic austerity it is vital that the CDOPs add value to the invested resources. Although CDOP paediatricians feel that panels are working well, there is scope for improvement through enhancing relationships with commissioning bodies, aggregate review and analysis of CDOP data at a national level and consideration of specialist and/or network review of certain categories of deaths such as cardiac surgery, oncology and neonates.

A tale of CIN--the Cannabis infringement notice scheme in Western Australia.

AIMS: To describe the development and enactment of the Western Australian (WA) Cannabis Infringement Notice scheme and reflect on the lessons for researchers and policy-makers interested in the translation of policy research to policy practice. METHODS: An insiders' description of the background research, knowledge transfer strategies and political and legislative processes leading to the enactment and implementation of the WA Cannabis Control Act 2003. Lenton and Allsop were involved centrally in the process as policy-researcher and policy-bureaucrat. RESULTS: In March 2004, Western Australia became the fourth Australian jurisdiction to adopt a 'prohibition with civil penalties' scheme for possession and cultivation of small amounts of cannabis. We reflect upon: the role of research evidence in the policy process; windows for policy change; disseminating findings when apparently no one is listening; the risks and benefits of the researcher as advocate; the differences between working on the inside and outside of government; and the importance of relationships, trust and track record. CONCLUSIONS: There was a window of opportunity and change was influenced by research that was communicated by a reliable and trusted source. Those who want to conduct research that informs policy need to understand the policy process more clearly, look for and help create emerging windows that occur in the problem and political spheres, and make partnerships with key stakeholders in the policy arena. The flipside of the process is that, when governments change, policy born in windows of opportunity can be a casualty.