Cannabis Social Clubs in Contemporary Legalization Reforms: Talking Consumption Sites and Social Justice.

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

Uruguayan Cannabis Social Clubs: From activism to dispensaries?

BACKGROUND: In 2013 Uruguay regulated three models for the supply of cannabis for recreational use (Law 19.172), including Cannabis Social Clubs (CSCs). According to the Cannabis Regulation and Control Institute, 110 CSCs are active at the time of writing. OBJECTIVES: This paper has a twofold goal. Firstly, it aims to take stock of how the CSC model has continued to be implemented in practice, drawing on the first-hand accounts of those involved in its management. Secondly, our analysis seeks to contribute to the understanding of the CSC model by considering the different variants of the model that have emerged in Uruguay. METHODOLOGY: Our analysis draws on qualitative research conducted in Uruguay between June and October of 2018. We conducted 15 semi-structured and face-to-face interviews with representatives of registered Uruguayan CSCs and with 13 other stakeholders. RESULTS/CONCLUSIONS: CSCs' role as cannabis suppliers is perceived positively in terms of the type of cannabis produced and the means of distribution. We found that truly social CSCs co-exist with, and may be losing ground to, quasi-dispensary clubs. A number of factors may have contributed to this, including the Uruguayan regulatory framework, institutional context, and disengagement of members and/or CSC managers. This raises potential new challenges as to the contribution of the CSC model from a harm reduction perspective.

An analysis of Belgian Cannabis Social Clubs' supply practices: A shapeshifting model?

BACKGROUND AND RESEARCH QUESTIONS: Cannabis Social Clubs (CSCs) are associations of cannabis users that collectively organize the cultivation and distribution of cannabis. As this middle ground supply model has been active in Belgium for over a decade, this paper aims to examine CSCs' supply practices, noting any shifts from previously reported features of the model. METHODS: We draw on interviews with directors of seven currently active Belgian CSCs (n = 21) and their cannabis growers (n = 23). This data was complemented by additional fieldwork, as well as a review of CSCs' key internal documents. RESULTS: Most Belgian CSCs are formally registered non-profit associations. One of the Belgian CSCs has developed a structure of sub-divisions and regional chapters. The Belgian CSCs supply cannabis to members only, and in some cases only medical users are admitted. CSCs rely on in-house growers, ensuring supply in a cooperative and closed-circuit way, despite changes to the distribution methods The associations are relatively small-scale and non-commercially driven. The introduction of formal quality control practices remains challenging. DISCUSSION: As the CSC model is often included in discussions about cannabis policy, but remains in most cases driven by self-regulatory efforts, it is important to take stock of how CSCs' supply function has been implemented in practice - as doing so will improve our understanding of the model and of the wider range of cannabis 'supply architectures'. This paper highlights the continuity and changes in CSC practices, noting the emergence of several different variants of the CSC model, which are classified in a first CSC typology.

"The difference is in the tomato at the end": Understanding the motivations and practices of cannabis growers operating within Belgian Cannabis Social Clubs.

BACKGROUND: In Belgium, Cannabis Social Clubs (CSCs) collectively organize the cultivation and distribution of cannabis for the personal use of their members. In this paper we seek to improve understanding of the motivations and practices of cannabis growers operating within CSCs, shedding light on the cultivation process. METHODS: We draw on data gathered through face-to-face semi-structured interviews with the directors of seven active Belgian CSCs (n = 21) and CSC growers (n = 23). These data are complemented by additional fieldwork and a review of policies relating to CSCs', including bylaws and growing protocols. FINDINGS: The Belgian CSCs rely on single and multiple in-house grower arrangements. Most CSC growers had been cultivating cannabis prior to joining their current CSC, albeit growing in different contexts (non-commercial and commercial). The CSC growers discussed both ideological and pragmatic motives for operating within a CSC. Cultivation took place indoors and followed organic practices. Despite their small-scale (20 plants on average), the grow sites used specialized equipment. The growers reported receiving financial compensation to cover production costs. CONCLUSION: This paper offers new insights into a particular sector of domestic cannabis cultivation - CSC growers and their practices within those collectives - which has not been studied previously. The Belgian CSCs have decentralized production among small-scale grow sites, at a size comparable to that found in other small-scale cultivation studies. In terms of motivations and practices, CSC growers share some features typically ascribed to small-scale cannabis cultivators. At the same time, CSC growers seemed particularly engaged with the CSC model and willing to adhere to the (self-)regulated practices developed by the organizations. This had implications for the way cultivation was organized and for the role of the grower within the CSC.

Regulating Cannabis Social Clubs: A comparative analysis of legal and self-regulatory practices in Spain, Belgium and Uruguay.

BACKGROUND: Cannabis Social Clubs (CSCs) are a model of non-profit production and distribution of cannabis among a closed circuit of adult cannabis users. CSCs are now operating in several countries around the world, albeit under very different legal regimes and in different socio-political contexts. AIM: In this paper we describe and compare the legal framework and the self-regulatory practices of Cannabis Social Clubs in three countries (Spain, Belgium, and Uruguay). The objective of our comparative analysis is to investigate how CSCs operate in each of these countries. To foster discussions about how one might regulate CSCs to promote public health objectives, we conclude this paper with a discussion on the balance between adequate governmental control and self-regulatory competences of CSCs. METHODS: The data used for this analysis stem from independently conducted local studies by the authors in their countries. Although the particular designs of the studies differ, the data in all three countries was collected through similar data collection methods: analysis of (legal and other documents), field visits to the clubs, interviews with staff members, media content analysis. FINDINGS: We identified a number of similarities and differences among the CSCs' practices in the three countries. Formal registration as non-profit association seems to be a common standard among CSCs. We found nevertheless great variation in terms of the size of these organisations. Generally, only adult nationals and/or residents are able to join the CSCs, upon the payment of a membership fee. While production seems to be guided by consumption estimates of the members (Spain and Belgium) or by the legal framework (Uruguay), the thresholds applied by the clubs vary significantly across countries. Quality control practices remain an issue in the three settings studied here. The CSCs have developed different arrangements with regards to the distribution of cannabis to their members. CONCLUSIONS: By uncovering the current practices of CSCs in three key settings, this paper contributes to the understanding of the model, which has to some extent been shaped by the self-regulatory efforts of those involved on the ground. We suggest that some of these self-regulatory practices could be accommodated in future regulation in this area, while other aspects of the functioning of the CSCs may require more formal regulation and monitoring. Decisions on this model should also take into account the local context where the clubs have emerged. Finally, the integration of medical supply within this model warrants further attention.

Strategies for a risky business: How drug dealers manage customers, suppliers and competitors in Italy, Slovenia and Germany.

BACKGROUND: A growing body of literature aims to improve understanding of the operations of drug trafficking markets through conducting interviews with dealers and traffickers. Insight into how these individuals conduct business can provide evidence to inform the efforts by policy makers, law enforcement and practitioners to disrupt illicit markets. This paper aims to make a contribution to this evidence base by extending the number of European countries in which interviews have been conducted with incarcerated drug dealers and traffickers. METHODS: It draws on interviews with 135 men convicted of offences related to the distribution or sale of heroin or cocaine and imprisoned in Italy, Slovenia and Germany. The research was conducted as part of the Reframing Addictions Project (ALICE-RAP) funded by the European Commission. The sample was diverse. It included a range of nationalities and some individuals who were members of organised crime groups. The majority of the interviewees were dealers who sold at the retail and street level, but there were some who were importers and wholesalers. FINDINGS: Most dealers in each of the three countries reported having more than one regular supplier, and were able to respond to periods of over and under supply without losing customers. Supply arrangements varied in terms of frequency and quantities bought. Dealers engaged in repeated transactions and their relationships with customers were based on trust and reputation. Dealers aimed to sell to regular customers and to provide drugs of good quality. While dealers sought to maximise their profits by cutting drugs with cutting agents, the quality of drugs that they sold could affect their reputation and thus their profits and position in the market. Lastly, while there are some significant differences in the approach between those involved in organised crime groups and those who are not, and between street dealers and those operating at higher levels of the market, there were striking similarities in terms of the day-to-day operational concerns and modes of relationship management. CONCLUSIONS: Interviewees' arrangements for securing supplies of drugs provide support to the notion that drug markets are resilient and flexible. Our findings correspond with other empirical research in relation to the centrality of trust in the practical operation of supply and sale of drugs. The research highlights some differences, but important similarities between dealers who were part of organised crime groups and those who were not; dealers all faced some common challenges and adopted some common responses to these.

Modeling the structure and operation of drug supply chains: The case of cocaine and heroin in Italy and Slovenia.

Multiple layers of dealers connect international drug traffickers to users. The fundamental activity of these dealers is buying from higher-level dealers and re-selling in smaller quantities at the next lower market level. Each instance of this can be viewed as completing a drug dealing "cycle". This paper introduces an approach for combining isolated accounts of such cycles into a coherent model of the structure, span, and profitability of the various layers of the domestic supply chain for illegal drugs. The approach is illustrated by synthesizing data from interviews with 116 incarcerated dealers to elucidate the structure and operation of distribution networks for cocaine and heroin in Italy and Slovenia. Inmates' descriptions of cycles in the Italian cocaine market suggest fairly orderly networks, with reasonably well-defined market levels. The Italian heroin market appears to have more "level-jumpers" who skip a market level by making a larger number of sales per cycle, with each sale being of a considerably smaller weight. Slovenian data are sparser, but broadly consistent. Incorporating prices allows calculation of how much of the revenue from retail sales is retained by dealers at each market level. In the Italian cocaine market, both retail sellers and the international supply chain outside of Italy each appear to receive about 30-40% of what users spend, with the remaining 30% going to higher-level dealers operating in Italy (roughly 10% to those at the multi-kilo level and 20% to lower level wholesale dealers). Factoring in cycle frequencies permits rough estimation of the number of organizations at each market level per billion euros in retail sales, and of annual net revenues for organizations at each level. These analyses provide an approach to gaining insight into the structure and operation of the supply chain for illegal drugs. They also illustrate the value of two new graphical tools for describing illicit drug supply chains and hint at possible biases in how respondents describe their drug dealing activities.

Antimicrobial Stewardship: The Effectiveness of Educational Interventions to Change Risk-Related Behaviours in the General Population: A Systematic Review.

RAND Europe undertook a systematic review of the evidence of effectiveness and cost effectiveness on changing the public's risk related behaviour pertaining to antimicrobial use to inform the development of a NICE public health guideline aimed at delaying antimicrobial resistance (AMR). The review considered educational interventions targeting individuals, communities or the general public delivered via any mode. Specifically, it aimed to address: 1. Which educational interventions are effective and cost-effective in changing the public's behaviour to ensure they only ask for antimicrobials when appropriate and use them correctly? 2. Which educational interventions are effective and cost-effective in changing the public's behaviour to prevent infection and reduce the spread of antimicrobial resistance? Overall, 60 studies met the inclusion criteria; 29 related to research question 1, and 36 related to research question 2 (five studies were applicable to both). The key findings are summarised in "Evidence Statements" in accordance with NICE guidelines. Evidence Statements provide a high level overview of the key features of the evidence including: the number of studies, the quality of evidence, and the direction of the estimated effect followed by a brief summary of each of the supporting studies. Studies are grouped into Evidence Statements by setting and intervention.

Development of a Framework to Estimate the Cost of Opioid Dependence.

Opioid dependence imposes a range of costs on individuals, families, communities and society, and understanding these costs is important to inform policy and decision making in this area, especially when budgets for services to address challenges such as substance misuse are under pressure. This article sets out the findings of a targeted review of the harms of opioid dependence, and an assessment of existing estimates of the costs of opioid dependence. A proposed framework for developing new, more comprehensive estimates of the costs of opioid dependence is outlined.