 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|
|
|
Medicinal Use of Cannabis - adopted 99.10.16 MEDICINAL USE OF CANNABIS: PERSPECTIVES AND POLICY STATEMENT Cannabis is chemically classified in the hallucinogen category of psychoactive substances. The regular use of cannabis products is known to cause harmful health effects, including addiction, with its associated consequences to individuals, communities and society, among those that are susceptible. Although there is anecdotal, pre-clinical and limited controlled evidence
that cannabis products may be effective in some conditions such as wasting
syndromes, related to cancerand AIDS, chemotherapy induced nausea and |
Therefore, our Medicinal Use of Cannabis Products Policy Statement is:
Currently, available scientific information and clinical practice
experience indicate that overall, there is more risk than benefit, in the
use of cannabis products for medicinal purposes. Ongoing well-designed
clinical research into the possible medicinal uses of cannabis products is
essential, using the same rigorous standards that are applied to any
therapeutic agent prior to its introduction into general clinical practice.
Adopted 1999 October 16
back to index
HARM REDUCTION - PERSPECTIVES AND POLICY STATEMENT
Harm reduction is an important but diffuse concept that requires clarification. Not all people who have addictive disorders are amenable to an abstinence-based recovery at any given time. Therefore, it is essential that intervention(s) be provided to reduce the harm associated with continued drug use and/or engagement in addictive behaviour.
Addiction is a primary, chronic disease, characterised by impaired control over the use of a psychoactive substance and/or behaviour. Decreasing the negative, harmful consequences of drug use, to the user, those around him/her and society, is much harder to achieve in the face of continuing drug use.
Harm reduction and abstinence-based treatment must not be viewed as
polarised concepts. Rather, interventions need to be viewed on a
continuum, where containment and amelioration of drug-related harms are
appreciated as an early, necessary step, where cessation of drug use is not
feasible and/or acceptable to the affected person. Abstinence-based
treatment must be made readily available taking individual needs into
account. A spectrum of interventions needs to be provided after proper
assessment for problems related to drug use and other addictive disorders.
Hence, the Canadian Society of Addiction Medicine Harm Reduction Policy Statement is:
Health promotion, prevention, assessment and intervention options that aim
to decrease the health and socio-economic consequences of drug use and
addictive behaviour, without necessarily requiring abstinence, must be made
readily available to all people. Abstinence-based strategies are an
integral component of a comprehensive harm reduction policy.
The implications of this policy would be:
(a) As a prevention activity, there needs to be more emphasis on
educating all members of our society about harms resulting from drug use,
abuse and addictive behaviours;
(b) Education of health care providers to utilise harm reduction and
abstinence-based treatment as complementary strategies;
(c) Provision of a spectrum of prevention, intervention and treatment
resources for individuals, families and communities to minimise
addiction-related harm, including comprehensive addiction treatment when
needed;
(d) Commitment to research and utilisation of evidence-based practice to
clarify and validate the various approaches to harm reduction; and
(e) Co-operation with law enforcement and legislators to implement and
monitor changes resulting from harm reduction policies.
Adopted 1999 October 16
back to index
USE OF OPIOIDS FOR THE TREATMENT OF CHRONIC PAIN
The principal obligation of the physician in the treatment on pain is first, do no harm, and then whenever possible, to relieve pain and suffering.
Opioid analgesics are potent and effective medications that relieve pain. In some patients, the therapeutic use of opioids may result in physical dependence and/or addiction.
Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of opioid use that may involve any or all of the following:
- Continued use of opioids in spite of adverse consequences associated with the Use of opioids.
- Loss of control over the use of opioids.
- Preoccupation with obtaining opioids, despite the presence of adequate analgesia.
- Denial on the part of the patient that a problem exists.
Repeated exposure to opioids in the context of pain treatment does not, by itself, cause addiction. There is a variety of biological, psychological, social, and spiritual factors that may increase the risk of addiction in susceptible patients who are prescribed opioid therapy. Tolerance to the analgesic effects of opioids may occur with regular therapeutic use in some patients. Most people taking opioids regularly will have characteristic withdrawal symptoms upon abrupt cessation. Neither of the phenomena, by themselves, is diagnostic of addiction.
The etiology, presentation, assessment, and treatment of acute pain differ from that of cancer pain and also from that of chronic non-cancer pain (CNCP). Opioid analgesics are one of a variety of pharmacological and non-pharmacological therapeutic interventions used to treat pain. They have an established role in the treatment of acute pain and cancer-related pain, and more recently have been advocated for some patients with intractable CNCP. In many patients, CNCP can be managed effectively without opioids. Since pain is a subjective phenomenon, it is often a difficult clinical judgment as to whether or not opioid therapy might benefit a particular patient with a particular pain syndrome. The majority of patients treated with long-term opioids are at low risk of addiction. Patients with addictive disorders or with the potential for addiction present additional risks when prescribed opioid medication. The decision to prescribe opioids to theses patients requires extra caution, additional expertise, and a level of comfort on the part of the physician.
Despite appropriate medical practice, competent physicians may occasionally be misled by skillful patients who wish to obtain opioid medications for purposes other than pain treatment, such as diversion for profit, recreation, abuse, or maintenance of an addicted state. It must be recognized that physicians who are willing to provide compassionate, ongoing medical care to challenging psychosocially stress patients may more often be face with deception than physicians who decline to treat this difficult population.
Medical training has traditionally provided little education in addiction and pain management. This omission is not a reason for inadequate treatment of pain and/or inadequate treatment of addictions by those physicians who choose to prescribe opioids for the treatment of pain.
Therefore, The Canadian Society of Addiction Medicine endorses the following:
Policy On The Use Of Opioids To Treat Pain
Addiction to opioids may occur in the course of opioid therapy of pain in susceptible individuals under some conditions. The decision to prescribe opioid therapy for a patient in pain is a medical judgment based on careful biopsychosocial assessment, which includes an assessment of risk factors for addiction. All patients in whom long-term opioid therapy is prescribed as part of the treatment plan require careful ongoing monitoring. If an addiction disorder is pre-existing or is uncovered during the course of treatment, appropriate addiction assessment and treatment needs to be provided together with appropriate pain management. Opioid therapy may still be beneficial for those patients but requires extra caution and monitoring.
Recommendations:
1. Physicians who choose to prescribe opioid analgesics are obligated to have obtained an appropriate level of knowledge, training, and experience to enable them to apply the principles of good medical care to the treatment of pain.
2. Physicians who prescribe opioids for the treatment of pain must perform a comprehensive assessment to establish that a pain state exists and to determine whether of not opioids are an indicated component of treatment. Opioids need to prescribed in a legal and clinically sound manner. Patients need to be followed at reasonable intervals for ongoing medical management and to confirm, as nearly as is reasonable, that the medications are being used as prescribed. Such management needs to be appropriately documented in the patient’s medical record.
3. Physicians who use reasonable medical judgment regarding the prescription of opioids for the treatment of pain must not be held responsible for the willful and deceptive behavior of patients who successfully obtain opioids for non-medical purposes. It is the appropriate role of the regulatory bodies and pharmacies to inform physicians of the behavior of such patients. Physicians who consistently fail to recognize addictive disorders in their patients need to be offered education, not sanction, as a first intervention. Similarly, physicians who consistently fail to appropriately evaluate and treat pain in their patients need to be offered education as a first-line intervention.
5. For the purposes of performing regulatory, legal, quality assurance, and other clinical case reviews, it should be recognized that judgment regarding: a) the medical appropriateness of the prescription of the opioids for pain in a specific context; b) the selection of a particular opioid drug or drugs, and c) the determination of indicated opioid dosage and interval of medication administration, can only be made properly with full and detailed understanding of a particular case.
6. Regulatory, legal, quality assurance and other reviews of clinical cases involving the use of opioids for the treatment of pain should be preformed, when they are indicated, by reviewers with a requisite level of understanding of Pain Medicine and Addiction Medicine.
7. Appropriate education in Addiction Medicine and Pain Medicine should be provided as part of the core curriculum at all medical schools.
Adopted October 2000
back to index
National Drug Policy Statement
Background:
Public policy regarding drugs capable of producing dependence, including nicotine, alcohol, opiates,
sedatives, stimulants, inhalants and others, has shifted in content and emphasis over the course of Canadian history. These policy changes have resulted from changes in the public perception of the relative health and social consequences associated with the use of these substances, as well as from deliberate choices of strategy deemed most likely to prevent and ameliorate drug-related problems.
Public debate on national drug policy, requires consideration of various proposals that would change laws or regulations related to the cultivation, manufacture, importation, distribution, advertising, sale, possession and use of various psychoactive substances. Some of these proposals, classified under the general categories of "decriminalization", or "legalization", would increase drug availability.
"Legalization" means relaxation or removal of legal restrictions on the cultivation, manufacture, distribution, possession and/or use of psychoactive substance, whereas "Decriminalization" refers to the relaxation or removal of criminal penalties for the possession and/or use of an illicit psychoactive substance. Other proposals call for increased restrictions on the marketing and availability of drugs now sold under controlled conditions, such as tobacco, alcohol and psychoactive prescription pharmaceuticals.
Finally the total resources allocated to a National Drug Policy require a balance between supply reduction and demand reduction strategies.
The C
SAM Public Policy Statement regarding a National Drug Policy is that:
- Canada must have a clear strategy for dealing with the cultivation, manufacture, importation, distribution, advertising, sale, possession and use of psychoactive substances regardless of whether they are classified as legal or illegal.
- Drug possession for personal use must be decriminalized and distinguished from the trafficking or illegal sale/distribution of drugs to others that must carry appropriate criminal sanctions.
- The individual and public health impact substance use, Substance Abuse and Substance Dependence must be taken into account at all times.
- An assessment to ascertain the extent of a substance use disorder and screening for Addiction must be an essential part of dealing with someone identified as an illicit drug user or possessor.
- Appropriate funding must be made available for supply reduction and demand reduction of various psychoactive substances that carry an abuse or addiction liability.
Recommendations:
1. National policies and regulations must present a comprehensive and coordinated strategy aimed at reducing the harm done to individuals, families and society by the use of all drugs of dependence regardless of the classification of "legal" or "illegal"
2. Prevention programs need to be comprehensively designed to target the entire range of dependence-producing drugs to enhance public awareness and affect social attitudes with scientific information about the pharmacology of drugs and the effects of recreational and problem use on individuals, families, communities and society.
3. Outreach, identification, referral and treatment programs for all persons with Addiction need to be increased in number and type until they are available and accessible in every part of the country to all in need of such services.
4. Law enforcement measures aimed at interrupting the distribution of illicit drugs need to be balanced with evidenced based treatment and prevention programs, as well as programs to ameliorate those social factors that exacerbate Addiction and its related problems.
5. Any changes in laws that would affect access to dependence-producing drugs should be carefully thought out, implemented gradually and sequentially, and scientifically evaluated at each step of implementation, including evaluating the effects on:
. access to young people and prevalence of use among youth;
. prevalence of use in pregnancy and effects on offspring;
. prevalence rates of alcoholism and other drug dependencies;
. crime, violence and incarceration rates;
. law enforcement and criminal justice costs;
. industrial safety and productivity;
. costs to the health care system;
. family and social disruption;
. other human, social and economic costs.
6. CSAM opposes:
- any changes in law and regulation that would lead to a sudden significant
increase in the availability of any dependence-producing drug (outside of a medically-prescribed setting for therapeutic indications). All changes need to be gradual and carefully monitored.
- any system of distribution of dependence-producing drugs that would involve
physicians in the prescription of such drugs for other than therapeutic or rehabilitative purposes.
7. CSAM supports:
- public policies that would offer treatment and rehabilitation in place of criminal
penalties for persons with psychoactive substance dependence and whose offense is possession of a dependence-producing drug for their own use. Those who are found guilty of an offense related to Addiction, proper assessment and treatment services must be offered as part of their sentence. This goal may be attained through a variety of sentencing options, depending upon the nature of the offense.
- an increase in resources devoted to basic and applied research into the causes, extent and consequences of alcohol and other drug use, problems and dependence, and into methods of prevention and treatment.