As earlier outlined, a radical shift in the approach to drug-related problems worldwide has occurred over the past three decades (Lader et al., 1992; Saunders, 2002a). Synchronous with the ‘new public health’ prevention approach to population morbidity and mortality, drug use problems and disabilities are recognized as “public health
concerns of pervasive importance in their own right” (Drummond, 1992, p. 8). Signaling movement away from “yesterday’s vision” and medical hegemony:
The idea which for too long held sway, that the exclusive focus for concern relating to misuse of alcohol or drugs should be with ‘the addict’, is now clearly ripe for abandonment. (Lader et al., 1992, p. 189)
Reexamination of the fundamental philosophies, techniques, and delivery of drug treatment services at the most appropriate time in the natural history of drug problems, soon followed (Lader et al., 1992). Proposing diametrically opposite strategies to traditional intensive tertiary treatment and rehabilitation, the problems model recognized the need to “broaden the base” of interventions (Institute of Medicine, 1990a) to encompass the whole spectrum of drug consumption and related problems that exist along severity continua among the population. The far end of the continuum includes dependence, with a gradient of misuse and risky use that encompasses a greater proportion of the population and the greatest amount of harms (Fleming, 2002; Heather, 1996; Kreitman, 1986; Saunders, 2002a, 2002b). This requires a matching continuum of intervention responses, ranging from minimal (advice, education) through brief motivational counselling to intensive, specialized psychological treatments (Hall & Swift, 2006).
This chapter has clarified that, as with alcohol, risky/unsafe and harmful cannabis consumption exist as continua. Similarly, acute cannabis intoxication and certain patterns of consumption often cause considerable damage to people’s lives. The comorbid association of cannabis use with other mental health and drug disorders is widespread (APA, 1994, 2000; WHO, 2004). Other common correlates include medical, interpersonal, social (marital, parental, school, employment, financial, and legal/criminal) problems, and increased risk of serious accidents. The magnitude of these cannabis-related problems in themselves embody a rationale for screening and early intervention, and not merely as precursors of more severe levels of dependence (Anthony, 2000; Compton et al., 2004; Copeland, 2004; Copeland et al., 1999, 2001a; Hall & Swift, 2006; WHO, 2004). In short, cannabis consumption with or without cannabis dependence is itself an important risk factor for a multiplicity of potentially
serious medical and psychosocial problems, a risk exacerbated with increasing levels of consumption (Compton et al., 2004). The ‘problems’ approach views the goal of screening as identification of a broad range of cannabis-related health and social problems and, along with dependence, harmful as well as potentially harmful/risky cannabis use are legitimate targets of intervention (Anthony, 2000; Babor & Higgins- Biddle, 2000; Hall & Swift, 2006; Jaffe & Compton, 1997).
Research consistently shows individuals at early stages of drug use problems have better prognoses. Chronicity and severity of drug dependence predict treatment outcomes (Carroll, 1998; Skinner, 1990). The importance of detecting and treating early stagecannabis use problems highlights the need for an expanded repertoire of treatment approaches beyond the traditional tertiary response (Anthony, 2000; Hall & Swift, 2006). A narrow preoccupation with the most serious dependence cases neglects pre- dependent drug users who, in an “epidemic-like pattern”, account for mounting numbers of new users, and eventually more cases of drug dependence (Anthony, 2000). The rigid application of one approach to a narrow population is indefensible (Brown & Fleming, 1998; Drummond, 1992). The vast majority of those with drug problems do not access specialist services (Carroll, 1998; Copeland et al., 1999; Degenhardt et al., 2001; Hall et al., 2001; IOM, 1990a; MOH, 2004). Demand for help far exceeds treatment capacity, and rationing of health care with triage rules for allocating limited resources is inevitable globally (Anthony, 2000; Ustun, 2000). An equitable, efficient health system will prioritize services and allocate resources to maximize possible health gains to ensure the greatest good for the greatest number. By definition, a ‘problems’ approach to prevention must deal with the larger number of potential, as well as actual, victims to prevent long-term adverse consequences of cannabis use (Anthony, 2000; Fleming, 2002; Hall & Swift, 2006).
A major development in conceptualising and responding to alcohol-related health problems has been the adoption of a public health perspective on alcohol use (Hall & Teesson, 2000). Rather than an exclusive focus on the ‘alcoholic’ this approach spans the entire spectrum of health problems caused by alcohol. As argued throughout this thesis, a similar perspective could productively inform the approach to cannabis-related
problems, including screening/early identification and intervention for potentially harmful/risky, harmful, and dependent patterns of cannabis consumption (Anthony, 2000; Hall & Swift, 2006; MOH, 2004; NHC, 1999). This paradigm also advocates a youth focus (Anthony, 2000; MOH, 2002b, 2002c; Shrier, Harris, Kurland, & Knight, 2003; Smart, 1992), since data show conclusively that young people are much more likely to use cannabis.
Predicated on the public health harm minimization philosophy, this revolutionary proactive approach has spawned such initiatives as population screening and early/brief intervention (SEI/SBI) for both harmful and potentially harmful cannabis use to prevent progression to a more serious- perhaps irreversible - stage of disorder. Capitalising on their accessibility and high throughput, primary health and social services have been identified as the ideal environment for screening and early intervention for cannabis use problems (Gerada, 2003; Copeland et al., 1999, 2001a; MOH, 2002c, 2005a; McArdle, 2004; McCambridge et al., 2003; Monti, Colby, & O’Leary, 2001; NHC, 1999; Shrier et al., 2003; WHO, 1998, 2004). This paradigm shift has introduced novel challenges to the cannabis problem recognition process, highlighting a conspicuous gap in suitable screening instrumentation. These issues are explored in the following two chapters.